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Farag RS, Spicer AC, Iyer G, Stevens JP, King A, Bain PA, McAlvin JB. Incidence of emergence agitation in children undergoing sevoflurane anesthesia compared to isoflurane anesthesia: An updated systematic review and meta-analysis. Paediatr Anaesth 2024; 34:304-317. [PMID: 38093624 DOI: 10.1111/pan.14819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 11/23/2023] [Accepted: 11/25/2023] [Indexed: 03/04/2024]
Abstract
BACKGROUND Emergence agitation is a complex syndrome of altered consciousness after emergence from anesthesia. It can result in injury to patients and staff and is associated with other postoperative complications. Sevoflurane has been associated with emergence agitation, potentially due to low tissue solubility and therefore speed of emergence. Prior meta-analyses comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics did not demonstrate a statistically significant difference. Given the publication of additional relevant studies not included in prior meta-analyses as well as improved diagnosis of emergence agitation, we aim to perform an updated, comprehensive meta-analysis comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics in children. METHODS We conducted an updated systematic review and meta-analysis of clinical trials comparing sevoflurane to isoflurane in children <18 years of age, reporting emergence agitation as an outcome, published before July 2023 using databases and registers. Our primary outcome was the incidence of emergence agitation. Secondary outcomes were time to extubation, awakening time, and length of stay in the postanesthetic care unit. We assessed the risk of bias using the Cochrane Risk of Bias tool version 2. We pooled the effect size for the outcomes using the fixed effects model if we had low heterogeneity, otherwise, we used a random-effects model. RESULTS Eight randomized controlled trials (523 children) were included in the final analysis. The incidence of emergence agitation after isoflurane was significantly lower compared to sevoflurane (risk ratio: 0.62 (95% CI: [0.46-0.83]; I2 = 40.01%, p < .001)). Time to extubation, awakening times, and postanesthetic care unit duration were not significantly different. The protective effect of isoflurane compared to sevoflurane remained significant in subgroups of patients who received premedication or intraoperative systemic analgesics (risk ratios: (0.48 [0.28-0.82]; I2 = 60.78%, p = .01), (0.52 [0.37-0.75]; I2 = 0.00%, p < .001), respectively). CONCLUSION The risk of emergence agitation in children after maintenance anesthesia with sevoflurane is significantly greater than with isoflurane; we did not find evidence of prolonged emergence or postanesthetic length of stay. When possible, isoflurane should be considered for maintenance anesthesia over sevoflurane in patients at high risk of emergence agitation.
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Affiliation(s)
- Rasha S Farag
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Clinical Research, Damietta Directorate for Health Affairs, Egyptian Ministry of Health and Population, Damietta, Egypt
| | - Aaron C Spicer
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Geetha Iyer
- Postdoctoral Fellow, Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Jennifer P Stevens
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew King
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul A Bain
- Countway Library of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - J Brian McAlvin
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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2
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López Segura M, Busto-Aguirreurreta N. Postoperative agitation or delirium in paediatric patients. What we know and how to avoid it. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:467-472. [PMID: 37678453 DOI: 10.1016/j.redare.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/10/2022] [Indexed: 09/09/2023]
Abstract
Emergence delirium or postoperative agitation is the name given to the state of altered consciousness that occurs after surgery and especially affects pediatric patients. Its incidence is not negligible, reaching 80% of cases in certain studies. It is frequently confused with other clinical entities, for which reason a scale has been validated to facilitate its diagnosis. Risk factors include age under 5 years, the presence of pain after surgery and especially intense preoperative anxiety. Pediatric emergence delirium presents as an adverse event after surgery and influences patient safety by significantly increasing patient comorbidity. It is essential to recognize the entity, as well as its risk factors, in order to apply effective preventive measures to reduce its incidence and intensity when it occurs.
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Affiliation(s)
- M López Segura
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - N Busto-Aguirreurreta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Navarra, Pamplona, Spain
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3
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Devi EA, Nagaprasad YVSR, Shiva PV, Nirmalan P. Incidence and risk factors for emergence delirium in children undergoing surgery under general anaesthesia - A prospective, observational study. Indian J Anaesth 2023; 67:725-729. [PMID: 37693021 PMCID: PMC10488589 DOI: 10.4103/ija.ija_784_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 06/25/2023] [Accepted: 07/09/2023] [Indexed: 09/12/2023] Open
Abstract
Background and Aims Emergence delirium (ED) is a common complication after general anaesthesia (GA) in children, with an incidence of 2%-80%. This study evaluated the incidence and risk factors for ED in children undergoing surgery under GA. Methods This observational, prospective study was conducted in 336 children of either gender aged 2-13 years scheduled for surgeries under GA. Preoperative anxiety and demographics were noted. Paediatric Anaesthesia Emergence Delirium (PAED) scale, Watcha scale, and Face, Legs, Activity, Cry, Consolability (FLACC) scale were monitored 30 min postsurgery. A PAED score ≥12 and a Watcha scale score ≥3 were taken as ED. The primary outcome was the incidence of ED. An adjusted multivariate linear regression model explored the association with ED. Results The incidence of ED was 3.87% (n = 13, 95% confidence interval [CI]: 1.80, 5.94). ED was significantly associated with male sex (β coefficient 0.06, 95% CI: 0.003, 0.11) and severe preoperative anxiety (β coefficient 0.07, 95% CI: 0.01, 0.12) in a multivariate linear regression model adjusted for other confounders. When pain scores were added to the regression model, ED was significantly associated only with pain at 0 and 10 min after surgery (P values 0.005 and 0.002, respectively). Both PAED (AUROC 0.99, 95% CI: 0.98, 1.00) and Watcha (AUROC 0.99, 95% CI: 0.98, 1.00) scores showed an excellent ability to detect ED. Conclusion The incidence of ED was 3.87% (95% CI: 1.80, 5.94) and was significantly associated with male sex, severe preoperative anxiety and pain.
