The Effect of Intraoperative Magnesium Sulphate Infusion on Emergence Agitation after Ambulatory Ophthalmic Surgery in Children

Possible role of high calcium concentrations in rat neocortical neurons in inducing hyper excitatory behavior during emergence from sevoflurane: a proposed pathophysiology

Sevoflurane has been shown to increase the incidence of emergence delirium in children; however, the mechanism remains unclear. Sevoflurane increases cytoplasmic calcium concentration which in turn may play a role in emergence delirium. This study aimed to investigate the level of intracellular calcium in rats experiencing hyperexcitatory behavior after exposure to sevoflurane, as well as the role of magnesium in preventing this phenomenon. After ethical approval, 2-5-week-old Sprague-Dawley rats (n = 34) were insufflated with sevoflurane in a modified anesthesia chamber. One group received magnesium sulphate intraperitoneally. After termination of sevoflurane exposure, the occurrence of hyperexcitation was observed. Brain tissue samples from the rats were studied for intracellular calcium levels under a two-channel laser scanning confocal microscope and were quantitatively calculated using ratiometric calculation. The presence of inflammation or oxidative stress reaction was assessed using nuclear factor κB and malondialdehyde. The incidence of hyperexcitatory behavior post sevoflurane exposure was 9 in 16 rats in the observation group and none in the magnesium group. Tests for inflammation and oxidative stress were within normal limits in both groups. The rats showing hyperexcitation had a higher level of cytosol calcium concentration compared to the other groups. To conclude, the calcium concentration of neocortical neurons in Sprague-Dawley rats with hyperexcitatory behavior is increased after exposure to sevoflurane. Administration of magnesium sulphate can prevent the occurrence of hyperexcitation in experimental animals.

Effect of intra-operative Magnesium sulphate on the occurrence of post-operative delirium and insomnia in patients undergoing lumbar fixation: a randomized controlled trial

BACKGROUND

Over the last two decades, a large body of literature has focused on studying the prevalence and outcome of the postoperative delirium and sleep disturbance. The aim of this work was to evaluate the effect of intraoperative administration of Magnesium sulphate on the occurrence of post-operative delirium and insomnia in patients undergoing lumbar fixation.

METHODS

This prospective randomized controlled trial was carried out on 80 patients indicated for lumbar fixation; 40 of them received conventional general anesthesia with extra administration of intraoperative magnesium sulphate (Mg sulphate group), and the other 40 received conventional general anesthesia only (control group). Both groups were submitted to pre-operative assessment of depression using Beck Depression inventory (BDI) scale, pre-operative assessment of fatigue using a fatigue questionnaire, pre- and post-operative assessment of insomnia using Insomnia severity index (ISI), post-operative assessment of delirium using Memorial delirium assessment scale (MDAS), post-operative assessment of pain using Visual Analogue Scale (VAS), and pre- and post-operative Quantitative electroencephalography (QEEG).

RESULTS

Mg sulphate administration, age, pre-operative BDI, pre-operative ISI, and post-operative VAS were independent predictors of post-operative ISI (P-value < 0.001, 0.047, 0.021, < 0.001, and < 0.001 respectively). Age and post-operative VAS were independent predictors of post-operative MDAS (P-value = 0.008, 0.013 respectively). Mg sulphate administration and pre-operative ISI were independent predictors of post-operative VAS (P-value = 0.010, 0.006 respectively).

CONCLUSION

There was a significant relationship between intraoperative Mg sulphate administration and both post-operative insomnia and pain in unadjusted and adjusted analysis.

Effectiveness of Intravenous Ibuprofen on Emergence Agitation in Children Undergoing Tonsillectomy with Propofol and Remifentanil Anesthesia: A Randomized Controlled Trial

Background

Emergence agitation (EA) has a negative effect on the recovery from general anesthesia in children. This study aimed to evaluate the effectiveness of intravenous ibuprofen in reducing the incidence of EA in children.

Methods

This randomized, double-blind, placebo-controlled, single-center study analyzed data from patients aged 3–9 years undergoing tonsillectomy under general anesthesia with propofol and remifentanil. These patients were randomly assigned to receive either the ibuprofen or the placebo intraoperatively. The primary endpoint was a between-group difference in the incidence of EA at 15 min following extubation. EA was defined as Pediatric Anesthesia Emergence Delirium score ≥10. The secondary endpoint included the associated factors of EA.

