Pediatric Anesthesia Emergence Delirium Scores Research Articles

Does heart rate variability using the Newborn Infant Parasympathetic Evaluation index identify postsurgical pain levels and emergence delirium in toddlers? A prospective observational study.

Children recovering from anesthesia commonly experience early postoperative negative behaviour, caused by pain and emergence delirium. Differentiating the two is challenging in young children. Perioperative pain influences the heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE) index and may also affect emergence delirium. We sought to investigate whether the perioperative NIPE index can discriminate between mild, moderate, or severe pain levels and can detect emergence delirium. This prospective observational study enrolled children aged three years or younger undergoing elective adenotonsillectomy, tonsillectomy, or adenoidectomy. The NIPE index, the Faces, Legs, Activity, Cry, Consolability (FLACC) score, and the Pediatric Anesthesia Emergence Delirium (PAED) score were recorded in the postanesthesia care unit (PACU). The primary aim was to investigate the relationship between the postoperative NIPE index and postoperative pain severity. The secondary aims were to evaluate the association between the NIPE index and emergence delirium (PAED ≥ 10) and its delirium-specific (ED-I) and pain-specific (ED-II) components. Sixty-nine children were recruited. In the PACU, the mean (standard deviation [SD]) NIPE values in children experiencing moderate and severe pain were 50 (12) and 49 (14), respectively. These values were significantly lower than the mean (SD) value of 64 (13) observed in children with mild pain (mean difference moderate vs no/mild pain, -14; 95% confidence interval [CI], -17 to -11; P < 0.001, and mean difference severe vs no/mild pain, -17; 95% CI, -20 to -14; P < 0.001, respectively). The NIPE index was significantly lower in children experiencing pain-specific ED-II (mean [SD] NIPE instantaneous [NIPEi] for ED-II 49 [10] vs no ED-II 55 [13]; mean difference, -6; 95% CI, -11 to -2; P = 0.009). The NIPE index was unable to detect emergence delirium (mean [SD] NIPEi for ED, 54 [15] vs no ED, 51 [10]; mean difference, 3; 95% CI, -2 to 8; P = 0.23) or the delirium-specific component ED-I (mean [SD] NIPEi for ED-I, 55 [15] vs no ED-I, 51 [11]; mean difference, 4; 95% CI, 0 to 8; P = 0.06). The NIPE index can identify moderate and severe postoperative pain after adenotonsillectomy but not emergence delirium in children aged three years and younger. This discrimination can be valuable in the early postoperative phase when the differentiation between pain and emergence delirium is difficult. ClinicalTrials.gov ( NCT04909060 ); first submitted 26 May 2021.

The effect on perioperative anxiety and emergence delirium of the child or parent's preference for parental accompaniment during anesthesia induction in children undergoing adenotonsillectomy surgery.

Pediatric emergence delirium (ED) occurs in the early postoperative period and is defined as a complex psychiatric disorder. Non-pharmacological methods of treatment, such as perioperative parental presence, have been the focus of many studies, but the impact on preventing ED of which parent accompanies the child during anesthesia induction has not been identified as yet. Therefore, the aim of this study was to determine whether the selection made by children undergoing adenotonsillectomy of which parent will accompany them during anesthesia induction has the effect of reducing postoperative delirium scores and incidence compared to selections made by the parents. The study included 80 children of both genders, aged 5-12 years, who underwent day-case surgery in the otorhinolaryngology clinic. The patients were separated randomly into two groups of 40. In Group 1, the children were asked to choose which of their parents would accompany them during general anesthesia induction, and in Group 2, the parents were asked to decide who would be the accompanying parent. Evaluation of postoperative delirium was made using the Pediatric Anesthesia Emergence Delirium (PAED) scale. The anxiety level of the children was evaluated with the modified Yale Preoperative Anxiety Scale (mYPAS) both in the preoperative waiting area and during the anesthesia induction. The State-Trait Anxiety Inventory (STAI) was used to evaluate the anxiety level of the parents. The mean PAED scores were similar in both groups (mean difference [95% CI]: -0.1 [-2.8 to 0.7]). The incidence of emergence delirium was also similar in both groups (risk ratio 0.9 [0.4 to 1.8]). The mean mYPAS scores during the induction of anesthesia of Group 1 was lower than that of Group 2 (mean difference [95% CI]: -8.4 [-15.2 to -1.6]). The mean mYPAS scores evaluated in the preoperative waiting area were found to be similar in the two groups (mean difference [95% CI]: -1.9 [-7.5 to 3.5]). The mean STAI anxiety scores of the parents were similar in both groups, with higher scores obtained by mothers compared to fathers, at all measurement times. The incidence or severity of ED did not decrease significantly even though lower anxiety scores were obtained during anesthesia induction in children who were allowed to make the decision of accompanying parent. Based on these findings, it can be concluded that postoperative delirium is a more complicated process that can be affected by many other variables rather than just the parent-child general interaction.

