Clonidine Treatment for Agitation in Children After Sevoflurane Anesthesia

Is PONV still a problem in pediatric surgery: a prospective study of what children tell us

Background

Postoperative nausea and vomiting (PONV) is an unpleasant complication after surgery that commonly co-occurs with pain. Considering the high prevalence among pediatric patients, it is important to explore the main risk factors leading to PONV in order to optimize treatment strategies. The objectives of this study are as follows: (1) to determine the prevalence of PONV on the day of surgery by conducting interviews with pediatric patients, (2) to assess PONV prevalence in the recovery room and on the ward by analyzing nursing records, and (3) to collect information on PONV risk factors on the day of surgery and the following postoperative days. We wanted to investigate real-life scenarios rather than relying on artificially designed studies.

Methods

A prospective analysis [according to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines] of PONV on the day of surgery and the following postoperative days was conducted by evaluating demographic and procedural parameters, as well as conducting interviews with the children under study. A total of 626 children and adolescents, ranging in age from 4 to 18 years, were interviewed on the ward following their surgery. The interviews were conducted using a questionnaire, as children aged 4 and above can participate in an outcome-based survey.

Results

On the day of surgery, several multivariable independent predictors were identified for PONV. The type of surgery was found to be a significant factor (p = 0.040) with the highest odds ratio (OR) in patients with procedural investigations [OR 5.9, 95% confidence interval (CI): 1.8-19.2], followed by abdominal surgery (OR 3.1, 95% CI: 0.9-11.1) when inguinal surgery was used as the reference category. In addition, the study identified several predictors, including the amount of fentanyl administered during anesthesia (µg/kg body weight) (OR 1.4, 95% CI: 1.1-1.8), intraoperative use of piritramide (OR 2.6, 95% CI: 1.5-4.4) and diclofenac (OR 2.0, 95% CI: 1. 3-3.1), opioid administration in the recovery room (OR 3.0, 95% CI: 1.9-4.7), and piritramide use on the ward (OR 4.5, 95% CI: 1.7-11.6).

Conclusions

The main risk factors for PONV include the intraoperative administration of opioids during the recovery room stay and at the ward, the intraoperative use of non-opioids (diclofenac), and the specific type of surgical procedure. Real-life data demonstrated that in clinical praxis, there is a gap between the adherence to established guidelines and the use of antiemetic prophylaxis in surgeries that are generally not associated with a high PONV prevalence. Further efforts are needed to improve the existing procedures and thus improve the overall outcome.

Association of pharmacological prophylaxis with the risk of pediatric emergence delirium after sevoflurane anesthesia: An updated network meta-analysis

STUDY OBJECTIVE

This updated network meta-analysis aims at exploring whether the concurrent use of midazolam or antiemetics may enhance the efficacy of other pharmacological regimens for delirium prophylaxis in pediatric population after general anesthesia (GA).

DESIGN

Network meta-analysis (PROSPERO registration: CRD42020179483).

SETTING

Postoperative recovery area.

PATIENTS

Pediatric patients undergoing GA with sevoflurane.

INTERVENTIONS

Pharmacological interventions applied during GA with sevoflurane.

MEASUREMENTS

This network meta-analysis of randomized controlled trials (RCTs) was conducted with a frequentist model. PubMed, Embase, ProQuest, ScienceDirect, Cochrane CENTRAL, ClinicalKey, Web of Science, and ClinicalTrials.gov were searched from their inception dates to April 12, 2020, for RCTs of either placebo-controlled or active-controlled design containing information on the incidence of emergence delirium in pediatric patients undergoing sevoflurane anesthesia.

MAIN RESULTS

Seventy studies comprising 6904 participants were included for the analysis of 30 pharmacological interventions. Based on surface under the cumulative ranking curve (SUCRA) analysis, midazolam was ranked the lowest in therapeutic effect (SUCRA: 20%), while antiemetics as a monotherapy had no effect on delirium prophylaxis. However, there was a trend that most combination therapies with midazolam or antiemetics were superior to monotherapies for delirium prophylaxis. Subgroup analyses based on age (i.e., ≤7 years) and a validated scoring system (i.e., the Pediatric Anesthesia Emergence Delirium scale) for delirium also suggested a better efficacy of combination therapies than monotherapies. Overall, combination therapies with midazolam or antiemetics did not have a negative impact on the incidence of postoperative nausea and vomiting, length of stay in the postanesthesia care unit, or time to extubation. The dexmedetomidine-midazolam-antiemetic combination was the most effective strategy for the prevention of emergence delirium.

CONCLUSIONS

This network meta-analysis suggested that the incorporation of midazolam or antiemetics as adjuncts for combination therapies may have synergistic effects against pediatric postoperative emergence delirium. Future large-scale placebo-controlled RCTs are warranted to validate our findings.

Clonidine for pain in non-ventilated infants

BACKGROUND

Critically ill newborn infants undergo a variety of painful procedures or experience a variety of painful conditions during their early life in the neonatal unit. In the critically ill paediatric and neonatal population, clonidine is prescribed as an adjunct to opioids or benzodiazepines aiming to reduce the doses of these drugs that are required for analgesia or sedation, or to facilitate weaning from mechanical ventilation. It has been shown that clonidine premedication might have a positive effect on postoperative pain in children.

OBJECTIVES

To assess the benefit and harms of clonidine for the prevention or treatment of procedural pain; postoperative pain; or pain associated with clinical conditions in non-ventilated neonates.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the CENTRAL, MEDLINE via PubMed, Embase, and CINAHL to December 2018. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We ran an updated search from 1 January 2018 to 11 March 2020 in CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials, and cluster trials comparing clonidine to placebo or no treatment, opioids, paracetamol, dexmedetomidine, or non-pharmacological pain-reducing interventions for the management of procedural pain, postoperative pain, and pain associated with clinical conditions in preterm and term newborns.

DATA COLLECTION AND ANALYSIS

Two review authors independently planned to extract data (e.g. number of participants, birth weight, gestational age, modality of administration, and dose of clonidine) and assess the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). The primary outcome considered was pain: for procedural pain, the mean values of each analgesia scale assessed during the procedure and at one to two hours after the procedure; for postoperative pain and for pain associated with clinical conditions, the mean values of each analgesia scale assessed at 30 minutes, three hours, and 12 hours after the administration of the intervention. We planned to use the GRADE approach to assess the quality of evidence.

MAIN RESULTS

Our search strategy yielded 3383 references. Two review authors independently assessed all references for inclusion. We did not find any completed studies for inclusion. We excluded three trials where clonidine was administered for spinal anaesthesia.

AUTHORS' CONCLUSIONS

We did not find any studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of clonidine for the prevention or treatment of procedural or postoperative pain, or pain associated with clinical conditions in neonates.