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Affiliation(s)
- E Adithi Devi
- Department of Anaesthesiology and Critical Care, Niloufer Hospital, Osmania Medical College, Hyderabad, Telangana, India
| | - YVS Ravi Nagaprasad
- Department of Anaesthesiology and Critical Care, Niloufer Hospital, Osmania Medical College, Hyderabad, Telangana, India
| | - P V Shiva
- Department of Anaesthesiology and Critical Care, Niloufer Hospital, Osmania Medical College, Hyderabad, Telangana, India
| | - Praveen Nirmalan
- Department of Research, AMMA Healthcare Research Gurukul, Kochi, Kerala, India
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4
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Simonini A, Vittori A, Cascella M, Calevo MG, Marinangeli F. The impact of emergence delirium on hospital length of stay for children who underwent tonsillectomy/adenotonsillectomy: an observational retrospective study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:171-176. [PMID: 34843805 PMCID: PMC10068575 DOI: 10.1016/j.bjane.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 10/09/2021] [Accepted: 10/24/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Emergence Delirium (ED) is a combination of disturbance of perception and psychomotor agitation that is common in pediatric patients after general anesthesia, especially at preschool age. Since the effect of ED on the length of stay has been studied in adults but infrequently in children, the aim of this study was to investigate the relationship between ED and length of stay in this population. METHODS A single center, retrospective, observational study was carried out in children who underwent tonsillectomy or adenotonsillectomy. The Pediatric Anesthesia Emergence Delirium (PAED) scale was used to assess ED. In addition to the time to hospital discharge (time frame 24 hours), drugs used, comorbidities, early postoperative complications, and pain were investigated if potentially associated with the complication. RESULTS Four hundred sixteen children aged from 1.5 to 10 years (183 female, 233 male) were included. ED occurred in 25.5% of patients (n = 106). Patients were divided into the ED group and the No-ED group. The discharge time was similar in both groups. No significant differences were observed in the frequency of postoperative complications. The use of fentanyl or dexmedetomidine did not affect ED occurrence. The frequency of pain was greater in the ED group, both in the recovery room and in the ward (p = 0.01). CONCLUSIONS The occurrence of ED in children after tonsillectomy/adenotonsillectomy did not extend the length of stay.
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Affiliation(s)
- Alessandro Simonini
- Salesi Children's Hospital, Department of Pediatric Anaesthesia and Intensive Care, Ancona, Italy.
| | - Alessandro Vittori
- IRCCS, Ospedale Pediatrico Bambino Gesù, ARCO ROMA, Department of Anesthesia and Critical Care, Rome, Italy
| | - Marco Cascella
- Istituto Nazionale Tumori-IRCCS-Fondazione Pascale, Division of Anesthesia and Pain Medicine, Naples, Italy
| | - Maria Grazia Calevo
- IRCCS Istituto Giannina Gaslini, Department of Epidemiology and Biostatistic, Genova, Italy
| | - Franco Marinangeli
- University of L'Aquila, Department of Anesthesiology, Intensive Care and Pain Treatment, Aquila, Italy
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Modi D, Goyal S, Kothari N, Sharma A, Kumar R, Chhabra S, Goel A, Bhatia P. Comparison of incidence of emergence delirium in pediatric patients with three different techniques of general anesthesia using sevoflurane and propofol: a randomized controlled trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 72:841-842. [PMID: 35605692 PMCID: PMC9660000 DOI: 10.1016/j.bjane.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/26/2022] [Accepted: 05/10/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Deepak Modi
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India
| | - Shilpa Goyal
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India.
