Pediatric Anesthesia Emergence Delirium Scores Research Articles

Effects of ketamine and ketamine with midazolam on emergence agitation in children following sevoflurane anesthesia

Background : Emergence agitation is a distressful phenomenon associated with inhalational agents such as Sevoflurane in short surgical procedures. Various drugs have been used in the past but some come at the cost of increased complications. We aim to study the effects of ketamine alone and ketamine with midazolam on emergence agitation and their effects on recovery and discharge times.Methods: We conducted a prospective randomized controlled trial among 94 patients aged two to ten years presenting for ophthalmic surgeries in which 45 patients were allocated to each group: group K (Ketamine) and group KM (Ketamine with Midazolam). Group K received Ketamine 0.3 mg/kg IV and Group KM received Ketamine 0.3 mg/kg IV and Midazolam 0.03 mg/kg IV. Intraoperatively heart rate and post-operatively emergence agitation, recovery times, discharge times were studied.Results: Demographic variables were comparable between the two groups. Median Pediatric Anesthesia Emergence Delirium (PAED) score of 6 with IQR (4-6) in group K was comparable to the median score of 5 with IQR (4-6) in group KM. The mean recovery time of 22}4.82 min in group K was significantly lower compared to the mean time of 25.75}3.32 min in group KM. Mean time to discharge of 67}11 min from the hospital in group K was significantly shorter compared to that in group KM (108}18 mins).Conclusion: We concluded from our study that ketamine alone is as effective as ketamine with midazolam in reducing the emergence agitation following Sevoflurane anesthesia for ophthalmic surgery. Journal of Society of Anesthesiologists of NepalVol. 4, No. 2, 2017, page: 57-65

Study of the effects of hydromorphone on emergence agitation of children anesthetized by sevoflurane

Objective: To observe the effect of hydromorphone on emergence agitation of children anesthetized by Sevoflurane. Methods: One hundred patients without any analgetic, aged 3 to 7 years, ASA Ⅰ-Ⅱ, undergoing strabismus surgery in Beijing Tongren Hospital from March, 2017 to December, 2017 were selected and they were randomly divided into two groups(n=50), H group and F group by random number table. After standardized tidal volume method induction by 8% sevoflurane and oxygen, suiltable laryngeal mask was inserted, and each patient was left spontaneously breathing anesthetized by 2.5%-3.0% sevoflurane.Ten minutes before the surgery, patients in H group were administered a dose of 0.01 mg/kg hydromorphone (diluted to 5 ml with normal saline) by pump control injection in 10 min, whereas patients in F group administered a dose of 1 μg/kg fentanyl in the same way. After the surgery , the patient was sent to postanesthesia care unit. A nurse who was blinded measured the vital signs, pediatric anesthesia emergence delirium(PAED) score, face legs activity cry consolability behavioral pain assessment tool(FLACC) score, the time of opening the eyes and departing from postanesthesia care unit(PACU), and the occurence rates of hypoxemia, swirl or nausea, drowsiness, and other scores. Results: The incidence of emergence agitation(EA) in H group was lower than in F group, whether EA was defined as PAED>10 (18.0% vs 28.0%, P>0.05) or PAED>12(12.0% vs 24.0%, P>0.05), there were not significant differences between them. The ratio of patients whose PAED>15 in F group was 12.0%, while the ratio of H group was 0, there was significant difference between the two groups(P=0.027). The occurrence rates of swirl, glossocoma in H group were 0 and 10.0% while those of F group were all 6.0%, there were no significant differences between the two groups(P>0.05). Conclusions: Comparing with fentanyl, hydromorphone can prevent the occurrence rate of EA of the children anesthetized by sevoflurane equally, even decrease the occurrence rate of the severe EA more observably, and reduce postoperation pain more significantly with less occurrence rate of swirl or nausea. Glossocoma need be paid attention to when HM is administered.

