Emergence agitation in children

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Editor—I was interested in the article concerning emergence agitation in children after sevoflurane or desflurane anaesthesia.1Dahmani S Stany I Brasher C et al.Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies.Br J Anaesth. 2010; 104: 216-223Abstract Full Text Full Text PDF PubMed Scopus (234) Google Scholar I anaesthetize a large number of pre-school children each year and my practice is mainly ENT. The authors found from their meta-analysis that propofol, ketamine, fentanyl, and preoperative analgesia all had a preventative effect on emergence agitation. I, like them, was slightly surprised that midazolam did not prevent emergence agitation. I would personally expect all agents such as sedatives, hypnotics, and analgesics to have a preventative effect on emergence agitation as they will all tend to give a smoother recovery. I have long felt that a large number of pre-school children anaesthetized in my local hospitals suffer emergence agitation after operation when maintained with sevoflurane (we do not have desflurane available). For many years, I have maintained anaesthesia for these children, after induction of anaesthesia with either propofol or sevoflurane, with isoflurane. Isoflurane is possibly a slightly more difficult agent to use as it is more irritant to the airway than sevoflurane. I feel that the children maintained with isoflurane show less signs of emergence agitation. The children tend to wake slower than those maintained with sevoflurane but seem generally less distressed and their discharge from hospital is not delayed, compared with those maintained with sevoflurane. As the authors mentioned, emergence agitation is distressing for recovery staff, ward staff, and parents and also puts the child at risk of self-harm and I feel that the simple substitution of isoflurane for sevoflurane for maintenance of anaesthesia decreases this risk. I have no evidence that isoflurane decreases the incidence of emergence agitation; indeed, some papers support the very opposite view but I would be interested if the authors came across any evidence to support or refute the suggestion that isoflurane leads to less postoperative emergence agitation? Editor—I thank Dr Huddy for his interest in our study.1Dahmani S Stany I Brasher C et al.Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies.Br J Anaesth. 2010; 104: 216-223Abstract Full Text Full Text PDF PubMed Scopus (234) Google Scholar In response, two studies comparing sevoflurane and isoflurane have been published.2Meyer RR Münster P Werner C Brambrink AM Isoflurane is associated with a similar incidence of emergence agitation/delirium as sevoflurane in young children—a randomized controlled study.Paediatr Anaesth. 2007; 17: 56-60Crossref PubMed Scopus (52) Google Scholar 3Bortone L Ingelmo P Grossi S et al.Emergence agitation in preschool children: double-blind, randomized, controlled trial comparing sevoflurane and isoflurane anesthesia.Paediatr Anaesth. 2006; 16: 1138-1143Crossref PubMed Scopus (37) Google Scholar These studies had divergent conclusions, despite similar methodologies especially concerning the preoperative pain management. However, the quantification of the emergence agitation was different, which may explain the conflicting results. It is established that the rapidity of the emergence is one of the factors favouring the agitation. Consequently, despite these conflicting results, isoflurane, because of its slower offset, may be considered as a prophylactic treatment of emergence agitation. None declared. Dahmani S.* Paris, France *E-mail: [email protected]