Effect of Dexmedetomidine versus Propofol on Sevoflurane related Emergence Agitation in Paediatric Patients: A Randomised Clinical Study

Introduction: Postoperative Emergence Agitation (EA) is a troublesome side-effect of sevoflurane anaesthesia. Drugs like dexmedetomidine and propofol offer significant benefits in reducing the incidence and severity of sevoflurane-related postoperative EA in paediatric patients. Aim: To compare the efficacy of intravenous dexmedetomidine and propofol in reducing the incidence and severity of EA associated with sevoflurane anaesthesia in paediatric patients. Materials and Methods: A randomised clinical study was conducted on 140 patients, belonging to American Society of Anaesthesiologists Physical Status (ASA PS) classes I and II, aged between 2-6 years, undergoing infraumbilical surgery lasting more than one hour. The patients were divided into two equal groups receiving dexmedetomidine 0.3 μg/kg (Group SD) and propofol 1 mg/kg (Group SP) at the start of skin closure, administered over 10 minutes. The incidence of EA in the Post Anaesthesia Care Unit (PACU) was evaluated using the Watcha scale, and the severity of EA was assessed using the Paediatric Anaesthesia Emergence Delirium (PAED) scale. A Watcha score of 3 or 4 indicated the presence of EA, while a PAED score of ≥12 was deemed significant. Statistical analysis of the data was performed using International Business Machines (IBM) Statistical Package for Social Sciences (SPSS) version 22.0, with an Independent sample t-test for comparing normally distributed quantitative parameters, and the Chi-square test for comparing categorical outcomes between the study groups. Results: The mean age of the patients in group SD was 4.19±0.78 years, and in group SP was 4.03±0.71 years. Both study groups were found to be comparable in terms of patient characteristics such as age, sex, weight, and duration of surgery (p-value &gt;0.05). The incidence of postoperative EA, as measured by the Watcha scale, was higher in group SP compared to group SD upon arrival and up to 30 minutes in the PACU (p-value &lt;0.001). The severity of EA, assessed using the PAED score, was greater in group SP compared to group SD at 0, 5, 10,15 and 20 minutes in the PACU (p-value &lt;0.001). Conclusion: Dexmedetomidine 0.3 μg/kg was more effective than propofol 1 mg/kg in reducing the incidence and severity of EA associated with sevoflurane anaesthesia, with minimal haemodynamic effects and no clinically relevant severe adverse effects in both the groups. The significantly prolonged extubation times observed in the propofol group did not result in significantly longer stays in the PACU.

Protocol for a randomized controlled trial to reduce pediatric anesthesia emergence delirium by titration of sevoflurane anesthesia using brain function monitoring