The Effect of Dexmedetomidine on Emergence Agitation in Children After Desflurane Anesthesia

Objective: To evaluate the effect of dexmedetomidine on the emergence agitation in children after desflurane anesthesia.
 Materials-Methods: In this prospective randomized comparative study, 50 children between the age group 2-10 years of American Society of Anesthesiologists physical status I or II, who were scheduled for infrainguinal urologic surgery were enrolled and randomly divided into two groups. Group dexmedetomidine (Group B) (n=25) received 0.2 μg/kg dexmedetomidine in 10 ml saline intravenously over 10 minutes after induction and group control (Group A) (n=25) received only 10 ml saline infusion after induction. The emergence agitation levels of the children were evaluated according to the Pediatric Anesthesia Emergence Delirium Scale in the recovery room and postoperative pain scores were evaluated using Children’s and Infants’ Postoperative Pain Scale at the 10th and 30th minutes after extubation. Age, gender, weight, hemodynamic parameters, duration of anesthesia, duration of surgery and side effects were recorded. 
 Results: There was no significant difference in Pediatric Anesthesia Emergence Delirium scores at the 10th and 30th minutes after extubation between dexmedetomidine and saline groups. The decrease in emergence agitation at the 30th minute compared to the 10th minute was independent from sex, age and anesthesia duration in both groups. Incidence of hypotension and bradycardia was higher in the dexmedetomidine group compared to the saline group. 
 Conclusion: In children aged from two to 10 who undergo surgery with desflurane anesthesia, dexmedetomidine administration was not effective in preventing postoperative emergence agitation and caused increased side effects, such as hypotension and bradycardia.

Recovery characteristics of total intravenous anesthesia with propofol versus sevoflurane anesthesia: a prospective randomized clinical trial.

BackgroundPediatric dental procedures are performed under anesthesia because children may be uncooperative in the dental clinic due to their young age. Emergence delirium (ED), which involves a variety of behavioral disturbances that are frequently observed in children following emergence from general anesthesia, remains an unclear phenomenon. The aim of this randomized controlled trial is to compare the incidence of ED in children who underwent full mouth dental rehabilitation under either sevoflurane (SEVO) anesthesia or propofol-based total intravenous anesthesia (TIVA).Patients and methodsOne hundred and twenty children with American Society of Anesthesiologists status I–II, aged ≥3 and ≤6 years, undergoing dental rehabilitation were assigned to receive either TIVA or SEVO. ED and postoperative pain were evaluated by a blinded investigator using the Pediatric Anesthesia Emergence Delirium scale and the Face, Legs, Activity, Cry, Consolability scale every 5 min. The recovery time, satisfaction levels of parents or guardians, extubation time, duration of the operation, and type of dental procedure were also recorded.ResultsData of 116 subjects were analyzed. The incidence of ED was higher after SEVO than after TIVA (65.5 vs 3.4%, P=0.00). Greater postoperative pain was observed in the SEVO group (median 3 vs 1, P=0.000). A statistically significant, moderate correlation (rs=0.46, P<0.0001) was found between the Face, Legs, Activity, Cry, Consolability and Pediatric Anesthesia Emergence Delirium scores. A higher parental satisfaction level was observed in the TIVA group.ConclusionA lower incidence of ED and a higher parental satisfaction level were observed after TIVA. Moreover, TIVA resulted in a more comfortable postoperative period due to reduced postoperative pain, and the extubation time and recovery time were not increased.

Visual preconditioning reduces emergence delirium in children undergoing ophthalmic surgery: a randomised controlled trial

BackgroundEmergence delirium is a common complication in children, especially in preschool children undergoing ophthalmic surgery. The aim of the study was to investigate the effects of visual preconditioning (application of an eyepatch over the eye to be operated for ≥3 h the day before surgery) on emergence delirium after ophthalmic surgery under sevoflurane anaesthesia. MethodsOne hundred and seventy-nine children undergoing unilateral cataract surgery, aged 3–7 yr, were involved in this prospective, blinded, randomised study. Subjects were randomised to receive visual preconditioning (Group P, n=89) or to receive programmed explanation the day before surgery (Group C, n=90). The primary outcome was incidence of emergence delirium evaluated by the paediatric anaesthesia emergence delirium (PAED) scale. The secondary outcomes included emergence time and post-anaesthesia care unit (PACU) stay time. ResultsChildren in Group P had a significantly lower incidence of emergence delirium than those in Group C [16.9% vs 44.4%, odds ratio (OR) 4.0, 95% confidence interval (CI) 2.0 to 8.0]. The maximal PAED score was lower in Group P than in Group C [4 (0–20) vs 9 (0–20), median difference –3.0, 95% CI –5.0 to –1.0]. Visual preconditioning prolonged emergence time (P<0.001) and PACU stay time (P=0.002). ConclusionVisual disturbance contributes to emergence delirium in preschool children undergoing ophthalmic surgery with sevoflurane, and prophylactic eyepatch treatment can reduce emergence delirium. Clinical trials registrationNCT02590744.