| | - Nikhil Kothari
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India
| | - Ankur Sharma
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Trauma & Emergency (Anaesthesiology), Rajasthan, India
| | - Rakesh Kumar
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India
| | - Swati Chhabra
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India
| | - Akhil Goel
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Community Medicine and Family Medicine, Rajasthan, India
| | - Pradeep Bhatia
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India
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Thaware P, Lakra P, Bharati. Assessment of intraoperative hemodynamics and recovery characteristics in pediatric patients receiving buprenorphine and propofol anesthesia for cleft palate surgery: A prospective observational study. Anesth Essays Res 2022; 16:255-262. [PMID: 36447914 PMCID: PMC9701334 DOI: 10.4103/aer.aer_95_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Children with cleft palate are usually operated on before 18 months of age. Cleft palate surgery demands stable hemodynamic parameters, a bloodless surgical field, and an awake and pain-free child after surgery. Aims: We aimed to study the anesthesia technique using buprenorphine and propofol for cleft palate surgery. Settings and Design: The design involves prospective observational study. The study was conducted at a tertiary care hospital. Materials and Methods: After the Institutional Ethics Committee approval, 42 patients aged 6 months to 12 years undergoing cleft palate surgery were enrolled. Anesthesia induction commenced with sevoflurane or propofol 3 mg.kg−1. After intubation, buprenorphine 3 μg.kg−1 was given, and propofol infusion was started at 2–8 mg.kg−1.h−1. Hemodynamic parameters, awakening time, and surgeon's satisfaction score were noted. After extubation, pain score, emergence agitation (EA) score, sedation score, recovery score, and adverse events were noted. Statistical Analysis: All statistical analyses were performed using the 20.0 version of the Statistical Package for the Social Science (SPSS) software program. Continuous data were summarized as mean and standard deviation, and were analyzed using a two-sided Student's unpaired t-test. Categorical data were represented using frequencies and proportions. Results: The single dose of buprenorphine with propofol infusion started immediately postintubation causes a significant decrease in heart rate after 1 h. This contributed to a favorable operative field, increasing the surgeon's satisfaction score. In the recovery room, patients were essentially pain-free till 2.5 h after surgery, with only one patient requiring rescue analgesia. Furthermore, 90% of patients showed a smooth and calm recovery with no EA. The Steward's recovery score remained high throughout without any complication. Conclusions: In cleft palate surgeries, a single-dose buprenorphine 3 μg.kg−1 and propofol maintenance infusion 2–8 mg.kg−1.h−1 were effective in maintaining hemodynamic parameters and a bloodless surgical field and managing postoperative pain with a good recovery profile.
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Abstract
Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were “delirium,” “delirious,” “delirium tremens” AND “India.” No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms “delirium,” “delirious,” “delirium tremens” in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles (
n
= 81), and these were followed by, case reports (
n
= 58), review articles (
n
= 10), letter to the editor (not as case reports but as a communication;
n
= 13), editorials (
n
= 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjana Kathiravan
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Devakshi Dua
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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8
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Dexmedetomidine reduces postoperative cognitive and behavioral dysfunction in adults submitted to general anesthesia for non-cardiac surgery: meta-analysis of randomized clinical trials. Braz J Anesthesiol 2021; 71:413-420. [PMID: 33685760 PMCID: PMC9373211 DOI: 10.1016/j.bjane.2021.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 08/26/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction and objectives Dexmedetomidine (DEX) has been associated with a decrease in postoperative cognitive and behavioral dysfunction in patients submitted to general anesthesia, whether inhalation or total intravenous anesthesia. Consequently, the DEX effects on postoperative agitation and delirium in patients submitted to general anesthesia for non-cardiac surgery have been investigated. Method A systematic review and meta-analysis of randomized and double-blind clinical trials (RCTs) was undertaken assessing adults submitted to elective procedures under general anesthesia receiving DEX or placebo. The search included articles published in English in the Pubmed and Web of Science databases using keywords such as dexmedetomidine, delirium, and agitation. Duplicate publications, studies involving cardiac surgery or using active control (other than saline solution) were included. A random effects model was adopted using the DerSimonian-Laird method and estimate of Odds Ratio (OR) for dichotomous variables, and weighted mean difference for continuous variables, with their respective 95% Confidence Intervals (95% CI). Results Of the 484 articles identified, 15 were selected comprising 2,183 patients (1,079 and 1,104 patients in the DEX and control group, respectively). The administration of DEX was considered a protective factor for postoperative cognitive and behavioral dysfunction (OR = 0.36; 95% CI 0.23–0.57 and p < 0.001), regardless of the anesthesia technique used. Conclusion Dexmedetomidine administration reduced by at least 43% the likelihood of postoperative cognitive and behavioral dysfunction in adult patients submitted to general anesthesia for non-cardiac surgery.
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Andriyanto L, Utariani A, Hanindito E, Santoso KHSH, Hamzah H, Puspita EA. Incidence of Emergence Agitation in Pediatric Patient after General Anesthesia. FOLIA MEDICA INDONESIANA 2021. [DOI: 10.20473/fmi.v55i1.24340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Post anesthesia agitation is common problem in pediatric post anesthesia care unit. The incidences range from 10 to 80%. EA has been described as a dissociated state of consciousness in which the child is inconsolable, irritable, and uncooperative typically thrashing, crying, moaning or incoherent. This study was done to determine the incidence of emergence agitation and associated risk factors in pediatric patients who underwent general anesthesia. This descriptive and analytic study was performed on 105 pediatric patient aged 1-12 years that underwent general anesthesia for various elective diagnostic and surgeries at Dr. Soetomo Hospital between January and February 2016. The presence of emergence agitation was recorded using Pediatric Anesthesia Emergence Delirium (PAED) scale. The factors that linked with Emergence Agitation were recorded in a questionnaire. The data were analyzed using SPSS software with logistic regression. p - values less than 0.05 were considered as significant. Forty two (40%) children had Emergence Agitation. Preoperative anxiety (p = 0.006) and Pain (p=0.035) were associated with higher rates of post anesthetic emergence agitation. This study identified preoperative anxiety and pain as risk factors, which are associated with emergence agitation in children. To minimize the incidence of post anesthetic emergence agitation, these risk factors should be considered in the routine care by anesthetist.