Clonidine in pediatric anesthesia: the new panacea or a drug still looking for an indication?

PURPOSE OF REVIEW

Clonidine, an α2-receptor agonist is a widely used drug in pediatrics with a large scope of indications ranging from prevention of postoperative emergence agitation, analgesia, anxiolysis, sedation, weaning to shivering. In the era of 'opioid-free' medicine with much attention be directed toward increasing problems with opioid use, clonidine due to its global availability, low cost and safety profile has become an even more interesting option.

RECENT FINDINGS

Increasing evidence from randomised clinical trials support the use of clonidine in healthy children in the perioperative setting. Clonidine appears to significantly reduce postoperative emergence agitation, opioid consumption, shivering, nausea and vomiting. In addition, emerging evidence support the use of clonidine for sedation of critically ill children in ICUs. In this review, the current evidence for clonidine in pediatrics is described and analyzed including a meta-analysis for prevention of emergence agitation.

SUMMARY

Clonidine appears a safe and beneficial drug with moderate to high-quality evidence supporting its use in pediatric anesthesia. However, for some indications and populations such as children younger than 12 months old and those with hemodynamic instability, there is an urgent need for high-quality trials.

An Exploratory Study of Sevoflurane as an Alternative for Difficult Sedation in Critically Ill Children

OBJECTIVES

To analyze the effectiveness of inhaled sevoflurane in critically ill children with challenging sedation.

DESIGN

Prospective case series.

SETTING

Two PICUs of university hospitals in Spain.

INTERVENTIONS

Prospective observational study and exploratory investigation conducted in two PICUs in Madrid, Spain, over a 6-year period. Children treated with inhaled sevoflurane due to difficult sedation were included. Sevoflurane was administered via the anesthetic conserving device (AnaConDa) connected to a Servo-I ventilator (Maquet, Solna, Sweden). A morphine infusion was added to sevoflurane for analgesia. Demographic and clinical data, oral and IV sedatives, Sedation and Analgesic Clinical scores, and Bispectral Index Score monitoring were registered.

MEASUREMENTS AND MAIN RESULTS

Twenty-three patients with a median age of 6 months old were included. Fifty percentage of the patients had critical heart diseases. Sedative and analgesic drugs used before starting sevoflurane were mainly midazolam (63%) and fentanyl (53%). Six patients (32%) also received muscle relaxants. Sevoflurane was administered for a median of 5 days (interquartile range, 5.5-8.5 d). Median end-tidal sevoflurane concentration was 0.8% (interquartile range, 0.7-0.85%), achieved with an infusion rate of 7.5 mL/hr (5.7-8.6 mL/hr). After 48 hours of treatment, some sedative drugs could be removed in 18 patients (78%). Median Bispectral Index Score value prior to sevoflurane administration was 61 (interquartile range, 49-62), falling to 42 (interquartile range, 41-47; p < 0.05) after 6 hours of treatment. Six patients (26%) presented withdrawal syndrome after sevoflurane suspension, and all of them had received sevoflurane at least for 6 days. The main side effect was moderate hypotension in seven patients (30%).

CONCLUSIONS

Inhaled sevoflurane appeared to be an effective sedative agent in critically ill children and can be useful in those patients on mechanical ventilation difficult to sedate with conventional drugs. It can be administered easily in the PICU with conventional ventilators using the AnaConDa system. Withdrawal syndrome may occur with prolonged treatment.

Emergence Delirium in Pediatric Anesthesia

Emergence delirium (ED) is a complex of perceptual disturbances and psychomotor agitation that occurs most commonly in preschool-aged children in the early postanesthetic period. The incidence of ED varies between 10 and 80% in children and is perceived as a troublesome clinical situation by 42% of pediatric anesthesiologists. Although these events are often short lived, they increase the risk of self-injury and delayed discharge, require additional nursing staff and can increase medical care costs, all of which are causes for concern. The prevalence of ED has increased with the introduction and growing use of sevoflurane and desflurane, two low-solubility inhalational anesthetics. These agents promote early arousal post anesthetic, which contributes to ED. Physiological factors, pharmacological factors, the type of procedure, the anesthetic agent administered, painful stimuli, and various patient factors can all contribute to ED and thus need to be considered. Recent literature debates the cause-effect relationship between ED and pain, suggesting that they often occur concurrently but are sometimes independent findings. The consistent relation between ED and sevoflurane-based anesthesia has guided many studies to investigate its incidence compared with using other anesthetic techniques or various adjuncts. The risk of ED is lowest when propofol is used as a single-agent anesthetic compared with sevoflurane-based anesthetics. Adjunctive agents can be rated in the following order of most effective to least effective interventions: dexmedetomidine, fentanyl, ketamine, clonidine, and propofol bolus at the end of sevoflurane-based anesthesia. This review summarizes the factors that may predict ED and provides an intervention algorithm to guide effective prevention and treatment.

Efficacy and Acceptability of Different Auxiliary Drugs in Pediatric Sevoflurane Anesthesia: A Network Meta-analysis of Mixed Treatment Comparisons

Emergence agitation preventive medicine should be combined with pediatric anesthesia because of the high frequency of emergence agitation. However, it is challenging to determine the most appropriate medication that can be introduced into pediatric anesthesia for the sake of emergence agitation prevention. We reviewed and retrieved the data from PubMed and Embase. Various medications were assessed based on several endpoints including Emergence agitation outcomes (EA), postoperative nausea and vomiting (PONV), the number of patients who required analgesic (RA), pediatric anesthesia emergence delirium (PAED), the extubation time, the emergency time and the duration of post-anesthesia care unit (PACU) stay. Both traditional and network meta-analysis were carried in this study. A total of 45 articles were complied with the selection criteria and the corresponding articles were reviewed. Fentanyl demonstrated the highest cumulative ranking probability which was followed by those of ketamine and dexmedetomidine with respect to EA and PAED. When PONV and RA were concerned together, clonidine exhibited the highest cumulative ranking probability compared to other medications. Our study suggested that dexmedetomidine perhaps is the most appropriate prophylactic treatment which can be introduced into anesthesia for preventing emergence agitation.

Effects of remifentanil and remifentanil-alfentanil administration on emergence agitation after brief ophthalmic surgery in children

Background

Sevoflurane is commonly usedin pediatric anesthesia due to its non-irritating airway properties, and rapid induction and emergence. However, it is associated with emergence agitation (EA) in children. EA may cause injury to the child or damage to the surgical site and is a cause of stress to both caregivers and families. The efficacy of remifentanil and additional alfentanil on EA in the pediatric patients underwent ophthalmic surgery with sevofluraneanesthesiawas not well evaluated to date. This study was designed to compare the effects of remifentanil and remifentanil plus alfentanil on EA in children undergoing ophthalmic surgery with sevofluraneanesthesia.

