Emergence Agitation In Children Research Articles

Incidence of emergence agitation in children undergoing sevoflurane anesthesia compared to isoflurane anesthesia: Anupdated systematic review and meta-analysis.

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. 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. 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). 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.

Melatonin or its analogs as premedication to prevent emergence agitation in children: a systematic review and meta-analysis

BackgroundEmergence agitation (EA) is a prevalent complication in children following general anesthesia. Several studies have assessed the relationship between melatonin or its analogs and the incidence of pediatric EA, yielding conflicting results. This meta-analysis aims to assess the effects of premedication with melatonin or its analogs on preventing EA in children after general anesthesia.MethodsPubMed, EMBASE, the Cochrane Library, ProQuest Dissertations & Theses Global, Web of Science, CNKI, Wanfang Data, clinicaltrials.gov, and WHO International Clinical Trials Registry Platform were searched until 25 November 2022. We included randomized controlled trials that assessed EA in patients less than 18 years old who underwent general anesthesia. We excluded studies that did not use a specific evaluation to assess EA.ResultsNine studies (951 participants) were included in this systematic review. Melatonin significantly reduced the incidence of EA compared with placebos (risk ratio 0.40, 95% CI 0.26 to 0.61, P < 0.01) and midazolam (risk ratio 0.48, 95% CI 0.32 to 0.73, P < 0.01). Dexmedetomidine remarkably decreased the incidence of EA compared with melatonin (risk ratio 2.04, 95% CI 1.11 to 3.73, P = 0.02).ConclusionsMelatonin premedication significantly decreases the incidence of EA compared with placebos and midazolam. Dexmedetomidine premedication has a stronger effect than melatonin in preventing EA. Nevertheless, further studies are warranted to reinforce and validate the conclusion on the efficacy of melatonin premedication in mitigating EA in pediatric patients.

Prevalence and risk factors of emergence agitation among pediatric patients undergo ophthalmic and ENT Surgery: a cross-sectional study

BackgroundSome studies reported that pediatric patients undergoing otorhinolaryngology (ENT) and ophthalmic surgeries have higher incidences of emergence agitation (EA). Children with EA tend to carry the risk of self-harm, have longer periods of recovery and delayed hospital discharge. Consequently, EA needs to be monitored and risk factors ought to be emphasized to implement preventative measures. The objective of this study was to describe EA and to identify risk factors after pediatric ophthalmic or ENT surgery.MethodsBetween September 2021 and December 2021, a cross-sectional study was conducted in 100 children aged of 0–12 years who underwent ophthalmic or ENT surgery. The Watcha scale was used to observe and record EA, which was defined at levels of 3 or 4 at any time in the post-anesthesia care unit (PACU). The pain intensity was graded with the Face, Legs, Activity, Cry, Consolability (FLACC) Scale after surgery. Patient and surgery-related characteristics, the behavioral criteria of EA, the pharmacologic and non-pharmacologic interventions and recovery outcomes were objectively recorded. A binary logistic regression model was constructed to identify the associated factors of EA.ResultsFrom the 100 analyzed children, 58 were males and 42 were females, and 44 patients received ophthalmic surgery and 56 ENT surgery. The median age was 6 (IQR 4–7) years. The overall incidence of EA among pediatrics was 30% (34.5% for ENT and 24.4% for ophthalmic surgery). High preoperative modified Yale Preoperative Anxiety scale (m-YPAS) grade (OR = 1.19, 95%CI 1.06–1.33, P = 0.003) and high postoperative FLACC score (OR = 3.36, 95%CI 1.88–6.02, P < 0.001) were risk factors for EA.ConclusionsThis study identified that preoperative anxiety and postoperative pain are associated with EA in children after ophthalmic or ENT surgery. Preoperative anxiety assessment and management, and administration of adjunct analgesic treatments should be considered in the routine care.

Determination of the ED90 of Dexmedetomidine Infusion to Prevent Emergence Agitation in Children Undergoing Dental Rehabilitation With Sevoflurane Anesthesia: A Biased-Coin Up-and-Down Sequential Allocation Trial.