BackgroundEmergence agitation or emergence delirium is a common complication of unknown etiology in pediatric anesthesia. Pediatric anesthesia emergence delirium (PAED) has been reported most commonly in younger children and may occur in about 30% of children up to 5–6 years old. Exposure to anesthetic agents may contribute to PAED, and we hypothesized that a management strategy to minimize exposure to volatile anesthetics may reduce PAED. Electroencephalography (EEG) signatures captured and displayed by brain function monitors during anesthesia change with concentration of sevoflurane and level of unconsciousness, and these EEG signatures may be used to inform titration of anesthetics.MethodsA single-center, parallel-group, two-arm, superiority trial with a 1:1 allocation ratio will be performed to compare the incidence of PAED following standard sevoflurane anesthesia (maintained at 1.0MAC) and EEG-guided anesthesia (minimum concentration to sustain surgical anesthesia as determined by monitoring of EEG signatures). Participants between 1 and 6 years of age undergoing surgical procedures involving minimal postoperative pain will be randomly assigned to receive standard (n = 90) or EEG-guided (n = 90) anesthesia. PAED score will be assessed by a blinded observer in the PACU on arrival and after 5, 10, 15, and 30 min.DiscussionAnesthesia management with proactive use of brain function monitoring is expected to reduce exposure to sevoflurane without compromising surgical anesthesia. We expect this reduced exposure should help prevent PAED. Routinely administering what may be considered standard levels of anesthetic such as 1.0 MAC sevoflurane may be excessive and potentially associated with unfavorable sequelae such as PAED.Trial registrationJapan Registry of Clinical Trials (jRCT) jRCTs032210248. Prospectively registered on 17 August 2021.

Incidence and risk factors for emergence delirium in children undergoing surgery under general anaesthesia - A prospective, observational study.

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. 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. 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. 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.

Individual cartoon video for alleviating perioperative anxiety and reducing emergence delirium in children: a prospective randomised trial

BackgroundPerioperative anxiety and emergence delirium (ED) in young children may cause a series of adverse events, which are worth investigating. Pharmacological treatments of anxiety and delirium remain uncertain, while non-pharmacological...

Reduced regional cerebral oxygen saturation increases risk for emergence delirium in pediatric patients.

To assess whether decreased regional cerebral oxygen saturation (rScO2) is associated with the emergence delirium (ED) following general anesthesia in the pediatric population. A retrospective observational cohort study was conducted on 113 children (ASA I-III) aged 2-14 years who underwent selective surgery under general anesthesia between 2022-01 and 2022-04. Intraoperatively, the rScO2 was monitored using a cerebral oximeter. The Pediatric Anesthesia Emergence Delirium (PAED) score was used to evaluate the patients for ED. The incidence of ED was 31%. Low rScO2 was reported in 41.6% of patients, who had a higher incidence of ED (P < 0.001) than those who did not experience desaturation. Logistic regression analysis revealed that decreased rScO2 was significantly associated with incident ED events [odds ratio (OR), 10.77; 95% confidence interval, 3.31-35.05]. Children under 3 years of age had a higher incidence of ED after rScO2 desaturation during anesthesia compared to older children (OR, 14.17 vs. 4.64). Intraoperative rScO2 desaturation significantly increased the incidence of ED following general anesthesia. Monitoring should be enhanced to improve the oxygen balance in vital organs to improve the quality and safety of anesthesia.

Risk of esketamine anesthesia on the emergence delirium in preschool children after minor surgery: a prospective observational clinical study

Emergence delirium (ED) is a common mental complication during recovery from anesthesia. However, studies on the effects of esketamine, an intravenous anesthetic for pediatrics, on ED are still lacking. This study aimed to investigate the effects of a single-dose of esketamine during anesthesia induction on ED after minor surgery in preschool children. A total of 230 children (aged 2-7years) completed the study. The exposed group (0.46mgkg-1: average dose of esketamine) was associated with an increased incidence of ED and a higher maximum Pediatric Anesthesia Emergence Delirium score than the non-exposed group. The length of post-anesthesia care unit stay was longer in the exposed group than the non-exposed group. In contrast, extubation time, face, legs, activity, cry, and consolability (FLACC) scores, and the proportions of rescue analgesics were comparable between the two groups. Furthermore, five factors, including preoperative anxiety scores, sevoflurane and propofol compared with sevoflurane alone for anesthesia maintenance, dezocine for postoperative analgesia, FLACC scores, and esketamine exposure, were associated with ED. In conclusion, a near-anesthetic single-dose of esketamine for anesthesia induction may increase the incidence of ED in preschool children after minor surgery. The use of esketamine in preschool children for minor surgery should be noticed during clinical practice.

