Effects of propofol and nalbuphine on emergence agitation after sevoflurane anesthesia in children for strabismus surgery

The effect of nalbuphine on prevention of emergence delirium in children: a systematic review with meta-analysis

BACKGROUND

Emergence delirium remains a major postoperative concern for children undergoing surgery. Nalbuphine is a synthetic mixed agonist-antagonist opioid, which is believed to reduce the incidence of emergence delirium in children. The primary objective was to examine the effect of nalbuphine on emergence delirium in children undergoing surgery.

METHODS

Databases of MEDLINE, EMBASE, and CENTRAL were searched from their starting dates until April 2023. Randomized Clinical Trials (RCT) and observational studies comparing nalbuphine and control in children undergoing surgery were included.

RESULTS

Eight studies (n = 1466 patients) were eligible for inclusion of data analysis. Compared to the control, our pooled data showed that the nalbuphine group was associated with lower incidence of emergence delirium (RR = 0.38, 95% CI [0.30, 0.47], p < 0.001) and reduced postoperative pain scores (MD = -0.98, 95% CI [-1.92, -0.04], p = 0.04).

CONCLUSIONS

This review showed the administration of nalbuphine is associated with significant decrease in the incidence of emergence delirium and postoperative pain scores among children undergoing surgery. However, due to limited sample size, high degree of heterogeneity and low level of evidence, future adequately powered trials are warranted to explore the efficacy of nalbuphine on emergence delirium among the pediatric population.

Efficacy of propofol for the prevention of emergence agitation after sevoflurane anaesthesia in children: A meta-analysis

Background

Emergence agitation (EA) is a common postoperative behavioral disorder, predominantly in pediatric patients, after sevoflurane general anesthesia. This study was aimed at assessing propofol's efficacy and clinical conditions established for preventing EA in children under sevoflurane anesthesia.

Methods

Randomized controlled trials (RCTs) that comparatively investigated propofol and control treatment in terms of efficacy and safety on administration at the end of surgery and examinations to prevent EA in children under sevoflurane anesthesia were searched. The sources accessed included PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Furthermore, manual searches were performed to identify studies; the last review was conducted on March 21, 2022. When the risk of bias assessment of trials was performed with the Cochrane Risk of Bias Tool, we calculated risk ratios (RRs) with 95% confidence intervals (CIs) for EA incidence and mean differences (MDs) with 95% CI for continuous data.

Results

We included 12 RCTs with 1103 children. EA incidence (RR: 0.51, 95% CI: 0.39 to 0.67) and Pediatric Anesthesia Emergence Delirium scores (MD: −3.14, 95% CI: −4.37 to −1.92) were lower in the propofol group. Subgroup analyses showed lower EA incidences with 3 mg/kg propofol (RR: 0.22, 95% CI: 0.13 to 0.38) without extension of the PACU time (MD: 4.97, 95% CI: −0.84 to 10.78) in the laryngeal mask airway (LMA; RR: 0.52, 95% CI: 0.36 to 0.77) and spontaneous breathing (RR: 0.36, 95% CI: 0.21 to 0.62) groups.

Discussion

We confirmed that a prophylactic dose of propofol prevented EA and decreased its severity in children under sevoflurane anesthesia. Furthermore, several conditions such as 3 mg/kg propofol, LMA, and spontaneous breathing, potentially contributed to EA prevention.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=274692, identifier: PROSPERO (No. CRD42021274692).

Does a prophylactic dose of propofol reduce emergence agitation in children receiving anesthesia? A systematic review and meta-analysis

INTRODUCTION

Emergence agitation (EA) is common after sevoflurane anesthesia in children, and can lead to distressing inconsolability, agitation, crying, and injury. Use of a single dose of the short-acting sedative-hypnotic agent propofol at the end of a procedure has shown promise for preventing EA, but evidence evaluating the efficacy and safety of this approach has not been formally summarized.

OBJECTIVE

The objective of this review was to assess the effects of a prophylactic dose of propofol vs placebo on the incidence and severity of EA in children age 0-13 years receiving general inhalational anesthesia.

SEARCH METHODS

We searched PubMed (1946-2013) via Medline, CENTRAL (1898-2013), and Web of Science (1900-2013) without limits or language restrictions; we also searched ClinicalTrials.gov and reference lists. We reviewed abstracts from the 2012 and 2013 Society for Pediatric Anesthesia meetings and pediatric anesthesia-related abstracts from the 2012 and 2013 International Anesthesia Research Society meetings.