Methods

Children (aged 3–9 years) undergoing ophthalmic surgery undersevoflurane anesthesia were randomly assigned to group S (sevoflurane alone), group R (sevofluraneandremifentanil infusion, 0.1 μg/kg/min), or group RA (sevoflurane withremifentanil infusion and intravenous injection of alfentanil 5 μg/kg 10 min before the end of surgery). Mean arterial pressure (MAP), heart rate (HR), and sevoflurane concentration were checked every 15 min after induction of anesthesia. The incidence of EA, time to extubation from discontinuation of sevoflurane inhalation, and time to discharge from the postanesthesia care unit was assessed.

Results

The incidence of EA was significantly lower in groups R (32 %, 11/34; P = 0.01) and RA (31 %, 11/35; P = 0.008) than group S (64 %, 21/33). The time to extubation was prolonged in group RA (11.2 ± 2.3 min; P = 0.004 and P = 0.016) compared with groups S (9.2 ± 2.3 min) andR (9.5 ± 2.4 min). MAP and HR were similar in all three groups, apart from a reduction in HR at 45 min in groups R and RA. However, the sevoflurane concentration was lower in groups R and RA than group S (P < 0.001).

Conclusions

The administration of remifentanil to children undergoing ophthalmic surgery undersevoflurane anesthesia reduced the incidence of EA without clinically significant hemodynamic changes. However, the addition of alfentanil(5 μg/kg)10 min before the end of surgery provided no additional benefit compared withremifentanil alone.

Trial registration

Clinical trial number: NCT02486926, June.29.2015.

Preemptive Oral Clonidine Provides Better Sedation Than Intravenous Midazolam in Brachial Plexus Nerve Blocks

Background

Preemptive analgesia is the blocking of pain perception afferent pathways before noxious painful stimuli. Clonidine is an alpha agonist drug that is partially selective for α-2 adrenoreceptors. Clonidine is used as anti-anxiety medication and an, analgesic, and it prolongs the duration of the block in the brachial plexus block.

Objectives

To compare the effect of preemptive clonidine with midazolam on intraoperative sedation, duration of block, and postoperative pain scores.

Patients and Methods

In a randomized clinical trial, 80 patients with orthopedic fractures of an upper extremity who underwent supraclavicular nerve block were randomly assigned to receive 0.2 mg oral clonidine or 2 mg oral midazolam. Intraoperative sedation was measured at one hour after the start of urgery and again in the PACU (Post-Anesthesia Care Unit) using the Ramsay scale. The duration of sensory blockade was measured. Postoperative pain scores were measured using the VAS (Visual Analogue Scale) after entrance to recovery up to 2 hours.

Results

The percentages of patients in the calm and sedated scale were significantly higher in clonidine group (35 and 42.5%, respectively), compared to the midazolam group (17.5 and 17.5%, respectively) (P = 0.042, 0.029; respectively). Those administered fentanyl in the clonidine group 105 ± 30.8 was significantly lower than that for the midazolam group 165 ± 34.5 (P = 0.0018). The percentages of patients in the calm scale were significantly higher in the clonidine group (52.5), compared to the midazolam group (17.5) (P = 0.001) in the post-operative period. VAS scores were significantly lower at one (P = 0.01) and two hours (P = 0.001) after operation in the clonidine group, compared to the midazolam group.

Conclusions

Preemptive clonidine has many marvelous advantages over midazolam, including better sedation inside the operating room and then in the post-operative care unit, lower fentanyl doses are required during surgery, more stable heart rate and blood pressure are observed during the procedure, and patients report lower post-operative pain scores.

Swedish guidelines for the treatment of pain in tonsil surgery in pediatric patients up to 18 years

BACKGROUND

Surgery of the tonsils often causes severe pain lasting for many days as been shown by data from the National Tonsil Surgery Register in Sweden. Tonsillotomy is associated with fewer readmissions due to bleeding, number of days requiring analgesics and health care contacts due to pain compared to tonsillectomy. The register data demonstrate the necessity of better-evidenced based pain treatment guidelines for tonsil-surgery.

OBJECTIVES

To develop evidenced based pain treatment guidelines for tonsil-surgery in Sweden.

METHODS

The evidence based guidelines were designed by an updated literature review and from the clinical expertise in the pediatric pain field, which thereafter were reviewed by ENT-doctors and anesthetists from each ENT-clinic in Sweden.

RESULTS

A multimodal pain treatment approach is advocated, including premedication and administration during anesthesia, with paracetamol (acetaminophen), clonidine and betamethasone. If not given as a premedication the combination can be administered intravenously in the initial phase of anesthesia. At the end of surgery, if no bleeding problems, cox-inhibitors can be given. After discharge from hospital, the recommendations for pain relief are paracetamol combined with cox-inhibitors (ibuprofen, diclofenac) and if needed oral clonidine in favor of opioids. When pain intensity decreases, discontinue the analgesic treatment in the following order: opioid, clonidine, paracetamol and at last ibuprofen. The need for analgesic treatment after tonsillectomy is usually 5-8 days, after tonsillotomy only 3-5 days. Parents are recommended to contact the hospital if the child has difficulties in drinking or eating adequately and/or suffers from pain despite taking the recommended medication regularly.

CONCLUSIONS

Swedish guidelines for tonsil-surgery provide practical evidence-based pain treatment recommendations.

Pain in children--are we accomplishing the optimal pain treatment?

Morphine, paracetamol and local anesthetics have for a long time been the foremost used analgesics in the pediatric patient by tradition but not always enough effective and associated with side effects. The purpose with this article is to propose alternative approaches in pain management, not always supported up by substantial scientific work but from a combination of science and clinical experience in the field. The scientific literature has been reviewed in parts regarding different aspects of pain assessment and analgesics used for treatment of diverse pain conditions with focus on procedural and acute pain. Clinical experience has been added to form the suggested improvements in accomplishing an improved pain management in pediatric patients. The aim with pain management in children should be a tailored analgesic medication with an individual acceptable pain level and optimal degree of mobilization with as little side effects as possible. Simple techniques of pain control are as effective as and complex techniques in pediatrics but the technique used is not of the highest importance in achieving a good pain management. Increased interest and improved education of the doctors prescribing analgesics is important in accomplishing a better pain management. The optimal treatment with analgesics is depending on the analysis of pain origin and analgesics used should be adjusted thereafter. A multimodal treatment regime is advocated for optimal analgesic effect.

Preoperative anxiety management, emergence delirium, and postoperative behavior

Preoperative anxiolysis is important for children scheduled for surgery. The nature of the anxiety depends on several factors, including age, temperament, past hospitalizations, and socioeconomic and ethnic backgrounds. A panoply of interventions effect anxiolysis, including parental presence, distraction, and premedication, although no single strategy is effective for all ages. Emergence delirium (ED) occurs after the use of sevoflurane and desflurane in preschool-aged children in the recovery room. Symptoms usually last approximately 15 minutes and resolve spontaneously. The Pediatric Anesthesia Emergence Delirium scale is used to diagnose ED and evaluate therapeutic interventions for ED such as propofol and opioids.