Effect of S-ketamine administered at the end of anesthesia on emergence delirium in preschool children undergoing tonsillectomy and/or adenoidectomy.

Background: S-ketamine (the S-isomer of ketamine) is twice as potent as the racemic mixture of this agent and carries fewer side effects when administered to humans. Information regarding the use of S-ketamine for the prevention of emergence delirium (ED) is limited. Thus, we evaluated the effect of S-ketamine administered at the end of anesthesia on ED in preschool children undergoing tonsillectomy and/or adenoidectomy. Methods: We investigated 108 children aged 3-7years, who were scheduled for elective tonsillectomy and/or adenoidectomy under general anesthesia. They were randomly assigned to receive either S-ketamine 0.2mg/kg or an equal volume of normal saline at the end of anesthesia. The primary outcome was the highest score on the pediatric anesthesia ED (PAED) scale during the first 30min post-surgery. The secondary outcomes included the incidence of ED (defined as a score of ≥ 3 on Aono scale), pain score, time to extubation, and incidences of adverse events. Multivariate analyses were also performed using logistic regression to evaluate the independent factors predictive of ED. Results: The median (interquartile range) PAED score of the S-ketamine group (0 [0, 3]) was significantly lower than that in the control group (1 [0, 7]) (estimate median difference = 0, 95% confidence interval -2 to 0, p = 0.040). Significantly fewer patients in the S-ketamine group had an Aono scale score ≥ 3 (4 [7%] vs. 12 [22%], p = 0.030). Patients in the S-ketamine group also had a lower median pain score than did control subjects (4 [4, 6] vs. 6 [5, 8], p = 0.002). The time to extubation and incidences of adverse events were comparable between the two groups. However, multivariate analyses indicated that except S-ketamine use, pain scores, age and duration of anesthesia were independent factors predictive of ED. Conclusion: S-ketamine (0.2mg/kg) administered at the end of anesthesia effectively reduced the incidence and severity of ED in preschool children undergoing tonsillectomy and/or adenoidectomy without prolonging the time to extubation or increasing adverse events. However, S-ketamine use was not an independent factor predictive of ED.

Comparison of dexmedetomidine and clonidine for the prevention of emergence delirium in children undergoing lower abdominal surgery under sevoflurane anesthesia

Abstract Objective: In this study, we compared the efficacy of dexmedetomidine, clonidine, and placebo in the prevention of emergence delirium (ED) in children undergoing lower abdominal surgeries under sevoflurane anesthesia. Materials and Methods: We conducted a prospective randomized double-blinded study on 75 patients aged 4–10 years belonging to the American Society of Anesthesiologists I or II, undergoing lower abdominal surgeries of 1–2 h duration under sevoflurane anesthesia. The children were randomly distributed into three groups: dexmedetomidine (Group D), clonidine (Group C), and saline group (Group S). The study drug was administered 10 min after induction of anesthesia. Intraoperative hemodynamic parameters were recorded. The Pediatric Anesthesia Emergence Delirium (PAED) score was used to assess the incidence and severity of ED at 0, 5, 10, 15, 20, 30, 45, and 60 min of arrival to the postanesthesia care unit. A score of ≥10 was considered to have ED. The Ramsay Sedation Score and the Face, Legs, Activity, Cry, Consolability (FLACC) score were used to assess the degree of sedation and the severity of pain, respectively. Results: Dexmedetomidine showed the lowest incidence of ED while the highest incidence was seen in the saline group. The PAED score was lowest in the dexmedetomidine group, followed by clonidine, and highest in the control group at all time intervals. The Ramsay Sedation Score and FLACC score were also lower in the dexmedetomidine group as compared to the clonidine and saline groups. Conclusion: Dexmedetomidine was found to be more efficacious in preventing ED as compared to clonidine in children.