Emergence agitation (EA) is an adverse complication during early recovery from sevoflurane anesthesia. Continuous intravenous infusion of dexmedetomidine (DEX) is commonly used for EA prevention. However, a wide dose range is used for preventing EA, and the optimal dose remains unknown. This study was aimed at determining the optimal dose (the 90% effective dose [ED90]) of DEX for continuous intraoperative infusion for EA prevention in children. We enrolled children aged 3 to 7 years who underwent dental treatment under sevoflurane anesthesia. DEX was continuously infused from the time of the establishment of the intravenous access until 5 minutes before the end of surgery. The initial DEX dose was 0.5 µg/kg/h, and subsequent dose adjustments were determined based on the response of the previous patient by using an up-down sequential allocation with a biased-coin design. The primary outcome was the ED90 for continuous DEX infusion based on the success or failure of the EA-preventing dose. Forty-five patients were enrolled in the study. The DEX dose ranged from 0.50 to 0.90 µg/kg/h. The estimated ED90 (95% confidence interval [CI]) for preventing EA was 0.74 µg/kg/h (0.67-1.05 µg/kg/h). The duration of surgery (mean ± standard deviation [SD]) was 113 ± 30 minutes. The times (mean ± SD) for extubation, time to emergence, and recovery time were 5 ± 2 minutes, 27 ± 9 minutes, and 39 ± 7 minutes, respectively. The ED90 for continuous intraoperative DEX infusion for EA prevention in pediatric patients receiving dental treatment under sevoflurane anesthesia was 0.74 µg/kg/h (95% CI, 0.67-1.05 µg/kg/h).

Effectiveness of acupuncture therapy for the prevention of emergence agitation in children: A systematic review and meta-analysis with trial sequential analysis.

This study aimed to evaluate the effectiveness of acupuncture therapy in preventing emergence agitation (EA) in children. A systematic review and meta-analysis were conducted across multiple locations according to the articles searched. Seven databases, including trial registration sites, were searched. A total of six trials were included involving 489 patients; of them, 244 received acupuncture therapy. Randomized clinical trials (RCTs) evaluating the incidence of EA compared with placebo/sham or standard care in children were included. The primary outcome was the incidence of EA, as evaluated using a specific assessment tool. Data about the incidence rate of EA, heterogeneity, quality of trials and evidence, and adverse events were collected. Additionally, data about patient demographic characteristics, type of anesthesia, duration and onset of acupuncture therapy, EA and pain score, time taken for extubation, and post-anesthesia care unit length of stay were collected. The results indicated that the overall incidence of EA in the acupuncture therapy group and the control group was 23.4% and 39.5%, respectively, with no significant difference (risk ratio, 0.62; 95% confidence interval, 0.26-1.48; I2 = 63%). Subgroup analysis showed a significant difference in the overall incidence of EA in the acupuncture therapy and control groups according to surgery type (high-risk vs. low-risk surgery), suggesting that acupuncture therapy may be effective in reducing EA for patients undergoing high-risk surgery. The quality of evidence was downgraded to "very low" due to the study designs, inconsistency, and possible publication bias. In conclusion, this meta-analysis shows that the currently available RCTs are insufficient to determine the effectiveness of acupuncture therapy in preventing EA in children undergoing general anesthesia.

Subanesthetic-dose propofol infusion for preventing emergence agitation in children: a retrospective observational study.

Anesthesia maintenance using propofol and a propofol bolus dose at the end of surgery have been shown to prevent emergence agitation (EA).However, the preventive effect of subanesthetic propofol infusion during sevoflurane anesthesia on EA remains unknown. We aimed toevaluate the effect of subanesthetic propofol infusion on EA in children. We retrospectively compared the incidences of severe EA requiring pharmacological intervention in children who underwent adenoidectomy, tonsillectomy with or without adenoidectomy, or strabismus surgery between maintenance with sevoflurane alone (sevoflurane group) and maintenance with subanesthetic propofol with sevoflurane (combination group). A multivariable logistic regression model adjusted for confounders was used to assess the association between anesthesia methods and the occurrence of EA. Additionally, we estimated the direct effect of anesthesia methods by a mediation analysis, excluding the indirect effects of intraoperative fentanyl and droperidol administration. Among 244 eligible patients, 132 and 112 were in the sevoflurane and combination groups, respectively. The crude incidence of EA was significantly lower in the combination group (17.0% [n = 19]) than in the sevoflurane group (33.3% [n = 44]) (P = 0.005).After adjusting for confounders, the incidence of EA was still significantly lower in the combination group (adjusted odds ratio [aOR]: 0.48, 95% confidence interval [CI] 0.25-0.91). The mediation analysis revealed a direct association of anesthesia methods with a lower EA incidence in the combination group (aOR: 0.48, 95% CI 0.24-0.93) than in the sevoflurane group. Subanesthetic propofol infusion may effectively prevent severe EA requiring the administration of opioids or sedatives.

