Effect of BIS-guided anesthesia on emergence delirium following general anesthesia in children: A prospective randomized controlled trial

OBJECTIVE

Emergence delirium (ED) is a postoperative complication in pediatric anesthesia characterized by a perception and psychomotor disorder, with a negative impact on postoperative recovery. As the use of inhalation anesthesia is associated with a higher incidence of ED, we investigated whether titrating the depth of general anesthesia with BIS monitor can reduce the incidence of ED.

DESIGN

Randomized, prospective, and double-blind.

SETTING

Patients undergoing endoscopic adenoidectomy under general anesthesia according to a uniform protocol.

PATIENTS

A total of 163 patients of both sexes aged 3-8 years were enrolled over 18 months.

INTERVENTIONS

Immediately after the induction of general anesthesia, a bispectral index (BIS) electrode was placed on the patient's forehead. In the study group, the depth of general anesthesia was monitored with the aim of achieving BIS values of 40-60. In the control group, the dose of sevoflurane was determined by the anaesthesiologist based on MAC (minimum alveolar concentration) and the end-tidal concentration.

MEASUREMENTS

The primary objective was to compare the occurrence of ED during the PACU (post-anesthesia care unit) stay in both arms of the study. The secondary objective was to determine the PAED score at 10 and 30 min in the PACU and the need for rescue treatment of ED.

MAIN RESULTS

86 children were randomized in the intervention group and 77 children in the control group. During the entire PACU stay, 23.3% (38/163) of patients developed ED with PAED score >10: 35.1% (27/77) in the control group and 12.8% (11/86) in the intervention group (p = 0.001). Lower PAED scores were also found in the intervention group at 10 (p < 0.001) and 30 (p < 0.001) minutes compared to the control group. The need for rescue treatment did not differ between groups (p = 0.067).

CONCLUSION

Individualization of the depth of general anesthesia with BIS monitoring is an effective method of preventing ED in children.

CLINICAL TRIAL REGISTRATION

NCT04466579.

Predicting Acute Kidney Injury in Trauma Patients: Biomarkers as Early Indicators

BACKGROUND Acute kidney injury (AKI) is a common cause of organ failure in patients after major trauma and is associated with increased morbidity and mortality. Early identification of patients at risk enables the implementation of a bundle of supportive care, which reduces the incidence of AKI. The primary objective of our study was to investigate whether the levels of biomarkers on admission predicted the onset of early AKI in patients with serious injuries. MATERIAL AND METHODS This prospective observational study included 98 adult patients of both sexes with a serious injury (injury severity score >16). At admission, blood samples were taken, and creatinine, neutrophil gelatinase-associated lipocalin (NGAL), high mobility group box 1 (HMGB-1), and markers of rhabdomyolysis (creatine kinase, myoglobin) were evaluated. The patients were provided with standard resuscitation care, and the occurrence of AKI was monitored during the first 7 days after admission to the Intensive Care Unit, according to the Kidney Disease Improving Global Outcomes diagnostic criteria. RESULTS AKI occurred in 25 (25.5%) patients, in whom the admission levels of HMGB-1, NGAL, creatinine, and myoglobin were significantly higher than in non-AKI patients (48.3±98.4 vs 113.0±209.4 µg/L, P=0.006; 150.2±349.9 vs 181.4±152.2 µg/L, P=0.004; 83.1±20.8 vs 118.8±32.2 µmol/L, P<0.005; 2734.4±2214.5 vs 4182.3±2477.1 µg/L, P=0.008, respectively). Creatine kinase was 14.5±9.2 µkat/L in non-AKI patients and 13.7±7.9 µkat/L in AKI patients (P=0.916). CONCLUSIONS Admission levels of HMGB-1, NGAL, creatinine, and myoglobin predicted the risk of AKI in severely injured patients.

Dexamethasone Reduces the Incidence of Postoperative Nausea and Vomiting in Children Undergoing Endoscopic Adenoidectomy under General Anesthesia Without Increasing the Risk of Postoperative Hemorrhage

Background

Postoperative nausea and vomiting (PONV) is a common complication of pediatric anesthesia, but the overall incidence of PONV in patients undergoing adenoidectomy is unknown. The aim of this controlled study was to compare the effect of dexamethasone administration with placebo to reduce PONV in children undergoing endoscopic adenoidectomy under general anesthesia.

Material/Methods

A randomized placebo-controlled study included 118 pediatric patients who underwent elective endoscopic adenoidectomy under general anesthesia. A dexamethasone-treated (0.15 mg/kg) group (Group D) (n=56) and a placebo group (Group C) (n=62) were randomly assigned. The incidence of nausea and vomiting was recorded on the day of surgery. Postoperative nausea was assessed according to illustrated Baxter Animated Retching Faces (BARF) scale. The Face, Legs, Activity, Cry, and Consolability (FLACC) scale (scores between 0–10) was used to assess pain. Follow-up was performed on the 14^th postoperative day by a telephone call.

Results

Overall prevalence of postoperative nausea was 25% (30/118) and postoperative vomiting was 14% (17/118). In the first 24 hours following surgery, in Group D, the incidence of nausea and vomiting was 13% and 7%, respectively; in Group C, without pharmacological prophylaxis, the incidence of postoperative nausea and vomiting was 37%, and 21%, respectively.

Conclusions

A prospective controlled study in children undergoing endoscopic adenoidectomy under general anesthesia showed that dexamethasone (0.15 mg/kg) significantly reduced the incidence of PONV without increasing the risk of postoperative hemorrhage. Dexamethasone is a safe method for the prevention of PONV that may be recommended in pediatric anesthesiology.