Effects of bilateral transmucosal sphenopalatine ganglion block on intraoperative anesthetic requirements and recovery profile in children undergoing palatoplasty under general anesthesia.

Sphenopalatine ganglion block (SPGB) given as injection provides excellent perioperative analgesia during palatoplasty. Our objectives were to assess the effect of transmucosal SPGB on anesthetic requirements, intraoperative hemodynamics, recovery time, and emergence delirium in children undergoing palatoplasty. This prospective, randomized study was conducted in 30 children with cleft palate undergoing palatoplasty, divided into two equal groups. After induction and intubation, patients in Group B received bilateral SPGB using cotton-tipped applicators soaked in 2% lignocaine, which were passed through both the nares, and the distal tip was positioned just superior to middle turbinate and anterior to pterygopalatine fossa and sphenopalatine ganglion. In Group C, saline-soaked cotton applicators were used. All patients received general anesthesia as per a standardized protocol. Intraoperative heart rate, mean arterial pressure, the requirement of anesthetics, extubation time, and emergence delirium were compared. Compared with Group C, patients in Group B had significantly lower sevoflurane consumption (17.2 ± 2.6 vs. 27.5 ± 5.0mL, P < 0.001) and fentanyl consumption (2.2 ± 0.5 vs. 3.2 ± 0.6 μ/kg, P < 0.001).The extubation time was significantly shorter in Group B (3.9 ± 0.7 vs. 9.5 ± 1.6 minutes, P < 0.001). PAED (Pediatric Anesthesia Emergence Delirium Scale) scores at 5and 10 minutes were significantly higher in Group C (P < 0.001). Intraoperative heart rate was significantly higher in Group C. Group C had significantly higher mean arterial pressure at 15, 60, and 75 minutes. Preoperative, SPGB administered by mucosal application of local anesthetic significantly reduced sevoflurane and fentanyl requirements, with stable hemodynamics, quicker recovery, and less emergence delirium in children undergoing palatoplasty.

Analysis of anesthetic effect of dexmedetomidine in femoral shaft fracture surgery

To investigate the effect of dexmedetomidine (DEX) on hemodynamics and recovery period after femoral shaft fracture surgery. Fifty-two patients, aged 3 to 7 years, who underwent femoral shaft fracture reduction surgery in our hospital in 2019 were randomly divided into the experimental group (n = 26) and the control group (n = 26). Both groups were given routine propofol combined with remifentanil by intravenous anesthesia. The experimental group was continuously pumped with DEX after induction of anesthesia, while the control group was continuously pumped with the same volume of normal saline. The mean arterial pressure (MAP) and heart rate (HR) were recorded before anesthesia induction (T0), when laryngeal mask was inserted (T1), when skin was cut (T2), when intramedullary needle was inserted (T3), and when laryngeal mask was removed (T4). Extubation time after anesthesia withdrawal was recorded in the 2 groups. According to the Pediatric Anesthesia Emergence Delirium score, the agitation and the incidence of agitation were recorded immediately after extubation (T5), 10 minutes after entering the recovery room (T6) and 30 minutes after entering the recovery room (T7). There was no significant difference in MAP and HR between the 2 groups at T0 and T1 time points (P > .05). The MAP and HR of the experimental group at T2 to T4 were significantly lower than those of the control group (P < .05). The extubation time of the experimental group was longer than that of the control group (P < .05), but the Pediatric Anesthesia Emergence Delirium score and the incidence of agitation in the recovery period of the experimental group were lower than those of the control group (P < .05). In femoral shaft fracture surgery, intravenous anesthesia combined with continuous pumping DEX can effectively stabilize the hemodynamics of patients, and the incidence of postoperative agitation during anesthesia recovery is low.