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Elghamry MR, Elkeblawy AM. Effect of single-dose dexmedetomidine on the incidence of emergence delirium after sevoflurane-based anesthesia in children undergoing strabismus surgery. EGYPTIAN JOURNAL OF ANAESTHESIA 2020. [DOI: 10.1080/11101849.2020.1863309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Mona Raafat Elghamry
- Department of Anesthesiology, Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amira Mahfouz Elkeblawy
- Department of Anesthesiology, Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
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Ramlan AAW, Pardede DKB, Marsaban AHMS, Hidayat J, Peddyandhari FS. Efficacy of 0.5 mg/kg of propofol at the end of anesthesia to reduce the incidence of emergence agitation in children undergoing general anesthesia with sevoflurane. J Anaesthesiol Clin Pharmacol 2020; 36:177-181. [PMID: 33013031 PMCID: PMC7480301 DOI: 10.4103/joacp.joacp_257_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/25/2019] [Accepted: 11/10/2019] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Emergence agitation (EA) is a common transient behavioral disturbance after inhalational anesthesia and may cause harm to the patient. This study evaluated the efficacy of 0.5 mg/kg of propofol administered at the end of anesthesia to reduce the incidence of EA in children undergoing general inhalational anesthesia. Material and Methods This double-blind randomized clinical trial was done in children aged 1-5 years undergoing general anesthesia with sevoflurane. One hundred and eight subjects were included using consecutive sampling method and randomized into two equal groups. Propofol in the dose of 0.5 mg/kg was administered at the end of anesthesia to children in the propofol group, while those in the control group did not receive any intervention at the end of anesthesia. Incidence of EA, transfer time, postoperative hypotension, desaturation, and nausea-vomiting were observed. Aono and Pediatric Anesthesia Emergence Delirium scale were used to assess EA. Results Incidence of EA was 25.9% in the propofol group compared to 51.9% in the control group (RR = 0.500; 95% CI 0.298-0.840; P = 0.006). Mean transfer time in propofol group was longer (9.5 ± 3.9 min) than control group (7.8 ± 3.6 min) (mean difference 1.71 min; 95% CI 0.28-3.14; P = 0.020). Hypotension was found in one patient (1.9%) in propofol group, while in control group there was none. Nausea-vomiting was found in five patients (9.3%) in propofol group and eight patients (14.8%) in control. There was no desaturation in both the groups. Conclusion Administration of 0.5 mg/kg of propofol at the end of anesthesia effectively reduces the incidence of EA in children undergoing general inhalational anesthesia with sevoflurane.
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Affiliation(s)
- Andi Ade Wijaya Ramlan
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Dimas K Bonardo Pardede
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Arif H M S Marsaban
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Jefferson Hidayat
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Fildza Sasri Peddyandhari
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Ibrahem Amin OA, Kamel AAF. Effects of adding ketamine to dexmedetomidine on smooth recovery from isoflurane anesthesia in adults undergoing endoscopic sinus surgery. EGYPTIAN JOURNAL OF ANAESTHESIA 2020. [DOI: 10.1080/11101849.2020.1761144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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13
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Eshetie D, Getinet H, Abdissa Z, Mollalign M. Incidence and associated factors of emergence agitation after general anesthesia and surgery among pediatric patients: A prospective follow-up study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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14
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Abdelaziz HMM, Bakr RH, Kasem AA. Effect of intranasal dexmedetomidine or intranasal midazolam on prevention of emergence agitation in pediatric strabismus surgery: A randomized controlled study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2015.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
| | - Radwa Hamdi Bakr
- Department of Anesthesia and Intensive Care, College of Medicine, Ain Shams University, Saudi Arabia
| | - Ayman A. Kasem
- Department of Anesthesia and Intensive Care, College of Medicine, Ain Shams University, Saudi Arabia
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15
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Suzuki T, Kurazumi T, Ueda T, Nagata H, Yamada T, Kosugi S, Hashiguchi S, Ito K, Morisaki H. Desflurane anesthesia worsens emergence agitation in adult patients undergoing thyroid surgery compared to sevoflurane anesthesia. JA Clin Rep 2018; 3:36. [PMID: 29457080 PMCID: PMC5804615 DOI: 10.1186/s40981-017-0106-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 06/11/2017] [Indexed: 11/14/2022] Open
Abstract