Effect of ice popsicle treatment on emergence agitation in children undergoing oral surgery with sevoflurane anaesthesia: A prospective randomized controlled study

Emergence agitation is a common postoperative complication during recovery in children. The purpose of this study is to explore whether the use of ice popsicle could prevent emergence agitation in children undergoing oral surgery with sevoflurane anaesthesia. In this prospective randomized controlled study, 100 children undergoing oral surgery were randomly assigned to Group 1 which received ice popsicle after emergence (intervention, n=50) or Group 2 which received verbal encouragement from their parents (control, n=50). The primary outcome was the 2-hour postoperative incidence of EA. Group 1 had a significant lower incidence of emergence agitation (22% vs 58%, P<0.001) compared with Group 2. The mean agitation score was significantly lower in Group 1 vs Group 2 at 10 minutes (1.64 vs 2.12, P=0.024) and 20min (1.60 vs 2.14, P=0.004) after emergence. The peak agitation and pain scores were significantly lower in Group 1 than in Group 2 (P<0.001). Findings from this study suggest that ice popsicle is an effective, cheap, pleasurable, and easily administered method for alleviating emergence agitation in paediatric patients after oral surgery under general anaesthesia. These results are worthy of confirmation in other surgeries. This approach is highly accepted by both children and their parents, and our findings support the effectiveness of ice popsicle in relieving emergence agitation and pain after oral surgery in children. Chinese Clinical Trial Registry, ChiCTR1800015634.

Low Dose Propofol at the End of Sevoflurane Anesthesia Reduces Emergence Agitation in Children: A Prospective Observational Study

Introduction: EA is characterized by agitation, inconsolable sobbing, disorientation, delusions, and hallucinations, decreased cognition and memory. Sevoflurane is widely used as an anesthetic agent for children because of its less pungent nature, lower solubility but it has a greater incidence of EA in preschool aged children. Propofol is a hypnotic amnestic agent with a short duration of action, commonly used for sedation, induction, and maintaining anesthesia and it has been used to prevent Emergence agitation. Aim of the Study: The aim of this study was to determine the efficacy of low dose propofol in reducing the incidence of EA at the end of face-mask sedation with sevoflurane. Methods: This was a prospective observational study and was conducted in the Department of Pediatric Anesthesia of Bangladesh Shishu Hospital and Institute, Dhaka, Bangladesh during the period from July, 2021 to December, 2021.In our study we took 220 children operated for hernia were randomized into two groups – Group A (Control group, n=110) and Group B (Propofol group, n= 110). Result: In total 220 patients from both the groups completed the study. In our study we found the mean age in group A &amp; B was 6.3 ± 1.6 &amp; 6.1 ± 1.9 years respectively. The mean PAED score was 14.41 ± 2.59 &amp; 9.83 ± 3.51, the mean emergence time was 7.1 ± 2.0 &amp; 13.4 ± 2.5, time in PACU was 44.5 ± 5.9 &amp; 46.6 ± 7.6 mins in control &amp; propofol group respectively. In contrast to the control group, no patient in the propofol group experienced EA beyond 15 or 20 minutes of emergence. Conclusion: In our study, we found that 0.5mg,/kg propofol was effective in preventing Emergence Agitation in children underwent herniotomy with caudal block and who’s sedation were maintained with sevoflurane.

Association between the Depth of Sevoflurane or Propofol Anesthesia and the Incidence of Emergence Agitation in Children: A Single-Center Retrospective Study.

In the present study, we investigated the hypothesis that the depth of general anesthesia affects emergence agitation (EA) in children in the early postanesthetic period. We retrospectively examined male and female children (aged 1-9 years) who underwent ambulatory surgery that lasted < 2 h. Various parameters, including the modified Yale Preoperative Anxiety Score (mYPAS) before anesthesia induction, the Pediatric Anesthesia Emergence Delirium (PAED) score at recovery time, and the value of the patient state index (PSI), were extracted from our electronic anesthesia database. The relationships between the PAED score and the mean PSI values were examined with univariate analyses. We also investigated the associations among the mean PSI, propofol anesthesia, age, mYPAS, the type of surgery, and the total amount of fentanyl divided by body weight with the PAED score using multiple regression analysis with interaction terms. There were 32 and 34 patients in the sevoflurane and propofol groups, respectively. The PAED scores (all patients: r = -0.34, p = 0.0048; sevoflurane group: r = -0.37, p = 0.036) were negatively correlated with the mean PSI, whereas the PAED score in the propofol group [r = 0.31 (-0.03, 0.59), p = 0.073] did not show a significant positive correlation with the mean PSI in the univariate analysis. The multiple linear regression analysis outcomes revealed that the mean PSI value was an independent clinical factor associated with the PAED score. Intraoperative electroencephalogram monitoring may be proved as one of the useful tools for the assessment of EA risks in children.