Effects of sevoflurane versus other general anaesthesia on emergence agitation in children

BACKGROUND

Sevoflurane is an inhaled volatile anaesthetic that is widely used in paediatric anaesthetic practice. Since its introduction, postoperative behavioural disturbance known as emergence agitation (EA) or emergence delirium (ED) has been recognized as a problem that may occur during recovery from sevoflurane anaesthesia. For the purpose of this systematic review, EA has been used to describe this clinical entity. A child with EA may be restless, may cause self-injury or may disrupt the dressing, surgical site or indwelling devices, leading to the potential for parents to be dissatisfied with their child's anaesthetic. To prevent such outcomes, the child may require pharmacological or physical restraint. Sevoflurane may be a major contributing factor in the development of EA. Therefore, an evidence-based understanding of the risk/benefit profile regarding sevoflurane compared with other general anaesthetic agents and adjuncts would facilitate its rational and optimal use.

OBJECTIVES

To compare sevoflurane with other general anaesthetic (GA) agents, with or without pharmacological or non-pharmacological adjuncts, with regard to risk of EA in children during emergence from anaesthesia. The primary outcome was risk of EA; secondary outcome was agitation score.

SEARCH METHODS

We searched the following databases from the date of inception to 19 January 2013: CENTRAL, Ovid MEDLINE, Ovid EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost), Evidence-Based Medicine Reviews (EBMR) and the Web of Science, as well as the reference lists of other relevant articles and online trial registers.

SELECTION CRITERIA

We included all randomized (or quasi-randomized) controlled trials investigating children < 18 years of age presenting for general anaesthesia with or without surgical intervention. We included any study in which a sevoflurane anaesthetic was compared with any other GA, and any study in which researchers investigated adjuncts (pharmacological or non-pharmacological) to sevoflurane anaesthesia compared with no adjunct or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched the databases, decided on inclusion eligibility of publications, ascertained study quality and extracted data. They then resolved differences between their results by discussion. Data were entered into RevMan 5.2 for analyses and presentation. Comparisons of the risk of EA were presented as risk ratios (RRs) with 95% confidence intervals (CIs). Sevoflurane is treated as the control anaesthesia in this review. Sensitivity analyses were performed as appropriate, to exclude studies with a high risk of bias and to investigate heterogeneity.

MAIN RESULTS

We included 158 studies involving 14,045 children. Interventions to prevent EA fell into two broad groups. First, alternative GA compared with sevoflurane anaesthesia (69 studies), and second, use of an adjunct with sevoflurane anaesthesia versus sevoflurane without an adjunct (100 studies). The overall risk of bias in included studies was low. The overall Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) assessment of the quality of the evidence was moderate to high. A wide range of EA scales were used, as were different levels of cutoff, to determine the presence or absence of EA. Some studies involved children receiving potentially inadequate or no analgesia intraoperatively during painful procedures.Halothane (RR 0.51, 95% CI 0.41 to 0.63, 3534 participants, high quality of evidence) and propofol anaesthesia were associated with a lower risk of EA than sevoflurane anaesthesia. Propofol was effective when used throughout anaesthesia (RR 0.35, 95% CI 0.25 to 0.51, 1098 participants, high quality of evidence) and when used only during the maintenance phase of anaesthesia after sevoflurane induction (RR 0.59, 95% CI 0.46 to 0.76, 738 participants, high quality of evidence). No clear evidence was found of an effect on risk of EA of desflurane (RR 1.46, 95% CI 0.92 to 2.31, 408 participants, moderate quality of evidence) or isoflurane (RR 0.76, 95% CI 0.46 to 1.23, 379 participants, moderate quality of evidence) versus sevoflurane.Compared with no adjunct, effective adjuncts for reducing the risk of EA during sevoflurane anaesthesia included dexmedetomidine (RR 0.37, 95% CI 0.29 to 0.47, 851 participants, high quality of evidence), clonidine (RR 0.45, 95% CI 0.31 to 0.66, 739 participants, high quality of evidence), opioids, in particular fentanyl (RR 0.37, 95% CI 0.27 to 0.50, 1247 participants, high quality of evidence) and a bolus of propofol (RR 0.58, 95% CI 0.38 to 0.89, 394 participants, moderate quality of evidence), ketamine (RR 0.30, 95% CI 0.13 to 0.69, 231 participants, moderate quality of evidence) or midazolam (RR 0.57, 95% CI 0.41 to 0.81, 116 participants, moderate quality of evidence) at the end of anaesthesia. Midazolam oral premedication (RR 0.81, 95% CI 0.59 to 1.12, 370 participants, moderate quality of evidence) and parental presence at emergence (RR 0.91, 95% CI 0.51 to 1.60, 180 participants, moderate quality of evidence) did not reduce the risk of EA.One or more factors designated as high risk of bias were noted in less than 10% of the included studies. Sensitivity analyses of these studies showed no clinically relevant changes in the risk of EA. Heterogeneity was significant with respect to these comparisons: halothane; clonidine; fentanyl; midazolam premedication; propofol 1 mg/kg bolus at end; and ketamine 0.25 mg/kg bolus at end of anaesthesia. With investigation of heterogeneity, the only clinically relevant changes to findings were seen in the context of potential pain, namely, the setting of adenoidectomy/adenotonsillectomy (propofol bolus; midazolam premedication) and the absence of a regional block (clonidine).

AUTHORS' CONCLUSIONS

Propofol, halothane, alpha-2 agonists (dexmedetomidine, clonidine), opioids (e.g. fentanyl) and ketamine reduce the risk of EA compared with sevoflurane anaesthesia, whereas no clear evidence shows an effect for desflurane, isoflurane, midazolam premedication and parental presence at emergence. Therefore anaesthetists can consider several effective strategies to reduce the risk of EA in their clinical practice. Future studies should ensure adequate analgesia in the control group, for which pain may be a contributing or confounding factor in the diagnosis of EA. Regardless of the EA scale used, it would be helpful for study authors to report the risk of EA, so that this might be included in future meta-analyses. Researchers should also consider combining effective interventions as a multi-modal approach to further reduce the risk of EA.

The effect of fentanyl and clonidine on early postoperative negative behavior in children: a double-blind placebo controlled trial

BACKGROUND

Early negative postoperative behavior (e-PONB) is common in children and manifests itself as emergence agitation (EA), emergence delirium (ED), and pain. The objective of this prospective double blind, randomized, placebo-controlled trial was to determine whether IV clonidine or IV fentanyl prior to surgery modifies e-PONB in children.