Background The effect of volatile anesthetics on emergence agitation in adults remains unclear. We compared the degree of emergence agitation between desflurane and sevoflurane anesthesia in adults undergoing thyroid surgery. Findings One hundred and sixteen patients with American Society of Anesthesiologists status 1 or 2 were randomized into two groups: the desflurane group (group D) and the sevoflurane group (group S). After induction of anesthesia with fentanyl (1–2 μg/kg) and propofol (1.5–2.5 mg/kg), tracheal intubation was facilitated with suxamethonium (0.5–1.0 mg/kg). In group D, anesthesia was maintained with desflurane in 66% nitrous oxide and 33% oxygen supplemented with fentanyl when necessary; in group S, sevoflurane was used instead of desflurane. After the end of the surgery, emergence agitation was evaluated with a modified pediatric anesthesia emergence delirium scale (ranging from 0 to 16, with higher scores indicating more severe emergence agitation) before extubation. Time to extubation from the end of the surgery, postoperative pain (evaluated by a numerical rating scale [NRS]), and postoperative nausea and vomiting (PONV) after surgery were examined. The degree of emergence agitation was more severe in group D than in group S (median [interquartile range]: 5 [4–7] vs 4 [2–6], p = 0.008). Time to extubation, NRS scores, and PONV rates were similar between the two groups. Conclusions Desflurane anesthesia worsened emergence agitation as compared with sevoflurane in adult patients undergoing thyroid surgery, but did not affect time to extubation, postoperative pain, or PONV. Trial registration UMIN000014215 Electronic supplementary material The online version of this article (doi:10.1186/s40981-017-0106-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Takeshi Suzuki
- Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Takuya Kurazumi
- Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Tomomi Ueda
- Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hiromasa Nagata
- Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Takashige Yamada
- Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shizuko Kosugi
- Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Saori Hashiguchi
- Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Koichi Ito
- Department of Surgery, Ito Hospital, Tokyo, Japan
| | - Hiroshi Morisaki
- Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Feng JF, Wang XX, Lu YY, Pang DG, Peng W, Mo JL. Effects of dexmedetomidine versus midazolam for premedication in paediatric anaesthesia with sevoflurane: A meta-analysis. J Int Med Res 2017; 45:912-923. [PMID: 28425829 PMCID: PMC5536403 DOI: 10.1177/0300060517704595] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Dexmedetomidine (DEX), an α2-adrenergic receptor agonist, produces ideal sedation and early postoperative recovery for premedication in paediatric surgery, reducing preoperative anxiety and facilitating smooth induction of anaesthesia. We performed a meta-analysis to compare the effects of DEX and midazolam (MDZ) in paediatric anaesthesia with sevoflurane. Methods PubMed, Ovid, Web of Science, and Public Health Management Corporation were searched through December 2016 for randomized controlled trials (RCTs) that compared DEX and MDZ in children undergoing sevoflurane anaesthesia. The risk ratio (RR) with 95% incidence interval (95%CI) was used for dichotomous variables. Results Twelve RCTs involving 422 patients in the DEX group and 448 patients in the MDZ group were included. Patients in the DEX group had a significantly lower incidence of unsatisfactory sedation (RR [95%CI] = 0.71 [0.57-0.89]), unsatisfactory parental separation (RR [95%CI] = 0.56 [0.35-0.87]), and rescue analgesia (RR [95%CI] = 0.52 [0.35-0.77]) than patients in the MDZ group. However, both groups had a similar incidence of unsatisfactory mask acceptance, emergence agitation, and postoperative nausea and vomiting. Conclusion Compared with MDZ, DEX is beneficial in paediatric anaesthesia with sevoflurane because of its lower incidence of unsatisfactory sedation, parental separation, and rescue analgesia.
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Affiliation(s)
- Ji-Feng Feng
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Xiao-Xia Wang
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Yan-Yan Lu
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Deng-Ge Pang
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Wei Peng
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Jian-Lan Mo
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
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Pradeep T, Manissery JJ, Upadya* M. Emergence agitation in paediatric patients using sevoflurane and isoflurane anaesthesia: a randomised controlled study. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2017. [DOI: 10.1080/22201181.2017.1307568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34:192-214. [DOI: 10.1097/eja.0000000000000594] [Citation(s) in RCA: 491] [Impact Index Per Article: 70.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Li H, Zhang L, Shi M, Yang S, Li S, Gao S. Impact of Dexmedetomidine on Pediatric Agitation in the Postanesthesia Care Unit. J Perianesth Nurs 2017; 33:53-57. [PMID: 29362047 DOI: 10.1016/j.jopan.2016.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 02/14/2016] [Accepted: 03/05/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aims to investigate the impacts of dexmedetomidine (DEX) on agitation in the postanesthesia care unit (PACU) for pediatric patients undergoing tonsillectomy. DESIGN Eighty-two pediatric patients with elective tonsillectomy were randomly divided into the DEX group (group D) and the control group (group C). All patients' surgery in the two study groups were completed under tracheal cannula-based general anesthesia. Group D was infused 0.2 mcg/kg/hour DEX. The operation time, extubation time, PACU time, number of cases with nausea and vomiting, hemodynamic changes, and doses of rescue fentanyl, as well as every 10-minute observational pain scoring, and emergence agitation score in PACU, of the two groups were recorded. METHODS Chi-square and Fischer exact tests were applied for categorical variables. FINDINGS The maximum observational pain scoring and emergence agitation score of group D at 0, 10, and 20 minutes in PACU were significantly lower than group C (P < .01); the rescue doses of fentanyl and incidence of severe agitation in PACU in group D were significantly reduced than group C (P < .01). Group D showed significantly less cases with nausea and vomiting than group C (P < .05). CONCLUSIONS Low-dose DEX could significantly reduce the delirium and agitation in the PACU stage of pediatric tonsillectomy, and there were no untoward hemodynamic events in this study of 80 patients.