Results

Eighty-nine patients were included in the study. Ibuprofen decreased the incidence of EA at 15 min following extubation (8.9% in the treatment group vs 34.1% in the control group; odds ratio [OR], 0.261; 95% confidence interval [CI], 0.094–0.724; P=0.004). Compared with the control group, there was a significant reduction in the number of rescue fentanyl doses (P=0.045), and fewer patients experienced moderate to severe pain at 15 min following extubation in the treatment group (P=0.048). Upon logistic regression analysis, high modified Pediatric Anesthesia Behavior and pain scores following surgery were considered the risk factors related to EA (OR, 8.07; 95% CI, 1.12–58.07, P=0.038 and OR, 2.78; 95% CI, 1.60–4.82, P<0.001, respectively). Ibuprofen administration was the protective factor related to EA (OR, 0.05; 95% CI, 0.01–0.67, P=0.023).

Conclusion

Intraoperative ibuprofen infusion can significantly reduce the incidence of EA following general anesthesia with propofol and remifentanil in children.

Trial Registration

The study was registered with the Chinese Clinical Trial Registry on 7 April 2021 (number: ChiCTR2100045128; https://www.chictr.org.cn/edit.aspx?pid=124595&htm=4).

The effects of intraoperative magnesium sulfate administration on emergence agitation and delirium in pediatric patients: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The role of intraoperative magnesium for the prevention of emergence agitation or delirium is unclear as there have been conflicting results reported by several randomized controlled trials.

AIMS

The aim of this study was to investigate the effect of magnesium sulfate on emergence agitation or emergence delirium in pediatric patients.

METHODS

Electronic databases, including PubMed, EMBASE, CENTRAL, CINAHL, Scopus, and Web of Science, were searched to identify studies which evaluated the effects of magnesium on postoperative emergence agitation or emergence delirium. The primary outcome was the incidence of emergence agitation or emergence delirium during the post-anesthesia stay. The secondary outcome was the agitation or delirium score upon admission to the post-anesthesia care unit. We estimated the odds ratio and standardized mean difference using a random-effect model.

RESULTS

A total of 712 pediatric patients from 10 randomized controlled trials were included in the final analysis. The incidence of emergence agitation or emergence delirium was 29.7% in the magnesium group and 50.5% in the control group. The pooled effect size revealed that the administration of magnesium sulfate significantly reduced the incidence of postoperative emergence agitation or emergence delirium in pediatric patients undergoing surgery with general anesthesia (Odds ratio, 0.31; 95% confidence interval, 0.15 to 0.64; p = .002). Additionally, children in the magnesium group reported significantly lower agitation or delirium scores than those in the control group (standardized mean difference, -0.70; 95% confidence interval, -1.15 to -0.24; p = .003).

CONCLUSION

The administration of magnesium sulfate reduced the incidence and severity of emergence agitation or emergence delirium in pediatric patients after the use of general anesthesia during surgery.

The effect of magnesium sulfate on emergence agitation in children undergoing general anesthesia: A systematic review and meta-analysis

STUDY OBJECTIVE

Emergence agitation (EA) is a common complication in pediatric patients after general anesthesia. The effectiveness of magnesium sulfate in decreasing the incidence of EA in children remains controversial. Therefore, a systematic review and meta-analysis was performed to assess the efficacy of magnesium sulfate in preventing EA in pediatric patients following general anesthesia.

DESIGN

Systematic review and meta-analysis.

SETTING

PubMed, Embase, Web of Science, and Cochrane Library were searched to identify eligible randomized controlled trials from their respective database inception dates to June 30, 2021.

PATIENTS

Pediatric patients (< 18 years old) undergoing general anesthesia.

INTERVENTIONS

Intravenous administration of magnesium sulfate.

MEASUREMENTS

The primary outcome of the meta-analysis was EA incidence. The risk of bias of the included studies was evaluated using the revised Cochrane risk of bias tool for randomized trials (RoB 2.0). Grading of Recommendations, Assessment, Development, and Evaluation was applied to assess the level of certainty.

MAIN RESULTS

Eight studies with 635 participants were identified. The forest plot revealed no significant difference in the incidence of EA between patients treated with magnesium sulfate and the control group (risk ratio = 0.69, 95% confidence interval [0.44, 1.07]; P = 0.10, I² = 74%, moderate level of certainty). Additionally, magnesium sulfate did not reduce postoperative pediatric anesthesia emergence delirium scores but prolonged the emergence time. No significant differences were observed in postoperative complications (nausea, vomiting, laryngospasm, breath-holding, coughing, oxygen desaturation, and cardiac arrhythmias).

CONCLUSIONS

Administration of magnesium sulfate during general anesthesia did not affect the occurrence of EA in pediatric patients. However, magnesium sulfate can prolong the emergence time without adverse effects. PROSPERO registration number: CRD42021252924.