METHODS

Ninety children scheduled for subumbilical surgery under sevoflurane anesthesia supplemented with regional anesthesia were randomized to either receive IV clonidine 2 mcg·kg(-1) , IV fentanyl 2 mcg·kg(-1) or placebo (IV saline) before surgery. Primary outcome measures were the incidence of EA, ED and pain during the first hour after awakening. Secondary outcome measures were side effects such as nausea and vomiting and delayed discharge from PACU.

RESULTS

Eighty-seven children (n = 29 per group) completed the study. EA was present in 10 children (six clonidine, none fentanyl, and four placebo, P = 0.04) whereas ED was observed in 20 children (nine clonidine, three fentanyl, and eight placebo P = 0.13). Sixteen children who received placebo had a CHIPPS score of ≥4 compared with nine children in fentanyl group and 18 children receiving clonidine (P = 0.04). Ten children receiving fentanyl vomited during the first postoperative day, compared with six children in placebo group and none in clonidine group (P = 0.003). Discharge from PACU was not affected.

CONCLUSIONS

IV fentanyl before surgery but not IV clonidine modifies e-PONB in children undergoing lower abdominal surgery under general anesthesia supplemented with regional anesthesia. The use of fentanyl in this population was also associated with reduced pain scores after awakening but with significantly greater incidence of PONV.

Systematic review and meta-analysis of the effect of intraoperative α₂-adrenergic agonists on postoperative behaviour in children

Undergoing general anaesthesia is distressing for children, with up to two-thirds demonstrating abnormal behaviours after their procedure, such as emergence delirium (ED) and post-hospitalization behaviour change. The aim of this systematic review was to determine the effect of intraoperative i.v. α₂-adrenergic agonists on postoperative behaviour in children. We included published full-text reports of randomized controlled trials involving children who received i.v. clonidine or dexmedetomidine after induction of general anaesthesia, who were assessed for postoperative behavioural disturbance. After screening of references identified by the search strategy, a data collection form was developed and piloted. Data extraction was performed by one reviewer and checked by a second. Twelve randomized trials met the inclusion criteria. Ten studies (n=669) reported dichotomous data that were included in the pooled analysis of α₂-adrenergic agonists vs placebo. There was strong evidence that i.v. α₂-adrenergic agonists reduced postoperative ED (overall summary odds ratio 0.28, 95% confidence interval 0.19-0.40, P<0.001). No studies examined post-hospitalization negative behaviour changes. There was evidence that α₂-adrenergic agonists prolonged time in the recovery room. No adverse haemodynamic events were reported in any arm of any study. This meta-analysis provides evidence that intraoperative i.v. α₂-adrenergic agonists reduce the incidence of emergency delirium in children. The prolongation of time in recovery is unlikely to be clinically relevant. The absence of data regarding the effect on post-hospitalization behavioural changes provides an opportunity for future research.

Clonidine premedication for postoperative analgesia in children

BACKGROUND

Postoperative pain remains a significant problem following paediatric surgery. Premedication with a suitable agent may improve its management. Clonidine is an alpha-2 adrenergic agonist which has sedative, anxiolytic and analgesic properties. It may therefore be a useful premedication for reducing postoperative pain in children.

OBJECTIVES

To evaluate the evidence for the effectiveness of clonidine, when given as a premedication, in reducing postoperative pain in children less than 18 years of age. We also sought evidence of any clinically significant side effects.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 12, 2012), Ovid MEDLINE (1966 to 21 December 2012) and Ovid EMBASE (1982 to 21 December 2012), as well as reference lists of other relevant articles and online trial registers.

SELECTION CRITERIA

We included all randomized (or quasi-randomized), controlled trials comparing clonidine premedication to placebo, a higher dose of clonidine, or another agent when used for surgical or other invasive procedures in children under the age of 18 years and where pain or a surrogate (principally the need for supplementary analgesia) was reported.

DATA COLLECTION AND ANALYSIS

Two authors independently performed the database search, decided on the inclusion eligibility of publications, ascertained study quality and extracted data. They then resolved any differences between their results by discussion. The data were entered into RevMan 5 for analyses and presentation. Sensitivity analyses were performed, as appropriate, to exclude studies with a high risk of bias.

MAIN RESULTS

We identified 11 trials investigating a total of 742 children in treatment arms relevant to our study question. Risks of bias in the studies were mainly low or unclear, but two studies had aspects of their methodology that had a high risk of bias. Overall, the quality of the evidence from pooled studies was low or had unclear risk of bias. Four trials compared clonidine with a placebo or no treatment, six trials compared clonidine with midazolam, and one trial compared clonidine with fentanyl. There was substantial methodological heterogeneity between trials; the dose and route of clonidine administration varied as did the patient populations, the types of surgery and the outcomes measured. It was therefore difficult to combine the outcomes of some trials for meta-analysis.When clonidine was compared to placebo, pooling studies of low or unclear risk of bias, the need for additional analgesia was reduced when clonidine premedication was given orally at 4 µg/kg (risk ratio (RR) 0.24, 95% confidence interval (CI) 0.11 to 0.51). Only one small trial (15 patients per arm) compared clonidine to midazolam for the same outcome; this also found a reduction in the need for additional postoperative analgesia (RR 0.25, 95% CI 0.09 to 0.71) when clonidine premedication was given orally at 2 or 4 µg/kg compared to oral midazolam at 0.5 mg/kg. A trial comparing oral clonidine at 4 µg/kg with intravenous fentanyl at 3 µg/kg found no statistically significant difference in the need for rescue analgesia (RR 0.89, 95% CI 0.56 to 1.42). When clonidine 4 µg/kg was compared to clonidine 2 µg/kg, there was a statistically significant difference in the number of patients requiring additional analgesia, in favour of the higher dose, as reported by a single, higher-quality trial (RR 0.38, 95% CI 0.23 to 0.65).The effect of clonidine on pain scores was hard to interpret due to differences in study methodology, the doses and route of drug administration, and the pain scale used. However, when given at a dose of 4 µg/kg, clonidine may have reduced analgesia requirements after surgery. There were no significant side effects of clonidine that were reported such as severe hypotension, bradycardia, or excessive sedation requiring intervention. However, several studies used atropine prophylactically with the aim of preventing such adverse effects.

AUTHORS' CONCLUSIONS

There were only 11 relevant trials studying 742 children having surgery where premedication with clonidine was compared to placebo or other drug treatment. Despite heterogeneity between trials, clonidine premedication in an adequate dosage (4 µg/kg) was likely to have a beneficial effect on postoperative pain in children. Side effects were minimal, but some of the studies used atropine prophylactically with the intention of preventing bradycardia and hypotension. Further research is required to determine under what conditions clonidine premedication is most effective in providing postoperative pain relief in children.