SELECTION CRITERIA

We assessed randomized, double-blind trials evaluating the efficacy of a prophylactic dose of propofol (1 mg·kg(-1) ) vs placebo given at the end of inhalational anesthesia to prevent EA in pediatric patients. Studies were required to follow patients through recovery and report at least one prespecified outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data from included studies. We contacted study authors regarding any missing data. We used the random effects models to calculate pooled relative risks (RR) and weighted mean differences (WMD). We collected Pediatric Anesthesia Emergence Delirium (PAED) scale scores from included studies. PAED scale scores can range from 0 to 20.

MAIN RESULTS

Of 276 studies screened, nine trials involving 997 children met all inclusion criteria. All were considered low risk of bias. For one non-English trial, we obtained a full-text translation and for one non-English trial, we used the English-language abstract, tables, and figures. Based on available evidence, prophylactic propofol was associated with both decreased incidence of EA (29% vs 58%, RR 0.50, 95% confidence intervals [CI] 0.41, 0.61, I(2) = 37%, seven studies), and reduced severity of EA as assessed by mean PAED scale score (WMD -2.08 points, 95% CI -3.20, -0.96, I(2) = 0%, three studies), when compared to placebo. In addition, though prophylactic propofol did lengthen the time to awakening (WMD 4.07 min, 95% CI 2.22, 5.91, I(2) = 82%, six studies), it did not increase recovery time (WMD 2.91 min, 95% CI -0.59, 6.41, I(2) = 82%, six studies) when compared to placebo. No significant adverse events were reported in either arm.

CONCLUSION

Based on high quality evidence, prophylactic propofol appears to be effective for reducing the incidence and severity of EA in children emerging from general anesthesia.

The effect of propofol on emergence agitation in children receiving sevoflurane for adenotonsillectomy

BACKGROUND

The administration of a single dose of propofol is reported to be effective in decreasing the incidence and severity of emergence agitation (EA) in children following sevoflurane anesthesia. The aim of this study was to investigate the clinical usefulness of a single dose of propofol 1 mg/kg at the end of adenotonsillectomy for reducing the incidence of EA after sevoflurane anesthesia.

METHODS

Ninety children, aged 3-8 years, undergoing adenotonsillectomy were randomized into two groups: the propofol group (n = 45) and the saline group (n = 45), of which 88 children completed the study. Anesthesia was maintained with sevoflurane 2-2.5 vol% and nitrous oxide/oxygen (50%/50%). At the completion of adenotonsillectomy, the propofol group patients were given 1 mg/kg of propofol and the saline group patients were given saline 0.1 ml/kg in the same volume. The incidence of EA was assessed with Aono's four point scale and the severity of EA was assessed with pediatric anesthesia emergence delirium (PAED) scale at 5 min (T5), 15 min (T15) and 30 min (T30) after emergence.

RESULTS

Of the 88 patients, the incidence of EA at T5, T15 and T30 was 61.4%, 27.3%, and 4.5% in the propofol group while in the saline group was 68.2%, 29.5%, and 9.1%, respectively. The incidence and severity of EA were not found to be significantly different between the two groups, but the scales in each group decreased significantly over time.

CONCLUSIONS

The administration of propofol 1 mg/kg at the end of surgery did not have any significant effect in reducing the incidence and severity of EA in children undergoing adenotonsillectomy under sevoflurane anesthesia.

Effect of ketamine versus thiopental sodium anesthetic induction and a small dose of fentanyl on emergence agitation after sevoflurane anesthesia in children undergoing brief ophthalmic surgery

Background

Emergence agitation (EA) in children after sevoflurane anesthesia is common. The purpose of this study was to compare the incidences of EA between ketamine and thiopental sodium induction in children underwent sevoflurane anesthesia. We also evaluated if a small dose of fentanyl could reduce the incidence of EA.

Methods

The patients who were scheduled for strabismus or entropion surgery were divided into 4 groups. The patients in Groups 1 and 2 were induced anesthesia with ketamine 1.5 mg/kg; those in Groups 3 and 4 were induced with thiopental sodium 5 mg/kg. The patients in Groups 1 and 3 received an injection of fentanyl 1.5 µg/kg, whereas the patients in Groups 2 and 4 received IV saline of the same volume. Anesthesia was maintained with sevoflurane. The recovery characteristics and EA in recovery room were assessed.

Results

The incidence of EA was significantly higher in Groups 2 and 4 and there was no difference between Groups 2 and 4. Group 2 had almost an eleven-fold higher risk of developing EA than did Group 1, and the incidence of EA in Group 4 was sixty-nine-fold higher than that of Group 1. The risk factor for EA was only the kind of medication. Preoperative anxiety had no significant correlation with EA.

Conclusions

The incidence of EA after sevoflurane anesthesia is similar between ketamine and thiopental sodium anesthetic induction in children undergoing pediatric ophthalmic surgery. Also, the addition of a small dose of fentanyl after anesthetic induction decreases the incidence of EA.