Correlation between duration of preoperative fasting and emergence delirium in pediatric patients undergoing ophthalmic examination under anesthesia: A prospective observational study.

Preoperative fasting in children can cause anxiety, which may ultimately lead to postoperative emergence delirium. However, no data are available whether duration of preoperative fasting correlates with postoperative emergence delirium. The aim of this study was to identify if there is any correlation between the duration of preoperative fasting and emergence delirium in children undergoing ophthalmic examination under anesthesia. In this prospective observational study, 100 children between the age group 2-6years of American Society of Anesthesiologists physical status I or II, scheduled for examination of the eye under general anesthesia with sevoflurane were recruited. Data regarding preoperative fasting was recorded and presence of emergence delirium was assessed by the Pediatric Anesthesia Emergence Delirium (PAED) scale at 5minute interval till 30minutes from the time of leaving the operation theater. No premedication was used in any patients but parental presence was allowed in all of them. Mean (standard deviation) duration of fasting to clear liquid was 6.3 (1.7) hrs. Twenty-four children (24%) had at least 1 recorded PAED score >10 at any time point in the postoperative period. PAED scores at 15 and 25minutes were significantly correlated with duration of fasting (r2 [95% CI]=.24 [0.04, 0.41], P=.02, Pearsons's correlation and r2 [95% CI]=.23 [0.04, 0.41], P=.02, Pearsons's correlation, respectively). No correlation has been found between duration of fasting and blood glucose level (r2 [95% CI]=-.05 [-0.24, 0.15], P=.65, Pearsons's correlation) between fasting blood glucose and PAED score at any time point. Increased preoperative fasting duration may be a risk factor for postoperative emergence delirium in children undergoing ophthalmic examination under general anesthesia.

Emotion regulation and premedication success relationship in children who underwent general anesthesia

Background/aim: This study aims to investigate the relationship between emotion regulation characteristics and the efficacy of midazolam premedication. Materials and methods: Sixty-three children, aged 3 to 8 years old, with tonsillectomy and/or adenoidectomy and taking premedication with midazolam (Group 2) or without premedication (Group 1), were included in this study. The behavioral and emotional status of the children was evaluated with the Conners Parent Rating Scale-48 (CPRS-48) and Emotion Regulation Checklist (ERC). Age, sex, body weight, response to intravenous (IV) cannulation and mask, hemodynamic data, preoperative sedation scores [Wilton Sedation Scale (WSS)], postoperative pain intensity [Objective Pain Scale (OPS)], and emergence agitation (EA) level [Pediatric Anesthesia Emergence Delirium (PAED)] were recorded. Results: A total of 90.6% patients were quiet and sleepy in Group 2, and 25.8% in Group 1. The mean scores of OPS and PAED were higher in Group 1, and the percentage of patients with PAED score of >10 was 51.6% in Group 1 and 18.8% in Group 2 (P < 0.05). In Group 1, a significant correlation was found between PAED scores and WSS and the subfactors of the CPRS-48 (P < 0.05). A correlation was found between WSS and subfactors of ERS in Group 1 (P < 0.05). Conclusion: The incidence of anxiety and postoperative EA is increased in children with emotion regulation disorder, and midazolam premedication reduced the frequency of EA.

Effect of preoperative visiting operation room on emergence agitation in preschool children under sevoflurane anesthesia

BackgroundEmergence agitation (EA) is a common complication in children during recovery from sevoflurane anesthesia with an high incidence. The main objective of this study was to compare the effects of preoperative visiting operation room (PVOR) to administration of propofol at the end of anesthesia on EA in preschool children under sevoflurane anesthesia. MethodsSixty-nine preschool children aged from 3 to 6 years scheduled for tonsillectomy under sevoflurane anesthesia were randomly allocated to one of the three groups to receive either PVOR (Group PV), routine preoperative visit (Group RV) or routine preoperative visit plus propofol (Group RP), 23 patients were included in each group. General anesthesia was induced and maintained with sevoflurane. Parental separation status score, mask acceptance score, Aono's four point score and pediatric anesthesia emergence delirium (PAED) score and incidence of EA were recorded. PAED score >10 were regarded as EA. Recovery profile and adverse events were also recorded. ResultParental separation status score and mask acceptance score in group PV was significantly lower than that in group RV and group RP (P < 0.05); Aono's four point score, PAED score and incidence of EA in group PV and group RP was significantly lower than that in group RV (P < 0.05); Time to extubation and time to interaction in group PV and group RV was significantly shorter than that in group RP (P < 0.05); POV and rescue by fentanyl in group PV and group RP was significantly lower than that in group RV(P < 0.05). ConclusionPVOR can effectively reduce the incidence of EA as well as administration of propofol without additional medical expenses and other adverse effects.