Çocuklarda Obezitenin Postoperatif Derlenme Ajitasyonuna Etkisi

Objective: Although the factors affecting emergence agitation (EA) have been examined in the literature, the literature evaluating the effect of obesity on postoperative EA in children is limited. In this study, we aimed to evaluate whether obesity has an effect on postoperative EA.&#x0D; Material and method: The medical records of patients aged 2-14 years, with ASA I-II physical status and undergoing elective surgery were reviewed (November 2018 and November 2022). Patients who underwent emergency surgery or who used an anesthetic agent other than sevoflurane for the maintenance of anesthesia were excluded from the study. Patients will be divided into 3 groups according to their body mass index; Group 1; Normal (5th to 85% percentile), Group 2; Overweight (85-95% percentile), Group 3; Obese (95th percentile and above). Emergence agitation was assessed by anesthesiologists using the Watcha scale.&#x0D; Results: 567 patients were included in the study and EA occurred in 115 (20.3%) of them. Of the patients, 428 were considered normal, 64 were overweight and 75 were obese. When demographic data were compared, there was no statistical difference between the groups. EA incidence was statistically higher in Group II (28.1%) and Group III (29.3%)compared to Group I (17.5%) (p=0.006).&#x0D; Conclusion: In conclusion, we are of the opinion that both overweight and obesity increase the incidence of EA in children undergoing general anesthesia, but prospective further studies are also required.

Nalbuphine reduces the incidence of emergence agitation in children undergoing Adenotonsillectomy: A prospective, randomized, double-blind, multicenter study

ObjectiveTo evaluate the effect of nalbuphine on emergence agitation (EA) in children undergoing adenotonsillectomy. DesignMulticenter, prospective, double-blind, randomized controlled trial. SettingThe First People's Hospital of Foshan and three other participating institutions in China, from April 2020 to December 2021. PatientsEight hundred patients, 3–9 years of age, American Society of Anesthesiologists (ASA) classification I or II, undergoing elective adenotonsillectomy were included. InterventionsNalbuphine (0.1 mg/kg) or saline was administered intravenously. MeasurementsThe incidence of EA; the pediatric anesthesia emergence delirium (PAED) scale; and the faces, legs, activity, cry, and consolability (FLACC) scales. Extubation time, duration of post-anesthesia care unit (PACU) stay, anesthesia nurses' and parents' satisfaction, and other side effects. Main resultsThe incidence of EA in the nalbuphine group was lower than that in the saline group 30 min after extubation (10.28% vs. 28.39%, P = 0.000). In addition, the FLACC scores in the nalbuphine group were lower than those in the saline group 30 min after extubation (P < 0.05). Furthermore, the proportion of moderate-to-severe pain cases (FLACC scores >3) was significantly lower in the nalbuphine group than in the saline group (33.58% vs. 60.05%, P = 0.000). Adjusting the imbalance of postoperative pain intensity, the risk of EA was still lower in the nalbuphine group at 0 min (OR, 0.39; 95% CI, 0.26–0.60; P = 0.000), (OR, odds ratio; CI, confidence interval), 10 min (OR, 0.39; 95% CI, 0.19–0.79; P = 0.01), and 20 min (OR, 0.27; 95% CI, 0.08–0.99; P = 0.046) than in the saline group. There were no significant differences in extubation time, duration of PACU stay, nausea and vomiting, or respiratory depression between the two groups (P > 0.05). ConclusionNalbuphine reduced the incidence of EA in children after adenotonsillectomy under general anesthesia, which may be involved in both analgesic and non-analgesic pathways.

A RANDOMIZED CONTROL STUDY COMPARING EMERGENCE CHARACTERS OF DESFLURANE WITH HALOTHANE IN PAEDIATRIC PATIENTS UNDERGOING GENERAL ANAESTHESIA.