Association between ABO blood groups and postoperative pain in children after adenotonsillectomy: a prospective cohort study

BackgroundIt has been known that ABO blood groups are linked to the phenotypes of certain diseases; however, and the relationship between ABO blood groups and postoperative pain have not been extensively studied, especially in children. This study was to investigate whether there would be an association between the four major ABO blood groups and postoperative pain, as indicated by the differences in pain scores and rescue fentanyl requirements among blood groups in children after adenotonsillectomy.MethodsA total of 124 children, aged 3–7 years, ASA I or II, and undergoing elective adenotonsillectomy were enrolled in the study. Postoperative pain was evaluated using the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) and the rescue fentanyl requirement in post anesthesia care unit (PACU) was analyzed. Pediatric Anesthesia Emergence Delirium (PAED) score and the duration of PACU were recorded. The postoperative nausea and vomiting (PONV) within 24 h were documented.ResultsAmong four blood type groups, no significant differences were observed regarding surgery time, and the gaps of fentanyl given at the anesthesia induction and the first rescue fentanyl injection in PACU. However, patients from AB and B blood groups had significantly higher pain score at initial CHEOPS assessment and consequently, higher consumption of rescue fentanyl during PACU stay. A significantly higher percentage of patients had received > 1 μg/kg rescue fentanyl. Higher PAED scores were also observed in AB and B blood groups.ConclusionPaediatric patients with AB and B blood type had higher postoperative CHEOPS pain score and required significantly more fentanyl for pain control than those with A and O blood type after T&A. The initial scores of PAED in patients with AB and B blood type were also higher than that in patients with A and O blood type.

Relationship between Fasting Times and Emergence Delirium in Children Undergoing Magnetic Resonance Imaging under Sedation.

Background and Objectives: This study aimed to determine whether there is a relationship between preoperative fasting time, fasting blood glucose (FBG), and postoperative emergence delirium (ED) in pediatric patients undergoing MRI under sedation. Materials and Methods: 110 pediatric patients were included in the study. Preoperative fasting (solid-fluid) time and FBG were recorded. The development of ED in the patients who underwent MRI under sedation was evaluated with the pediatric anesthesia emergence delirium (PAED) value for 30 min every 5 min in the recovery room. PAED score of ≥10 was grouped as having ED, and a PAED score of &lt;10 as without ED at any time. The PAED scores were compared with other variables, ASA, age, weight, MRI examination time, and FBG level and fasting times. The risk factors affecting the occurrence of ED were examined. Results: Mean age was 3.94 ± 1.53 years, mean FBG was 106.97 ± 12.53 mg/dL, fasting time was 10.75 ± 2.61 h, solid food fasting time was 11.92 ± 2.33 h, and thirst time was 10.74 ± 2.58 h. FBG was never associated with PAED measurement at any time (p &gt; 0.05). There was a weak positive correlation between the fasting time and the 0th, 5th, and 10th minute PAED score (r = 0.225; p = 0.018, r = 0.195; p = 0.041, r = 0.195; p = 0.041). There was a weak positive correlation between the solid food fasting time and the PAED score at the 0th, 5th, 10th, 15th, and 20th minutes (r = 0.382; p &lt; 0.001, r = 0.357; p &lt; 0.001, r = 0.345; p &lt; 0.001, r = 0.360; p &lt; 0.001, r = 0.240; p &lt; 0.001). There was a weak positive correlation between thirst time and the PAED score at the 0th, 5th, and 10th minutes (r = 0.222; p = 0.020. r = 0.192; p = 0.045, r = 0.199; p = 0.037). The incidence of ED at any time was 34.5%. Conclusions: Prolonged fasting time, solid food fasting time and thirst time are risk factors for developing postoperative ED in children undergoing MRI under sedation.

Incidence of Emergence Delirium in the Pediatric PACU: Prospective Observational Trial.