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Kurhekar P, Vinod K, Krishna JSD, Raghuraman MS. Randomized Comparison of Isoflurane versus Sevoflurane and Desflurane for Maintenance of Ambulatory Anesthesia. Anesth Essays Res 2017; 11:875-880. [PMID: 29284842 PMCID: PMC5735481 DOI: 10.4103/aer.aer_174_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Ambulatory surgeries demand safe anesthesia with faster recovery which makes it expensive due to the cost of inhalational anesthetic agents such as sevoflurane and desflurane. Isoflurane is inexpensive agent but can cause delayed recovery. The aim of this study was to evaluate cost-benefit ratio of all three agent with respect to recovery and safety profile Materials and Methods: Patients posted for elective ambulatory surgeries were divided into three groups. Suitable size laryngeal mask airway was inserted following induction with propofol and vecuronium. Anesthesia was maintained on low-flow anesthesia with inhalational agent as isoflurane for Group I, sevoflurane for Group II and Group III received desflurane. Patients were monitored for recovery as per modified Aldrete score and as per postanesthesia discharge scoring system for discharge from hospital. Cost analysis was done by Dion's formula. Statistical analysis was done with analysis of variance for recovery profile, Chi-square test for safety profile and Kruskal Wallis test for cost comparison between groups. Results: Patient characteristics and duration of anesthesia were similar in all three groups. Time to eye-opening was significantly less with desflurane than sevoflurane and isoflurane (P = 0.001). Time to home readiness was similar in all three groups (P = 0.451). The incidence of airway irritation, pain, and nausea/vomiting was similar in all three groups. Cost of Group I was statistically lower than other two groups (P = 0.00). Conclusion: Home readiness and safety profile were comparable between agents; the cost involved was the least with isoflurane.
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Affiliation(s)
- Pranjali Kurhekar
- Department of Anaesthesiology, Shri Sathya Sai Medical College and Research Institute, Kancheepuram, Tamil Nadu, India
| | - Krishnagopal Vinod
- Department of Anaesthesiology, Shri Sathya Sai Medical College and Research Institute, Kancheepuram, Tamil Nadu, India
| | - J Shesha Dhiviya Krishna
- Department of Anaesthesiology, Shri Sathya Sai Medical College and Research Institute, Kancheepuram, Tamil Nadu, India
| | - M Sethuraman Raghuraman
- Department of Anaesthesiology, Shri Sathya Sai Medical College and Research Institute, Kancheepuram, Tamil Nadu, India
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Emergence and Recovery Characteristics of Five Common Anesthetics in Pediatric Anesthesia: a Network Meta-analysis. Mol Neurobiol 2016; 54:4353-4364. [DOI: 10.1007/s12035-016-9982-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/14/2016] [Indexed: 10/21/2022]
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Systematic review of the Face, Legs, Activity, Cry and Consolability scale for assessing pain in infants and children. Pain 2015. [DOI: 10.1097/j.pain.0000000000000305] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Costi D, Cyna AM, Ahmed S, Stephens K, Strickland P, Ellwood J, Larsson JN, Chooi C, Burgoyne LL, Middleton P. Effects of sevoflurane versus other general anaesthesia on emergence agitation in children. Cochrane Database Syst Rev 2014; 2014:CD007084. [PMID: 25212274 PMCID: PMC10898224 DOI: 10.1002/14651858.cd007084.pub2] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- David Costi
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - Allan M Cyna
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Samira Ahmed
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - Kate Stephens
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Penny Strickland
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - James Ellwood
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - Jessica N Larsson
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - Cheryl Chooi
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Laura L Burgoyne
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - Philippa Middleton
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
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Jannin V, Lemagnen G, Gueroult P, Larrouture D, Tuleu C. Rectal route in the 21st Century to treat children. Adv Drug Deliv Rev 2014; 73:34-49. [PMID: 24871671 DOI: 10.1016/j.addr.2014.05.012] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 02/07/2014] [Accepted: 05/19/2014] [Indexed: 02/06/2023]
Abstract
The rectal route can be considered a good alternative to the oral route for the paediatric population because these dosage forms are neither to be swallowed nor need to be taste-masked. Rectal forms can also be administered in an emergency to unconscious or vomiting children. Their manufacturing cost is low with excipients generally regarded as safe. Some new formulation strategies, including mucoadhesive gels and suppositories, were introduced to increase patient acceptability. Even if recent paediatric clinical studies have demonstrated the equivalence of the rectal route with others, in order to enable the use of this promising route for the treatment of children in the 21st Century, some effort should be focused on informing and educating parents and care givers. This review is the first ever to address all the aforementioned items, and to list all drugs used in paediatric rectal forms in literature and marketed products in developed countries.