Effect of dexmedetomidine combined with sufentanil on preventing emergence agitation in children receiving sevoflurane anesthesia for cleft palate repair surgery.

The aim of the present study was to observe whether dexmedetomidine (DEX) combined with sufentanil decreased emergence agitation (EA) in children receiving sevoflurane anesthesia for cleft palate repair surgery. Children undergoing elective cleft palate repair surgery were randomly allocated into the DEX + sufentanil group (group DS; n=50) and the normal saline + fentanyl group (group SF; n=50). Patients in group DS were treated with 0.5 µg/kg DEX prior to induction of anesthesia, whereas patients in group SF received an equal volume of normal saline. Sufentanil (0.2 µg/kg) was administered to induce anesthesia, and 30 min before the end of surgery for patients in group DS. Fentanyl (2 µg/kg) was administered at the same time point for patients in group SF. Mean arterial pressure (MAP), heart rate (HR), duration of surgery and anesthesia, and the dosage of remifentanil were assessed. EA score, Pediatric Anesthesia Emergence Delirium (PAED) score and the Children and Infants Postoperative Pain Scale (CHIPPS) score were documented every 15 min in the post-anesthesia care unit (PACU). The number of cases requiring fentanyl (1 µg/kg) and the recovery profile data were analyzed. Compared with group DS (P<0.05) and the baseline (P<0.05), HR and MAP were significantly increased in group SF immediately following tracheal intubation and extubation. Mean values of maximum EA, PAED and CHIPPS scores were significantly reduced in group DS compared with group SF at 0 (P<0.01), 15 (P<0.05), and 30 min (P<0.05) after arrival at PACU. The incidence of EA in group SF was significantly increased compared with group DS (P<0.05). The dosage of remifentanil during the surgery and the number of cases requiring fentanyl (1 µg/kg) in group DS were significantly decreased compared with group SF (P<0.05). The findings of the present study suggested that DEX combined with sufentanil was able to effectively decrease the incidence of EA in children receiving sevoflurane anesthesia for cleft palate repair surgery.

Tramadol vs dexmedetomidine for emergence agitation control in pediatric patients undergoing adenotonsillectomy with sevoflurane anesthesia: prospective randomized controlled clinical study

BackgroundThis study was designed to compare the efficacy of an intraoperative single dose administration of tramadol and dexmedetomidine on hemodynamics and postoperative recovery profile including pain, sedation, emerge reactions in pediatric patients undergoing adenotonsillectomy with sevoflurane anesthesia.MethodsSeventy-seven patient, aged 2–12, undergoing adenotonsillectomy with sevoflurane anesthesia was enrolled in this study. Patients were randomly assigned to receive either intravenous 2 mg/kg tramadol (Group T; n = 39) or 1 μg/kg dexmedetomidine (Group D; n = 38) after intubation. Heart rates (HR), mean arterial pressure (MAP) were recorded before induction, at induction and every 5 min after induction. Observational pain scores (OPS), pediatric anesthesia emergence delirium (PAED) scores, percentage of patients with OPS ≥ 4 or PAED scale items 4 or 5 with an intensity of 3 or 4, and Ramsay sedation scores (RSS) were recorded on arrival to the postoperative care unit (PACU) and at 5, 10, 15, 30, 45, 60 min. Extubation time and time to reach Alderete score > 9 were recorded.ResultsDexmedetomidine significantly decreased the HR and MAP 10 and 15 min after induction; increased the RSS 15, 30 and 45 min after arrival to PACU. OPS and PAED scores and percentage of patients with OPS ≥ 4 or PAED scale items 4 or 5 with an intensity of 3 or 4 in both groups did not show any significant difference. Extubation time and time to have Alderete score > 9 was significantly longer in Group D.ConclusionBoth tramadol and dexmedetomidine were effective for controlling pain and emergence agitation. When compared with tramadol intraoperative hypotension, bradycardia and prolonged sedation were problems related with dexmedetomidine administration.Trial registrationRetrospectively registered, registration number: ISRCTN89326952 registration date: 14.07.2016

Comparison of oral dexmedetomidine versus oral midazolam as premedication to prevent emergence agitation after sevoflurane anaesthesia in paediatric patients.