Background: Emergence agitation (EA) was described at rst by Eckenhoff et al in the early 1960s. EA has been described as a dissociated state of consciousness in which the child is inconsolable, irritable, uncooperative, typically thrashing, crying, moaning or incoherent. Although EA is usually self-limited and occurs within the rst 30-minutes of recovery in PACU, but it can last up to 2 days and lead to physical damage, disconnection of intravenous catheters, removing of dressing or drainage tube and monitoring devices. Although, numerous medications have been studied to prevent or reduce EA in children, no special preventive method has been shown to be highly superior. Aims and objectives: The aim of this study is to compare the emergence characters of Desurane with Halothane. The primary objective is to compare the Emergence characters using PAED (Pediatric Anaesthesia Emergence Delirium) score. The secondary objective is : 1) To compare the recovery characters(Time to recover) using Steward Recovery Scores. 2) To compare the PACU discharge criteria meeting time with Modied Aldrete Score. 3) To assess post operative Pain, nausea, vomiting, shivering. Materials and Methods: This Randomized interventional study (single blinded) was conducted in Institute of child health and hospital for children, egmore from October 2019 to December 2019. 70 Pediatric patients based on the parent article, Comparison of Emergence and Recovery characteristics of Sevourane, Desurane, and Halothane in Pediatric Patients undergoing General Anaesthesia, authored by Welborn ,Hannallallah Published AnesthAnalg. 1996 Nov;83(5):917-20. Result: Recovery time, Emergence Agitation, Time to reach discharge criteria and post operative complications were compared. Post anaesthesia Emergence Agitation was higher in Desurane group compared to Halothane group which was statistically signicant. Desurane resulted in faster recovery, early Emergence than Halothane which was statistically signicant. This is due the fact that Desurane has very low Blood Gas Solubility index which results in rapid emergence and thus Emergence Agitation. Though time to reach discharge criteria was not much prolonged in Halothane group, study showed statistically signicant difference between two groups. Post operative complications is not statistically signicant between two groups. Conclusion: In our study Post anaesthesia Emergence Agitation was signicantly higher in Desurane group compared to Halothane group. Desurane anaesthesia resulted in rapid Emergence, early recovery compared to Halothane anaesthesia .

Comparison of pre-extubation propofol and midazolam to prevent emergence agitation in children—a prospective randomized study

BackgroundEmergence delirium is one of the most common and troublesome complications seen after inhalational anesthesia, with an estimated 20–80% incidence rate. It can lead to an increase in mortality, morbidity, and hospital stay, which indirectly reflects a major economic burden. The aim of our study is to compare the effect of propofol and two different doses of midazolam to prevent emergence agitation in children given 5 min before extubation. Seventy-five ASA (American Society of Anesthesiologists) Physical Status I–II patients aged 2–14 years who were scheduled for elective surgeries under general anesthesia were included in the study. Patients in the study groups were randomized into three groups 25 in each group; group P (propofol of 0.5 mg/kg iv), group ML (midazolam low dose of 0.03 mg/kg iv), and group M (midazolam of 0.05 mg/kg iv) given 5 min before extubation. The primary objective was to study the effect of propofol and two different doses of midazolam for the prevention of emergence agitation in children. The secondary objective was to observe the complications like bronchospasm, laryngospasm, persistent cough, and desaturation in pediatric patients.ResultsThe time taken for emergence from anesthesia after surgery in the propofol group was 5.11 ± 1.223 min and in the group midazolam low dose and midazolam time taken was 8.53 ± 2.326 min and 12.45 ± 2.145 min, respectively, and was found to be statistically significant. The incidence of delirium observed with a Cole score of >3 was seen in 14 (56%) patients in group P, 7 (28%), and 6 (24%) patients of groups ML and M, respectively.ConclusionsMidazolam in low doses given before extubation is effective in preventing the emergence delirium during the postoperative period in pediatric patients without delay in recovery during general anesthesia.

Efficacy of different doses of intranasal dexmedetomidine in preventing emergence agitation in children with inhalational anaesthesia: A prospective randomised trial.