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Mohkamkar M, Farhoudi F, Alam-Sahebpour A, Mousavi SA, Khani S, Shahmohammadi S. Postanesthetic Emergence Agitation in Pediatric Patients under General Anesthesia. IRANIAN JOURNAL OF PEDIATRICS 2014; 24:184-90. [PMID: 25535538 PMCID: PMC4268839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 01/22/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Postanesthetic emergence agitation is a common problem in pediatric postanesthetic care unit with an incidence ranging from 10 to 80%. This study was done to determine the prevalence of emergence agitation and associated risk factors in pediatric patients who underwent general anesthesia. METHODS This cross-sectional descriptive and analytic study was performed on 747 pediatric patients aged 3- 7 years that underwent general anesthesia for various elective surgeries at Bou-Ali Sina Hospital in Sari, Iran between January 2010 and January 2011. A non-probability quota sampling technique was used. The presence of emergence agitation was recorded using Pediatric Anesthesia Emergence Delirium Scale. The factors linked with Emergence Agitation were recorded in a questionnaire. The data were analyzed using SPSS software 16 and independent sample t-test, χ(2) and binary logistic regression. P-values less than 0.05 were considered as significant. FINDINGS One hundred thirty-four (17.9%) children had emergence agitation. The most frequent surgical procedures were ENT surgical procedures 315 (42.2%), abdominal surgery 177 (23.7%), orthopedic surgery 137 (18.3%), urology 97 (13%) and ophthalmic surgery 24 (3.2%). Otorhinolaryngological surgical procedures (P=0.001), pain (P<0.05) and induction behavior of children (P<0.005) were associated with higher rates of post anesthetic emergence agitation (P=0.001). CONCLUSION This study identified the multiple independent risk factors which are associated with emergence agitation in children. To minimize the incidence of postanesthetic emergence agitation, these risk factors should be considered in the routine care by care providers in postanesthetic care unit.
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Affiliation(s)
| | | | | | | | - Soghra Khani
- Bouali Sina Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Soheila Shahmohammadi
- * Corresponding Author; Address: CRNA and Research Fellow Journal of Pediatric Review Editorial Office, Bouali Sina Hospital, Pasdaran Boulevard, Sari, Iran E-mail:
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Kim J, Kim SY, Lee JH, Kang YR, Koo BN. Low-dose dexmedetomidine reduces emergence agitation after desflurane anaesthesia in children undergoing strabismus surgery. Yonsei Med J 2014; 55:508-16. [PMID: 24532525 PMCID: PMC3936635 DOI: 10.3349/ymj.2014.55.2.508] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Emergence agitation (EA) is frequently observed in children undergoing general anaesthesia. This study tested whether the addition of an intra-operative low-dose infusion of dexmedetomidine to fentanyl treatment reduced the incidence of emergence delirium following desflurane anesthesia in children undergoing strabismus surgery. MATERIALS AND METHODS A total of 96 children (1-5 years old) undergoing strabismus surgery were enrolled. Anaesthesia was induced with propofol and maintained with desflurane. After induction, fentanyl (1 μg/kg) was administered to all children. During surgery, patients were infused with 0.2 μg/(kg·h)⁻¹ dexmedetomidine (Group FD, n=47) or normal saline (Group F, n=47). Postoperative objective pain score (OPS), Paediatric Agitation and Emergence Delirium (PAED) score, and EA score were documented every 10 minutes in the post-anaesthesia care unit. RESULTS There were no significant differences between the two groups in demographic characteristics and haemodynamic changes. The mean values of maximum EA, maximum PAED, and maximum OPS score were significantly lower in Group FD than in Group F at 0, 10, and 20 minutes after arrival at the post-anaesthesia care unit (p<0.001). The frequency of fentanyl rescue was lower in Group FD than in Group F (p<0.001). The incidence of severe EA was significantly lower in Group FD than in Group F (12.8% vs. 74.5%, p<0.001). CONCLUSION Intra-operative low-dose infusion of dexmedetomidine in addition to fentanyl reduces EA following desflurane anaesthesia in children undergoing strabismus surgeries.
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Affiliation(s)
- Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea.