Emergence delirium (ED) is a postoperative complication in pediatric anesthesia characterized by perception and psychomotor disorder and has a negative impact on morbidity in the form of maladaptive behavior, which can last weeks after anesthesia. Patients with developed ED present with psychomotor anxiety, agitation, and are at higher risk of unintentional extraction of an intravenous cannula, self-harm and nausea and vomiting. The described incidence of ED varies between 25–80%, with a higher prevalence among children younger than 6 years of age. We aimed to determine the incidence of ED in pediatric patients (>1 month) after general anesthesia in the post-anesthesia care unit (PACU), using Paediatric Anaesthesia Emergence Delirium (PAED) score, Watcha score and Richmond agitation and sedation scale (RASS). The incidence of ED was the highest in the PAED score with cutoff ≥10 points (89.0%, n = 1088). When using PAED score >12 points, ED incidence was 19.3% (n = 236). The lowest incidence was described by Watcha and RASS scores, 18.8% (n = 230) vs. 18.1% (n = 221), respectively. The threshold for PAED ≥10 points seems to give false-positive results, whereas the threshold >12 points is more accurate. RASS scale, although intended primarily for estimation of the depth of sedation, seems to have a good predictive value for ED.

The Ameliorating Role of A Playful Situational Game Intervention in School-Aged Children Undergoing Ophthalmic Surgeries: A Randomized Controlled Trial

Purpose The objective of the study was to investigate if a playful situational game (PSG) intervention, as a perioperative procedure, could effectively alleviate stress and anxiety and improve postoperative outcomes for children to receive ophthalmic surgeries. Methods This trial enrolled 153 children, among which 116 met inclusion criteria and were randomized to control (n = 58, who did not participate in PSG) or PSG group (n = 58, who participated PSG). In the PSG group, children were arranged in renovated wards and allocated to play situational games specifically designed to improve surgery readiness. Satisfaction of the care from parents, posthospitalization behavioral change incidences, Yale Preoperative Anxiety Scale (YPAS) scores, induction compliance checklist (ICC) scores, and pediatric anesthesia emergence delirium (PAED) scores were documented as postoperative assessments. Results The PSG group demonstrated significantly higher satisfaction of the care from the parents (p = 0.004), and posthospitalization behavioral change incidences were markedly rarer in the PSG group (p = 0.015). The YPAS scores of the PSG group showed a slower increase compared to the control group before and after surgery (p < 0.001). ICC and PAED scores were also lower in the PSG group (p < 0.01). Conclusion Our data could support that PSG is an effective intervention in alleviating the anxiety of children undergoing ophthalmic surgery and PSG can increase the satisfaction rate among patients and decrease behavioral change incidences. The adoption of PSG in children could potentially been promoted in the clinical setting.

Efficacy of propofol for the prevention of emergence agitation after sevoflurane anaesthesia in children: A meta-analysis.

BackgroundEmergence agitation (EA) is a common postoperative behavioral disorder, predominantly in pediatric patients, after sevoflurane general anesthesia. This study was aimed at assessing propofol's efficacy and clinical conditions established for preventing EA in children under sevoflurane anesthesia.MethodsRandomized controlled trials (RCTs) that comparatively investigated propofol and control treatment in terms of efficacy and safety on administration at the end of surgery and examinations to prevent EA in children under sevoflurane anesthesia were searched. The sources accessed included PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Furthermore, manual searches were performed to identify studies; the last review was conducted on March 21, 2022. When the risk of bias assessment of trials was performed with the Cochrane Risk of Bias Tool, we calculated risk ratios (RRs) with 95% confidence intervals (CIs) for EA incidence and mean differences (MDs) with 95% CI for continuous data.ResultsWe included 12 RCTs with 1103 children. EA incidence (RR: 0.51, 95% CI: 0.39 to 0.67) and Pediatric Anesthesia Emergence Delirium scores (MD: −3.14, 95% CI: −4.37 to −1.92) were lower in the propofol group. Subgroup analyses showed lower EA incidences with 3 mg/kg propofol (RR: 0.22, 95% CI: 0.13 to 0.38) without extension of the PACU time (MD: 4.97, 95% CI: −0.84 to 10.78) in the laryngeal mask airway (LMA; RR: 0.52, 95% CI: 0.36 to 0.77) and spontaneous breathing (RR: 0.36, 95% CI: 0.21 to 0.62) groups.DiscussionWe confirmed that a prophylactic dose of propofol prevented EA and decreased its severity in children under sevoflurane anesthesia. Furthermore, several conditions such as 3 mg/kg propofol, LMA, and spontaneous breathing, potentially contributed to EA prevention. Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=274692, identifier: PROSPERO (No. CRD42021274692).