Emergence agitation is a common paediatric complication after inhalational anaesthesia. Intranasal dexmedetomidine can prevent emergence agitation effectively, but the optimal dose is uncertain. The aim of our study was to investigate the 95% effective dose (ED 95 ) of intranasal dexmedetomidine for the prevention of emergence agitation after inhalational anaesthesia for paediatric ambulatory surgery. A prospective, randomised, placebo-controlled, double-blind, clinical trial. The study was conducted in Guangzhou Women and Children's Medical Center in China from August 2017 to December 2018. Three hundred and eighteen children scheduled for ambulatory surgery were enrolled into two age groups of less than 3 years and at least 3 years. The children in each age group were randomised into five equal subgroups to receive either intranasal dexmedetomidine 0.5, 1.0, 1.5 or 2.0 μg kg -1 (Groups D 0.5 , D 1.0 , D 1.5 and D 2.0 ), or intranasal isotonic saline (group C) after induction. The primary outcome was the ED 95 dose of intranasal dexmedetomidine for preventing emergence agitation after inhalational anaesthesia for paediatric ambulatory surgery. The incidences of emergence agitation for Groups C, D 0.5 , D 1.0 , D 1.5 and D 2.0 were 63, 40, 23, 13 and 3% in children less than 3 years, and 43, 27, 17, 7 and 3% in children at least 3 years. The ED 95 of intranasal dexmedetomidine for preventing emergence agitation was 1.99 μg kg -1 [95% confidence interval (CI), 1.83 to 3.80 μg kg -1 ] in children less than 3 years, and 1.78  μg kg -1 (95% CI, 0.93 to 4.29 μg kg -1 ) in children at least 3 years. LMA removal time for groups D 1.5 and D 2.0 was 9.6 ± 2.2 and 9.7 ± 2.5 min, respectively, for children less than 3 years, and 9.4 ± 2.0 and 9.9 ± 2.7 min in children at least 3 years, respectively. Length of stay in the postanaesthesia care unit for Groups D 1.5 and D 2.0 was 34.3 ± 9.6 and 37.1 ± 11.2 min, respectively, in children less than 3 years, and 34.7 ± 10.2 and 37.3 ± 8.3 min in children at least 3 years, respectively. These times were longer in the D 1.5 and D 2.0 subgroups than in the control subgroup in the two age groups of less than 3 years and at least 3 years, respectively: 7.2 ± 1.9 min in children less than 3 years and 7.3 ± 2.5 min in children at least 3 years for LMA removal time, 22.2 ± 7.9 min in children less than 3 years and 22.0 ± 7.7 min in children at least 3 years for PACU stay time in control subgroup, respectively ( P  < 0.05). Intranasal dexmedetomidine prevented emergence agitation after paediatric surgery in a dose-dependent manner. The optimal dose of intranasal dexmedetomidine for preventing emergence agitation was higher in younger children. chictr.org.cn: ChiCTR-IOR-17012415.

Fentanyl Versus Dexmedetomidine for the Prevention of Emergence Agitation in Children After Sevoflurane Anaesthesia: A Comparative Clinical Study.

IntroductionSevoflurane is widely used in pediatric anesthesia due to its rapid onset and offset of action, smooth induction, and less hepatotoxicity. However, it is associated with emergence agitation, which can be frightening and harm the patient or the caregiver. While a definite preventive measure of emergence agitation is in search, the use of some drugs is associated with a lesser incidence of emergence related to sevoflurane. Aims and objectiveThis study aimed to compare the efficacy of fentanyl with dexmedetomidine in preventing emergence agitation in children undergoing surgery with sevoflurane anesthesia. Also, we assessed the perioperative hemodynamic and postoperative recovery characteristics and side effects, if any, between children receiving the two groups of drugs.Material and methodWe conducted a prospective, double-blinded, randomized controlled trial after getting approval from the institutional ethical committee. A total of 120 patients were recruited into the study and divided into two groups, F and D, of 60 patients each. Patients in group F received an infusion of injection fentanyl at 1 mcg/kg and patients in group D received infusions of injection dexmedetomidine at 0.15 mcg/kg, respectively, after induction of general anaesthesia. Additionally, all patients received a caudal epidural block with 0.125% isobaric levobupivacaine. After the conclusion of surgery, we transferred the patients to the post-anaesthesia care unit for further observation and assessment.ResultThe Pediatric Anesthesia Emergence Delirium (PAED) score for emergence agitation was significantly greater in the fentanyl group compared to the dexmedetomidine group at 0 minutes (7.08 ± 1.03 vs. 6.43 ± 1.33, p = 0.003) and 15 minutes (5.51 ± 1.7 vs. 4.01 ± 1.08, p = 0.0001) postoperative period. The mean time to eye-opening was significantly earlier amongst children receiving fentanyl than those receiving dexmedetomidine (9.3 ± 1.1 min vs. 10.12 ±1.05 min, p = 0.0001). The modified Aldrete Score for adequacy of recovery was statistically insignificant initially, but as the duration progressed to 15 minutes, the children in the fentanyl group had significantly higher scores than those in the dexmedetomidine group (8.05 ± 0.67 vs. 7.76 ± 0.62, p = 0.01).ConclusionProphylactic administration of dexmedetomidine (0.15 mcg/kg) or fentanyl (1 mcg/kg) administered is effective in preventing emergence agitation. Although we found emergence agitation was higher amongst children receiving fentanyl than those receiving dexmedetomidine during the early recovery period, this difference became insignificant as the postoperative period increased to 30 minutes.