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Sethi S, Ghai B, Ram J, Wig J. Postoperative emergence delirium in pediatric patients undergoing cataract surgery--a comparison of desflurane and sevoflurane. Paediatr Anaesth 2013; 23:1131-7. [PMID: 24102666 DOI: 10.1111/pan.12260] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2013] [Indexed: 01/27/2023]
Abstract
BACKGROUND Desflurane and sevoflurane are associated with postoperative emergence delirium (ED) in children. The study aimed to compare the use of desflurane and sevoflurane to determine the postoperative ED in children undergoing cataract surgery using the validated Pediatric Anesthesia Emergence Delirium (PAED) scale. METHODS In this randomized double-blinded study, 88 children of American Society of Anesthesiologists (ASA) grade I and II aged 2-6 years, anesthesia was maintained with 1-1.2 MAC concentration of desflurane or sevoflurane after induction with sevoflurane. Subtenon block was administered in all children with 0.08-0.10 ml·kg(-1) of 0.5% bupivacaine before surgical incision. Primary outcome measured was PAED scale at different time intervals between the two groups, and secondary outcome measured was preoperative anxiety scores, postoperative pain scores, emergence, incidence of delirium and adverse effects. RESULTS Pediatric Anesthesia Emergence Delirium (PAED) scale showed no statistical difference between sevoflurane and desflurane at different time intervals. Incidence of ED using the cutoff of >12 in PAED scale was 8 of 44 (18.18%) in sevoflurane group and 9 of 44 (20.45%) in desflurane groups (P = 1.000). Emergence from anesthesia was faster in desflurane group (P = 0.001). Correlation between the m-YPAS anxiety scale and PAED scale in either group did not find any relationship (correlation coefficient = -0.060, P = 0.579). No correlation between the Face, Legs, Activity, Cry and Consolability (FLACC) scale and Pediatric Anesthesia Emergence Delirium (PAED) scale was found in 17 patients who had ED (correlation coefficient = 0.191, P-value = 0.462). Five patients of 17 (i.e., three patients in Group S and two patients in Group D) had PAED >12 but FLACC <4. CONCLUSION Emergence delirium (ED) after desflurane and sevoflurane anesthesia was comparable using a validated PAED scale in pediatric cataract surgery. There was no correlation between preoperative anxiety and ED in these children; however, children with higher pain scores were more likely to have a higher ED.
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Affiliation(s)
- Sameer Sethi
- Department of Anesthesia, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Ji F, Li Z, Young N, Moore P, Liu H. Perioperative dexmedetomidine improves mortality in patients undergoing coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2013; 28:267-73. [PMID: 24182835 DOI: 10.1053/j.jvca.2013.06.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Indexed: 01/05/2023]
Abstract
OBJECTIVE This study retrospectively investigated the effect of dexmedetomidine on outcomes of patients undergoing coronary artery bypass graft (CABG) surgery. DESIGN Retrospective investigation. SETTING Patients from a single tertiary medical center. PARTICIPANTS A total of 724 patients undergoing CABG surgery met the inclusion criteria and were categorized into 2 groups: 345 in the dexmedetomidine group (DEX) and 379 in the nondexmedetomidine group (Non-DEX). INTERVENTIONS Perioperative dexmedetomidine was used as an intravenous infusion (0.24 to 0.6 µg/kg/hour) initiated after cardiopulmonary bypass and continued for less than 24 hours postoperatively in the intensive care unit. MEASUREMENTS AND MAIN RESULTS Major outcome measures of this study were in-hospital, 30-day and 1-year all-cause mortality, delirium and major adverse cardiocerebral events. Perioperative dexmedetomidine infusion was associated with significant reductions in in-hospital, 30-day, and 1-year mortalities, compared with the patients who did not received dexmedetomidine. In-hospital, 30-day, and 1-year mortalities were 1.5% and 4.0% (adjusted odds ratio [OR], 0.332; 95% CI, 0.155 to 0.708; p = 0.0044), 2.0% and 4.5% (adjusted OR, 0.487; 95% CI, 0.253 to 0.985; p = 0.0305), and 3.2% and 6.9% (adjusted OR 0.421; 95% CI, 0.247 to 0.718, p = 0.0015), respectively. Perioperative dexmedetomidine infusion was associated with a reduced risk of delirium from 7.9% to 4.6% (adjusted OR, 0.431; 95% CI, 0.265-0.701; p = 0.0007). CONCLUSION Dexmedetomidine infusion during CABG surgery was more likely to achieve improved in-hospital, 30-day, and 1-year survival rates, and a significantly lower incidence of delirium.
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Affiliation(s)
- Fuhai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, CA
| | - Zhongmin Li
- Department of Internal Medicine, University of California Davis Health System, Sacramento, CA
| | - Nilas Young
- Department of Surgery, University of California Davis Health System, Sacramento, CA
| | - Peter Moore
- Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, CA
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, CA.
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Zhang C, Li J, Zhao D, Wang Y. Prophylactic midazolam and clonidine for emergence from agitation in children after emergence from sevoflurane anesthesia: a meta-analysis. Clin Ther 2013; 35:1622-31. [PMID: 24075150 DOI: 10.1016/j.clinthera.2013.08.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/26/2013] [Accepted: 08/21/2013] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Chengmi Zhang
- Department of Anesthesiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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