Prophylactic midazolam and clonidine for emergence from agitation in children after emergence from sevoflurane anesthesia: a meta-analysis

BACKGROUND

Emergence agitation (EA) after emergence from sevoflurane anesthesia is a common phenomenon in children. The efficacy of prophylactic midazolam or clonidine in preventing EA is controversial.

OBJECTIVE

We performed a meta-analysis of clinical trials of the 2 drugs to evaluate their ability to prevent EA in pediatric patients after emergence from sevoflurane anesthesia.

METHODS

A comprehensive literature search was conducted to identify clinical trials that observed the effect of midazolam and clonidine on preventing EA in children after their emergence from sevoflurane anesthesia. All data were examined using the Mantel-Haenszel model to calculate the pooled odds ratio (OR) and 95% CI. I(2) was used to assess heterogeneity. Subgroup analysis was used to assess the effects of preoperative analgesics, routes of administration, and dose, and funnel plots were used to check publication bias.

RESULTS

After a comprehensive literature search, we found 12 papers that met the criteria for inclusion in this analysis, with a total of 447 children in the midazolam group and 767 children in the clonidine group. We found that both midazolam and clonidine decreased the incidence of EA (OR = 0.45 [95% CI, 0.29-0.70], P = 0.0004, I(2) = 46%; and OR = 0.24 [95% CI, 0.13-0.43], P < 0.00001, I(2) = 48%, respectively). Subgroup analysis indicated that preoperative analgesia may decrease the effect of midazolam against EA, whereas for clonidine, neither the route of administration (intravenous or caudal) nor the dose affected the results. Funnel plots did not detect publication bias in the midazolam group, but a bias was detected in the clonidine group.

CONCLUSIONS

This meta-analysis suggests that prophylactic administration of midazolam or clonidine could significantly decrease the incidence of sevoflurane-induced EA in pediatric patients.

Clonidine premedication versus placebo: effects on postoperative agitation and recovery time in children undergoing strabismus surgery

PURPOSE

Postoperative agitation is common in adults and children following the use of several anesthetics, particularly inhalation anesthetics. This behavior has detrimental effects both physically for the patient following the procedure and psychologically for the parent or guardian. The authors propose that clonidine, an alpha-2 agonist, would provide a reduction in children's postoperative agitation and, in turn, improve parent satisfaction in children undergoing strabismus surgery.

METHODS

Fifty children were prospectively randomized to receive either clonidine or placebo in a double-blind fashion prior to surgery. The children were evaluated using preoperative and postoperative parent questionnaires and postoperative behavioral evaluation using standardized scales including the Pediatric Anesthesia Emergence Delirium and Watcha scales.

RESULTS

Children receiving clonidine immediately after anesthesia induction had statistically significant improvement in postoperative agitation at the 15-minute mark (P = .096) and last score obtained (P = .095) using the Watcha scale. The clonidine group spent an insignificantly longer time in the post-anesthesia care unit (average: 54 minutes) than the placebo group (average 47 minutes) (P = .17). Seventy-one percent of parents reported being "very satisfied" with their child's recovery from anesthesia in the clonidine group compared to 46% in the placebo group, although this was not statistically significant (P = .34).

CONCLUSIONS

Children receiving clonidine prior to undergoing strabismus surgery have a small but noticeable reduction in postoperative agitation, stay slightly longer in the post-anesthesia care unit, and have higher rates of parent satisfaction.

Emergence delirium in children: a comparison of sevoflurane and desflurane anesthesia using the Paediatric Anesthesia Emergence Delirium scale

OBJECTIVES/AIM

This randomized control trial was designed to evaluate the incidence of emergence delirium (ED) in preschool children receiving sevoflurane or desflurane anesthesia combined with an effective caudal block.

BACKGROUND

While ED has been described in children receiving sevoflurane or desflurane anesthesia, a direct comparison between the two agents using a validated ED assessment tool has not been reported previously.

METHODS/MATERIALS

Two hundred and sixty preschool children scheduled for elective sub-umbilical surgery were randomized to receive sevoflurane or desflurane anesthesia combined with a caudal block. ED was defined as a Paediatric Anesthesia Emergence Delirium scale (PAED) ≥ 10 points. A delirium-specific score (ED I) was calculated from the first three items of the PAED score (eye contact, purposeful actions, awareness of the surroundings) and a nonspecific score (ED II) from the last two items on the PAED score (restlessness and inconsolability) to test the hypothesis that some items of the PAED scale may better reflect clinical ED than others.

RESULTS

Thirty-one (25%) children in each group demonstrated ED after awakening with ED being of shorter duration in the desflurane group than the sevoflurane group. An ED I score of nine points had a sensitivity of 0.93 and a specificity of 0.94 for ED. An ED II score of five points had a sensitivity of 0.34 and specificity of 0.95 for ED.

CONCLUSION

Sevoflurane and desflurane anesthesia were associated with similar incidences of ED in children undergoing sub-umbilical surgery and receiving effective regional anesthesia. High scores on the first three items of the PAED scale were highly correlated with ED. The items restlessness and inconsolability had lower sensitivity for the diagnosis of ED.

Prophylactic use of midazolam or propofol at the end of surgery may reduce the incidence of emergence agitation after sevoflurane anaesthesia

Sevoflurane is associated with a high incidence of emergence agitation in children. Midazolam and propofol have been examined with the aim of reducing emergence agitation after sevoflurane anaesthesia. However the effect of both drugs on emergence agitation is still controversial. Therefore we designed this study to measure the effect of midazolam or propofol at the end of surgery on emergence agitation during the recovery period. One hundred and one children, aged one to 13 years, undergoing strabismus surgery were enrolled in this randomised double-blind study. Anaesthesia was induced and maintained with sevoflurane in N2O/O2. Children were randomly assigned to receive midazolam 0.05 mg/kg (group M, n = 35), propofol 1 mg/kg (group P, n = 31) or saline (group S, n = 35). A four-point scale was used to evaluate recovery characteristics upon awakening and during the first hour after emergence from anaesthesia. The incidence of emergence agitation in group M was 42.9% (15/35), in group P 48.4% (15/31) and in group S 74.3% (26/35). The incidence of emergence agitation in groups M and P was significantly less than in group S. The emergence time was prolonged for patients in groups M and P compared to group S. There was no significant difference in the incidence of emergence agitation or in emergence times between the groups P and M. We conclude that propofol or midazolam administration before the end of surgery may be effective in reducing the incidence of emergence agitation in children undergoing strabismus surgery under sevoflurane anaesthesia.

Characterizing the behavior of children emerging with delirium from general anesthesia

BACKGROUND

Emergence delirium (ED) frequently occurs in young children awakening from general anesthesia (GA). To date, research is limited by scales that are unable to discriminate the condition from other forms of agitation.