Background and Aims:Sevoflurane is the most often used inhalational agent in paediatric anaesthesia, but emergence agitation (EA) remains a major concern. Oral midazolam and parenteral dexmedetomidine are known to be effective in controlling EA. We attempted to elucidate whether oral dexmedetomidine is better than midazolam in controlling EA.Methods:Prospective double-blinded study involving ninety patients aged 1–10 years, undergoing elective surgeries of <2 h of expected duration under sevoflurane general anaesthesia, randomised to receive either midazolam (Group A) or dexmedetomidine (Group B) as oral premedication was carried out to record level of sedation before induction, haemodynamic parameters and recovery time. Incidence and severity of EA, post-operative pain and requirement of rescue analgesic were assessed at 0, 5, 15, 30 and 60 min postoperatively.Results:Data were analysed applying Student's t-test and Chi-square test using SPSS software. Mask acceptance was better in Group B (97.8% vs. 73.4%, P < 0.001). Mean arterial pressure was lower in Group B (P < 0.001) though clinically not significant. More rescue analgesic was required in Group A (5.6% vs. 0%). There was no significant difference in adverse effects. Although there was a higher incidence of EA in Group A (Aono's score 3 and 4; 40% vs. 4.4%), none of them required intervention (paediatric anaesthesia emergence delirium score >10; 0 vs. 0).Conclusion:Premedication with oral dexmedetomidine provides smooth induction and recovery, reduces the EA and provides better analgesia and sedation as compared to oral midazolam.

Clinical application of different approaches of ultrasound guided transversus abdominis plane block in children undergoing laparoscopic groin surgery

Objective To investigate the analgesic efficacy of ultrasound guided transversus abdominis plane block and to compare the efficacy of posterior approach and medial approach of ultrasound guided transversus abdominis plane block (TAPB) in providing postoperative analgesia after children laparoscopic groin surgery. Methods Eligible children 2~4 years old (n=60), American society of anesthesiologists (ASA)Ⅰ, undergoing elective laparoscopic unilateral groin surgery were randomly assigned into posterior approach group (Group P), medial approach group (Group M) and control group (Group C). Many parameters were measured and recorded during the study, including funk sedation scores, intraoperative circulation monitoring at time points of T1 (before induction), T2 (skin incision) and T3 (skin closure), length of surgery, the time from post anesthesia care unit (PACU) arrival to the first obtainable pain score, length of PACU stay, modified-children's hospital of eastern ontario pain scale(m-CHEOPS), pediatric anesthesia emergence delirium (PAED) scores, number of children with sufentanil administered in PACU, number of people occurred nausea and vomiting, and satisfaction of parents. Results There were no statistically significant difference in general characteristics, basic emotion score, duration of surgery, the time from PACU arrival to first obtainable score, haemodynamic parameter at T1 and satisfaction of parents among groups P, M, and C. However, the m-CHEOPS scores at the time points of first obtainable, 10 min, the number of children received sufentanil administration, PAED scores and haemodynamic parameter at T2 and T3 were significantly lower in groups P and M than in group C. There were no significant difference in parameters mentioned above between groups P and M. Conclusions Ultrasound guided transversus abdominis plane block could provide efficient and secure postoperative analgesia for children undergoing laparoscopic groin surgery. Both posterior approach and medial approach are ideal options. Key words: Ultrasonography; Nerve block; Abdominal muscles; Laparoscopy; Groin/SU; Analgesia

WITHDRAWN: Co-administration of sufentanil and dexmedetomidine prevents emergence agitation in pediatric patients

