Emergence agitation after sevoflurane anaesthesia in children

Abstract

Editor'We read with interest the article by Lee and colleagues comparing propofol and fentanyl for prevention of emergence agitation after sevoflurane anaesthesia in children.1Kim MS Moon BE Kim H Lee JR Comparison of propofol and fentanyl administered at the end of anaesthesia for prevention of emergence agitation after sevoflurane anaesthesia in children.Br J Anaesth. 2013; 110: 274-280doi:10.1093/bja/aes382Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar We thank the authors for their work in this very common and often very distressing scenario. We would like to raise a few important questions regarding this study. Pain is one of the important causes for emergence agitation particularly in children,2Reduque LL Verghese ST Paediatric emergence delirium.CEACCP (BJA). 2013; 13: 39-41Google Scholar and although the authors excluded the children in whom caudal analgesia had not worked, we think assessment of pain by appropriate scales would have been very helpful in addressing this confounding factor. Also considering the authors have used lidocaine for caudal analgesia and the patients had at least 60 min duration of anaesthesia and a further 40 min in Post Anaesthesia Care Unit (PACU), we consider assessment of pain in PACU would have been invaluable data in this study. Propofol was used as the rescue agent for severe agitation in PACU. Considering that propofol was one of the study drugs, we think that it introduces bias into the study. The starvation times used in this study were very long compared with the common clinical practice in the UK (where it is 6 h for solids and 2 h for clear fluids). We appreciate this could have been the standard protocol of the institution, but longer starvation periods would lead to more distress before induction, which possibly could have led to some exclusions from the study. Preoperative anxiety and distress is another significant contributing factor for emergence agitation in children.2Reduque LL Verghese ST Paediatric emergence delirium.CEACCP (BJA). 2013; 13: 39-41Google Scholar 3Aono J Mamiya K Manabe M Preoperative anxiety is associated with a high incidence of problematic behaviour on emergence after halothane anesthesia in boys.Acta Anaesthesiol Scand. 1999; 43: 542-544doi:10.1034/j.1399-6576.1999.430509.xCrossref PubMed Scopus (85) Google Scholar Parental stay during recovery of anaesthesia is another factor influencing emergence agitation in children.4Yoo JB Kim MJ Cho SH Shin YJ Kim NC The effects of pre-operative visual information and parental presence intervention on anxiety, delirium, and pain of post-operative paediatric patients in PACU.J Korean Acad Nurs. 2012; 42: 333-341doi:10.4040/jkan.2012.42.3.333Crossref PubMed Scopus (0) Google Scholar We understand the policy of the institution of not having parental presence in PACU influencing the study protocol, and we would like to commend the authors in acknowledging this factor for higher incidence of emergence agitation in Group S. None declared.