AIM

The primary aim of this study was to determine the core behaviors of ED that discriminate the condition from pain and tantrum in young children and to cluster these behaviors according to the DSM-IV/V core diagnostic criteria and associated behaviors of delirium.

METHOD

Children aged 18 months to 6 years (n=198) were observed upon awakening from GA following surgical or nonsurgical procedures to determine which behaviors categorize ED. Behaviors were recorded via a structured behavioral observation. Clinical opinion was sought to determine whether the child presented ED, pain, or tantrum.

RESULTS

A chi-square analysis revealed children with ED were significantly more likely to display activity, nonpurposefulness, eyes averted, stared or closed, no language, and nonresponsivity. These behaviors were not significantly associated with pain or tantrum. A logistic regression showed eyes averted or stared and nonpurposefulness were significant predictors of ED, while no language and activity were not significant predictors of ED.

CONCLUSIONS

Children with ED are significantly more likely to display nonpurposefulness, eyes averted, stared or closed, and nonresponsivity. These behaviors were not significantly associated with pain or tantrum and are believed to reflect the DSM-IV/V diagnostic criteria for delirium. Associated behaviors of ED identified by this research are irrelevant language, activity, and vocalization.

Alpha-2-agonists in day case anaesthesia

PURPOSE OF REVIEW

Alpha-2-agonists have long been known to have anaesthetic-sparing, sedative and analgesic properties which are desirable in day case anaesthesia. Their routine use was hampered by a high incidence of undesirable effects, however. In recent years, there have been many attempts to define a role for these unique agents in which their benefits would outweigh their apparent disadvantages.

RECENT FINDINGS

Many recent studies have confirmed the usefulness of alpha-2-agonists in providing sedation and analgesia, although the results have been far from consistent. Some, but by no means all studies have shown advantages over alternative agents, but concerns also remain over acute and possible long-term adverse effects.

SUMMARY

Alpha-2-agonists still have no clearly defined routine role in day surgery. Their most promising application is in limiting recovery agitation in children, but even here, there remain concerns about their routine use.

Effects of Clonidine on Recovery after Sevoflurane Anaesthesia in Children Undergoing Cataract Surgery

This trial assessed the effects of two doses of clonidine compared with placebo on the quality and speed of recovery in children premedicated with oral midazolam and anaesthetised with sevoflurane for cataract surgery.

One hundred and twenty American Society of Anesthesiologists physical status I to II children (aged one to six years), premedicated with oral midazolam 0.5 mg/kg and undergoing elective unilateral cataract surgery with sevoflurane anaesthesia were studied. Children were randomised to intravenous clonidine 1 μg/kg (group C1, n=39), 2 μg/kg (group C2, n=41) or normal saline (group NS, n=40). Clinically successful sub-Tenon local anaesthesia block was required for a patient to be included in the analysis.

The primary outcome was the incidence of postoperative agitation. Postoperative agitation was defined as a Pain Discomfort Score of ≥3 using items 3 to 5 only, which was assessed 15 minutely until discharge. Agitation was observed in 11/40 (27.5%) children in the NS group compared to 2/39 (5.1%) in group C1 and none in group C2 (P <0.001). Rescue medication to treat severe agitation was required in 5/40 (12.5%) in the NS group, 1/39 (2.6%) in group C1 and none in group C2 (P=0.025). Time to meet discharge criteria was significantly shorter in group C1 compared to the other two groups (48.4±14.0 minutes compared to C2 79.5±12.8 minutes and NS 73.1±20.4 minutes, P <0.001). There were no significant effects on blood pressure and heart rate.

Intravenous clonidine 1 μg/kg is effective for reducing agitation after sevoflurane anaesthesia and midazolam premedication in children undergoing cataract surgery. Intravenous clonidine 2 μg/kg was also effective and for a longer period, but was associated with a longer time to discharge.

Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies

BACKGROUND

Emergence agitation (EA) in children is increased after sevoflurane anaesthesia. The efficacy of prophylactic treatment is controversial. The aim of this study was to provide a meta-analysis of the studies of the pharmacological prevention of EA in children.

METHODS

A comprehensive literature search was conducted to identify clinical trials that focused on the prevention of EA in children anaesthetized with sevoflurane, desflurane, or both. The data from each trial were combined using the Mantel-Haenszel model to calculate the pooled odds ratio (OR) and 95% confidence interval. I(2) statistics were used to assess statistics heterogeneity and the funnel plot and the Begg-Mazumdar test to assess bias.

RESULTS

Thirty-seven articles were found which included a total of 1695 patients in the intervention groups and 1477 in the control ones. Midazolam and 5HT(3) inhibitors were not found to have a protective effect against EA [OR=0.88 (0.44, 1.76); OR=0.39 (0.12, 1.31), respectively], whereas propofol [OR=0.21 (0.16, 0.28)], ketamine [OR=0.28 (0.13, 0.60)], alpha(2)-adrenoceptors [OR=0.23 (0.17, 0.33)], fentanyl [OR=0.31 (0.18, 0.56)], and peroperative analgesia [OR=0.15 (0.07, 0.34)] were all found to have a preventive effect. Subgroup analysis according to the peroperative analgesia given does not affect the results.

CONCLUSIONS

This meta-analysis found that propofol, ketamine, fentanyl, and preoperative analgesia had a prophylactic effect in preventing EA. The analgesic properties of these drugs do not seem to have a role in this effect.

Intravenous clonidine infusion in infants after cardiovascular surgery

BACKGROUND

The aim of this study was to investigate the hemodynamic profile and heart rhythm in infants who were given intravenous clonidine infusion after prolonged analgesia/sedation following cardiac surgery.

METHODS

This is a single center retrospective review. A total of 542 cardiovascular surgical procedures in infants aged 0-24 months with congenital heart disease were performed between 01/2003 and 12/2005 at the Deutsches Herzzentrum in Berlin. The majority received no long-term analgesia/sedation, but 50 (9%) of these infants received clonidine (dosed at 0.18-3.6 microg.kg(-1).h(-1)) for sedation and to reduce withdrawal symptoms such as CNS hyperactivation, hypertension, tachycardia, and fever. The hospital records of these infants were studied.

RESULTS

Fifty infants (median age 5.0 months, median body weight 5.3 kg, 32 males/18 females) received prolonged analgesia/sedation to ensure hemodynamic stability. Clonidine infusion started on day 5 (median) after surgery. During clonidine treatment we found an age-related normalized profile of hemodynamic parameters with a reduction of heart rate and mean arterial pressure from the upper norm to the mean within 24 h (P < 0.001). In no case did clonidine cause low blood pressure resulting in additional therapy to reach the target blood pressure. There were no adverse effects on cardiac rhythm, especially no onset of atrioventricular block. Midazolam, fentanyl, and other opioids could be ended on day 4 of clonidine treatment.