Emergence agitation in children: A comparison of effect of intravenous midazolam and ketamine

Background- Emergence agitation (EA) is one of the most challenging conditions to manage in pediatric patients undergoing general anesthesia with sevoflurane as it can even lead to physical harm. Various pharmacological interventions are being used in anesthesia to manage this condition. So, the objective of this study is to compare the effects of intravenous midazolam and intravenous ketamine given as premedication, on the incidence and severity of EA and to assess parent separation anxiety and postoperative pain and analgesic requirement in the 2 groups. Methodology- This is a randomized control trial consisting of 70 children aged 3-7years, 35 in each midazolam and ketamine group that received 0.05mg/kg of i.v. inj. midazolam and 1mg/kg of i.v. inj. ketamine respectively, undergoing general anesthesia with sevoflurane. Emotional status of the child assessed and then allocated into either group through a computer-generated programme. A blinded anesthesiologist assessed the incidence and severity of emergence agitation based on WATCHA scale and Children and Infant Postoperative Pain Scale (CHIPPS). Results- The mean WATCHA and CHIPPS scores were lower in ketamine group at all timepoints versus midazolam group (p&lt;0.05 which is statistically significant). 

Postoperative propofol bolus treatment did not affect recovery time in patients with emergence agitation after sevoflurane anesthesia in pediatric patients undergoing strabismus surgery: Prospective nonrandomized case-control study.

The incidence of emergence agitation (EA) after sevoflurane anesthesia is high, especially in pediatric strabismus surgery. However, research thus far has focused on the pharmacological prophylaxis of EA and administering drugs to pediatric patients without EA is problematic. The purpose of this study was to determine whether the use of propofol after sevoflurane anesthesia affects recovery time in patients with EA. After obtaining informed written consent, 113 children (aged 2-12 years) with the American Society of Anesthesiologists physical status of I or II who underwent strabismus surgery were enrolled. Patients were divided into 2 groups; upon arrival at the postanesthetic care unit (PACU), patients who had EA (pediatric anesthesia emergence delirium [PAED] scale score ≥14) were treated with 1.0 mg/kg 1% propofol (group P: n = 30). Patients who did not have EA (PAED scale score <14, group C: n = 83) were taken care of in the PACU without propofol administration. There was no difference in the PAED scale scores between the 2 groups from 10 minutes to discharge from the PACU (P > .05). There was no difference in PACU stay time between the 2 groups (P > .05). We concluded that propofol administration for intense EA alleviated EA symptoms and prevented an increase in the duration of PACU stay due to EA in children undergoing strabismus surgery under sevoflurane anesthesia.

A systematic review and meta-analysis on the efficacy and safety of dexmedetomidine combined with sevoflurane anesthesia on emergence agitation in children.

BackgroundThe incidence of restlessness in the wake-up period of sevoflurane inhalation anesthesia is high. Although many studies have explored the relationship between dexmedetomidine and restlessness in the wake-up period of sevoflurane anesthesia in children, they can’t keep consistent conclusions and lack evidence-based medical evidence. Meta-analysis was conducted to explore the efficacy and safety of dexmedetomidine in the treatment of restlessness during the recovery period of sevoflurane anesthesia in children, and to provide reference for clinic.MethodsRelevant articles were retrieved from PubMed, Embase, MEDLINE, Science Direct, The Cochrane Library, the Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, the Chinese Science and Technology Periodical Database, and the Chinese BioMedical Literature Database (CBM). The Chinese and English search keywords included “dexmedetomidine”, “children”, “sevoflurane”, and “emergence agitation”. The articles included were independently evaluated and cross-checked by 2 professionals in strict accordance with the 5 evaluation criteria for randomized controlled trials (RCTs) in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.0.1).ResultsA total of 16 articles were included in this meta-analysis. Of the 16 RCTs, 14 described the generation of random sequences in detail, 8 described allocation concealment in detail, no patient blinding was described due to different surgical methods, 8 articles used operator blinding, and all 16 articles had complete outcome measures. The incidence of emergence agitation in the 0.5 µg/kg dexmedetomidine group was significantly lower than that in the control group, and the difference was statistically significant [odds ratio (OR) =0.22, 95% CI: 0.13, 0.40, P<0.00001]. The incidence of analgesic rescue in the experimental group was significantly lower than that in the control group, and the difference was statistically significant (OR =0.29, 95% CI: 0.13, 0.63, Z =3.13, P=0.002). The incidence of postoperative nausea and vomiting in the experimental group was significantly lower than that in the control group, and the difference was statistically significant (OR =0.33, 95% CI: 0.20, 0.55, Z =4.29, P<0.0001).DiscussionThe results of this meta-analysis confirmed that dexmedetomidine could reduce the incidence of emergence agitation, postoperative analgesic rescue, and nausea and vomiting in children after sevoflurane anesthesia.