Prevalence of Emergence Delirium in Children Undergoing Tonsillectomy and Adenoidectomy.

Objective Emergence delirium (ED) is associated with behavioral disturbances and psychomotor agitation, increased risk of selfinjury, delayed discharge, and parental dissatisfaction with quality of care. Otolaryngology procedures are associated with an increased risk of ED. The aims of this study were to determine the prevalence of ED in children who had tonsillectomy and adenoidectomy (T&A), assess the characteristics of children who had ED, and ascertain the recovery times of patients with ED. Methods Charts of patients who had tonsillectomy and adenoidectomy between Jan 1, 2018 and March 26, 2020 at a tertiary children's hospital were reviewed. Data collection included demographics, body mass index, indication for T&A, Pediatric Anesthesia Emergence Delirium (PAED) score, American Society of Anesthesiologists (ASA) physical status classification, total anesthesia time, postanesthesia care phase I time, and postanesthesia care phase II time. Results Of the 4974 patients who underwent T&A, ED occurred in 1.3% of patients. Toddlers (2.9%) and male children (1.6%) had a significantly higher prevalence of ED. Prevalence of ED was similar amongst patients with recurrent tonsillitis, patients with obstructive sleep disordered breathing, and patients with both obstructive sleep apnea (OSA) and recurrent tonsillitis. The prevalence of ED was not different amongst ASA I, ASA II, and ASA III. Males with ED had longer total anesthesia times (41 v. 34 minutes, p=0.02) and ASA I patients with ED had longer phase I times (p=0.04) in the postanesthesia care unit (PACU). There was no significant difference in total anesthesia time, phase I time, or phase II time when compared across the subgroups of gender, age, indication for T&A, severity of obstructive sleep apnea (OSA), and ASA score. Conclusions Males, toddlers, and preschool-age children were more likely to have ED. Males with ED had longer total anesthesia times. ED was associated with longer phase I times in ASA I patients.

EEG-Parameter-Guided Anesthesia for Prevention of Emergence Delirium in Children.

Background: Emergence delirium (ED) usually occurs in children after surgery with an incidence of 10−80%. Though ED is mostly self-limited, its potential injuries cannot be ignored. Whether electroencephalography (EEG)-parameter-guided anesthesia could reduce the incidence of ED in pediatric surgery has not been fully discussed to date. Methods: Fifty-four boys aged 2–12 years undergoing elective hypospadias surgery under sevoflurane anesthesia were selected. In the EEG-parameter-guided group (E group), sevoflurane was used for anesthesia induction and was maintained by titrating the spectral edge frequency (SEF) to 10–15 and combining the monitoring of density spectral array (DSA) power spectra and raw EEG. While in the control group (C group), anesthesiologists were blinded to the SedLine screen (including SEF, DSA, and raw EEG) and adjusted the intraoperative drug usage according to their experience. Patients with a Pediatric Anesthesia Emergence Delirium (PAED) score > 10 were diagnosed with ED, while patients with a PAED score > 2 were diagnosed with emergence agitation (EA). Results: Finally, a total of 37 patients were included in this trial. The incidence of ED in the E group was lower than in the C group (5.6% vs. 36.8%; p = 0.04), while the incidence of EA was similar in the two groups (61% vs. 78.9%; p = 0.48). Intraoperative parameters including remifentanil dosage and the decrease in mean arterial pressure (MAP) were not different between the two groups (p > 0.05), but the mean end-tidal sevoflurane concentration (EtSevo) was lower in the E group than in the C group (p > 0.05). Moreover, during PACU stay, the extubation time and discharge time of the groups were similar, while the PAED scores within 5 min from extubation and the Face, Legs, Activity, Cry, and Consolability (FLACC) scores within 30 min from extubation were lower in the E group than in the C group. Conclusion: EEG-parameter-guided anesthesia management reduced the incidence of ED in children. Studies with larger sample sizes are needed to obtain more convincing results.

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.