CONCLUSIONS

Although off-label, it is feasible to use clonidine infusions in infants in the PICU setting after cardiac surgery without hemodynamic problems arising.

Intranasal clonidine as a premedicant: three cases with unique indications

Clonidine is experiencing increasing use in the pediatric population as a sedative and analgesic because of its central alpha2-adrenergic agonism. We report three cases of preoperative use of intranasal clonidine in pediatric patients, all for different indications. One patient was treated for preoperative agitation and hallucinations associated with oral midazolam. One patient was given clonidine as a premedicant. The third patient was treated for preoperative agitation and hypertension. All three patients had subjective resolution of indicated symptoms and none experienced adverse outcomes.

Inhalation agents in pediatric anaesthesia – an update

PURPOSE OF REVIEW

To present the most recent publications on inhaled agents in children and their implications for clinical care.

RECENT FINDINGS

The roles of clonidine, dexmedetomidine, ketamine and nalbuphine in the treatment of emergence delirium after sevoflurane and desflurane are discussed. Bispectral index monitoring has generated several curious findings in children. Halothane consistently produced higher Bispectral index readings than equi-minimum-alveolar-concentration multiples of ether anesthetics. Bispectral index readings increased as the sevoflurane concentration increased beyond 3%. Inhalation agents may cause two serious complications when administered to children with Duchenne's muscular dystrophy: hyperkalemia in younger children and myocardial depression in adolescents. Recovery after desflurane anesthesia is more rapid than with the other ether anesthetics in infants and children. Single-breath inductions are of interest in children >6 years for rapid anesthesia induction.

SUMMARY

Sevoflurane and desflurane continue to challenge our abilities to anesthetize children safely and efficiently. Although transient emergence delirium after insoluble agents is a problem, several medications may be used to attenuate it. Inhaled agents must be used with caution in children with Duchenne's muscular dystrophy as hyperkalemia may occur in young males and myocardial depression in adolescents. Rapid recovery after desflurane and single-breath inductions with sevoflurane continue to fascinate clinicians.

Oral clonidine vs midazolam in the prevention of sevoflurane-induced agitation in children. A prospective, randomized, controlled trial †

BACKGROUND

This randomized, double-blind study tested the hypothesis that, in comparison with midazolam, premedication with oral clonidine reduces the incidence of emergence agitation in preschool children anaesthetized with sevoflurane.

METHODS

Sixty-eight ASA I-II children undergoing circumcision were randomized into three groups to receive different oral premedication given 30 min before anaesthesia: midazolam 0.5 mg kg-1, clonidine 2 microg kg-1, and clonidine 4 microg kg-1. Sevoflurane anaesthesia was administered via a facemask (O2/N2O: 40/60). Analgesia was with penile block (bupivacaine 0.5% 0.3 ml kg-1) and rectal paracetamol (30 mg kg-1). During the first postoperative hour, children were evaluated using a modified 'objective pain scale'.

RESULTS

Only the 4 microg kg-1 dose of clonidine was associated with a significant reduction in emergence agitation. Fewer children in the clonidine 4 microg kg-1 group displayed agitation (25%) than in the midazolam group (60%) (P=0.025). Incidence of hypotension and bradycardia, time to first micturition and first drink did not differ among groups.

CONCLUSIONS

In comparison with midazolam, clonidine 4 microg kg-1 reduced sevoflurane-induced emergence agitation without increasing postoperative side-effects.

Emergence Delirium in Children: Many Questions, Few Answers

The introduction of a new generation of inhaled anesthetics into pediatric clinical practice has been associated with a greater incidence of ED, a short-lived, but troublesome clinical phenomenon of uncertain etiology. A variety of anesthesia-, surgery-, patient-, and adjunct medication-related factors have been suggested to play a potential role in the development of such an event. Restless behavior upon emergence causes not only discomfort to the child, but also makes the caregivers and parents feel unhappy with the quality of recovery from anesthesia. Although the severity of agitation varies, it often requires additional nursing care, as well as treatment with analgesics or sedatives, which may delay discharge from hospital. To reduce the incidence of this adverse event, it is advisable to identify children at risk and take preventive measures, such as reducing preoperative anxiety, removing postoperative pain, and providing a quiet, stress-free environment for postanesthesia recovery. More clinical trials are needed to elucidate the cause as well as provide effective treatment.

Paediatric day-case anaesthesia and pain control

PURPOSE OF REVIEW

More surgery on children is being carried out on a day-case basis and we review the anaesthetic management. Selection of appropriate patients and procedures is vital and careful preparation of children and families minimizes fear and anxiety and streamlines the organizational aspects of care. Simple, noninvasive general-anaesthetic techniques with modern agents are recommended. Good analgesia is important and is based upon local or regional blockade, nonsteroidal antiinflammatory drugs and paracetamol, with opioids being reserved for rescue analgesia. Omission of opioids helps to minimize postoperative emesis. Discharge home is facilitated by clear instructions about activities, dressings, wound care and continuing pain control.

RECENT FINDINGS

Oral clonidine premedication, new, safer local anaesthetic agents, ultrasound guidance for blocks and prolongation of single-injection caudal blocks with clonidine or ketamine are recent developments. Guidelines for safe sedation and analgesia for procedures are available. Behavioural and cognitive changes can be seen in children after anaesthesia and surgery and parents should be informed of this possibility.

SUMMARY

Children benefit particularly from day care and recent advances in anaesthesia and pain management have allowed a huge expansion of this modality of care with a consequent reduction in the need for children to be in hospital.

Clonidine and modification of perioperative outcome

PURPOSE OF REVIEW

Perioperative cardiac risk reduction using perioperative beta-blockade is being widely adopted. Recent research has identified a second-line agent, perioperative clonidine, that can be used to reduce the risk of perioperative cardiac mortality. Perioperative clonidine has some advantages over perioperative beta-blockers because it has less risk of bronchospasm in asthmatics and it comes in a transcutaneous form that can be used in patients who are not taking oral medications ('NPO').

RECENT FINDINGS

Clonidine has been used for many purposes, including reduction of blood pressure in hypertension, reduction in alcohol and drug withdrawal phenomena, reduction in nicotine withdrawal symptoms during smoking cessation, analgesia, reduction in stress response, and now as an anti-ischemic agent to reduce the risk of perioperative myocardial ischemia and perioperative mortality.

SUMMARY

Administration of perioperative clonidine can reduce the risk of perioperative myocardial ischemia and mortality in patients undergoing non-cardiac surgery. Perioperative clonidine comes in a patch form that can be used in patients who are not taking medications by mouth, and can be used when beta-blockers are contraindicated (for asthmatics or patients with high-grade atrioventricular block).