Effectiveness of acupuncture therapy for preventing emergence agitation in children: A protocol for systematic review and meta-analysis with trial sequential analysis.

Pain, autonomic distress, and emergence agitation occur commonly in children undergoing general anesthesia. While acupuncture therapy has been reported to effectively reduce such pain and autonomic distress in children, its effect in preventing emergence agitation remains unclear. Therefore, we will conduct a systematic review and meta-analysis with trial sequential analysis to evaluate the effect of acupuncture therapy in preventing emergence agitation in children undergoing general anesthesia. Methods and analysis This protocol was prepared according to the 2015 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for Protocols guidelines. We will conduct a search for randomized controlled trials that evaluated the effect of acupuncture therapy in preventing emergence agitation. The following databases will be searched for relevant articles: MEDLINE, CENTRAL, Embase, and Web of Science; four pre-registration sites will be accessed from inception to April 1, 2021. No language restrictions will be applied. Two authors will independently scan and select eligible studies, extract the data, and assess the risk of bias. The incidence of emergence agitation will be combined as a risk ratio with a 95% confidence interval using a random-effect model. The I2 statistics will be used to assess heterogeneity. We will evaluate the quality of the clinical trials using the Cochrane methodology and assess the quality of evidence using the Grading of Recommendation Assessment, Development, and Evaluation approach. If appropriate, a trial sequential analysis will be performed. Expected outcomes This meta-analysis will be the first to evaluate the effect of acupuncture therapy in preventing emergence agitation in children. The findings from this meta-analysis have the potential to reveal pivotal factors that affect the clinical effect of acupuncture therapy, thereby supporting the optimization of acupuncture therapy for emergence agitation.Protocol registration University Hospital Medical Information Network Clinical Trials Registry (UMIN000040775).

The Effects of Different Doses of Alfentanil and Dexmedetomidine on Prevention of Emergence Agitation in Pediatric Tonsillectomy and Adenoidectomy Surgery.

Background: Emergence agitation (EA) is a common problem often observed in children after sevoflurane anesthesia, which can be prevented by dexmedetomidine and alfentanil. This study aims to compare the effectiveness of dexmedetomidine alone and with different doses of alfentanil in preventing EA in children under sevoflurane anesthesia. Materials and Methods: In a double-blind trial, 80 children (ASA I or II, 3–7 years old) undergoing tonsillectomy alone and adenotonsillectomy with sevoflurane anesthesia were randomly assigned into four groups: the control group, dexmedetomidine (DEX) group, dexmedetomidine plus 10 μg/kg alfentanil group (DEX + Alf1), and dexmedetomidine plus 20 μg/kg alfentanil group (DEX + ALf2). The incidence of EA was assessed with the Aono’s scale, and the severity of EA was evaluated with the Pediatric Anesthesia Emergence Delirium (PAED) scale. The time of tracheal extubation and time of wake were recorded. Postoperative pain and complications such as nausea and vomiting, cough, laryngospasm, and bradycardia were recorded. Results: The incidence of EA was 50% in the control group, 25% in the DEX group, and 5% in the DEX + Alf1 group, and it never happened in the DEX + Alf2 group. The Aono’s scale, the PAED scale, and the FLACC scale in the control group and the DEX group were significantly more than those in the DEX + Alf1 group and the DEX + Alf2 group after the tracheal extubation (p < 0.05). The time of tracheal extubation of the control group and the DEX group were significantly shorter than those in the DEX + Alf1 group and the DEX + Alf2 group (p < 0.05). The awakening time of the DEX + Alf2 group is significantly longer than those in other groups (p < 0.05). The case of postoperative nausea and vomiting in the DEX + Alf1 group was fewer than those in the other groups (p < 0.05). And, the cases of cough and laryngospasm and bronchospasm in the DEX + Alf1 group and the DEX + Alf2 group were significantly less than those in the control group and the DEX group after the tracheal extubation (p < 0.05). Conclusion: The combined administration of alfentanil and dexmedetomidine can reduce EA in children undergoing tonsillectomy alone and adenotonsillectomy with sevoflurane anesthesia. Dexmedetomidine plus 10 μg/kg alfentanil seems to be more appropriate than other dose combinations as it reduced EA and postoperative nausea and vomiting but did not prolong the time to awake.