// Li-Ting Hou 1 , Yong-Hong Bi 1 , Xiao-Guang Cui 1 , Zhi-Jia Feng 1 and Yan-Zhuo Zhang 1 1 Department of Anesthesiology, China and Heilongjiang Key Laboratory for Anesthesia and Critical Care, The Second Affiliated Hospital of Harbin Medical University, Harbin, China Correspondence to: Yan-Zhuo Zhang, email: zhangyanzhuo625@sina.com Keywords: tonsillectomy; adenoidectomy; emergence agitation; dexmedetomidine; sufentanil Received: July 07, 2017&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Accepted: December 01, 2017&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Published: January 02, 2018 ABSTRACT We compared the effectiveness of dexmedetomidine alone and combined with sufentanil for preventing emergence agitation in children under sevoflurane anesthesia. Eighty children scheduled for tonsillectomy or adenotonsillectomy under sevoflurane anesthesia were randomized into four groups: control, dexmedetomidine, dexmedetomidine with 0.1 &mu;g/kg sufentanil (Dex+Suf1), and dexmedetomidine with 0.2 &mu;g/kg sufentanil (Dex+Suf2). The incidence and severity of emergence agitation was evaluated based on Aono&rsquo;s scale and the pediatric anesthesia emergence delirium scale. The incidence of agitation was 45% in the control group, 20% in the dexmedetomidine group, 5% in Dex+Suf1 group, and 0% in Dex+Suf2 group. The Aono&rsquo;s and pediatric anesthesia emergence delirium scores in the Dex+Suf1 and Dex+Suf2 groups were lower than in the control or dexmedetomidine group during the tracheal extubation ( P &lt; 0.05). In the Dex+Suf1 and Dex+Suf2 groups, the time of tracheal extubation was longer than in the control or dexmedetomidine group ( P &lt; 0.05). The Dex+Suf2 group had longer tracheal extubation and awaken times than the other groups ( P &lt; 0.05). Thus dexmedetomidine with 0.1 &mu;g/kg sufentanil was the optimal dose combination that reduced emergence agitation without prolonging awaken time.

Prospective, Randomized Comparisons of Induction of Anesthesia with Ketamine, Propofol and Sevoflurane for Quality of Recovery from Short Sevoflurane Anesthesia in Pediatric Patients

Background: Emergence agitation (EA) after sevoflurane anesthesia is common in children. When rapid intravenous induction of general anesthesia is indicated in a brief procedure, the induction agent can reduce the incidence of EA after sevoflurane anesthesia. The aim of this study was to compare the efficacy of intravenous induction with ketamine and propofol for reducing EA in children after short sevoflurane anesthesia. Methods: Children aged 2 to 6 years who were scheduled to undergo inguinal hernia repair were randomly divided into 3 groups to receive 2 mg/kg ketamine iv, 3 mg/kg propofol iv, or inspired concentration of 8% sevoflurane for induction of anesthesia. After a laryngeal mask airway (LMA) insertion, a caudal block was performed in all children. Anesthesia was maintained with 1.5% sevoflurane and 65% nitrous oxide in oxygen with spontaneous ventilation. The recovery characteristics were recorded and EA were evaluated by using the Pediatric Anesthesia Emergence Delirium (PAED) scale. Results: One hundred and twenty children were enrolled and randomized to treatment. Children who received ketamine induction had higher incidence of EA than those who received propofol (42% vs 16%, P < 0.05) and showed delayed recovery (32 ± 9 min) as compared with those who received propofol or sevoflurane (22 ± 8 min and 20 ± 7 min, respectively, P < 0.05). The mean peak PAED score was significantly lower in children who received propofol induction (6.8 ± 4.0, P < 0.05) than ketamine (11.8 ± 4.1) or sevoflurane (11.6 ± 3.8). Conclusions: Intravenous induction with ketamine does not prevent the incidence of EA and delays recovery. Induction with propofol improves the quality of recovery by reducing the incidence of EA and provides a safe and early recovery.

Intranasal dexmedetomidine premedication reduces minimum alveolar concentration of sevoflurane for laryngeal mask airway insertion and emergence delirium in children: a prospective, randomized, double‐blind, placebo‐controlled trial

We conducted a prospective, randomized, double-blind, placebo-controlled study to verify the hypothesis that intranasal dexmedetomidine premedication can reduce the minimum alveolar concentration of sevoflurane for laryngeal mask airway insertion in children. Ninety American Society of Anesthesiologists (ASA) physical status I subjects, aged 3-7 years, were randomized to three equal groups to receive saline (Group S), dexmedetomidine 1 μg · kg(-1) (Group D1 ), or dexmedetomidine 2 μg · kg(-1) (Group D2 ) approximately 45 min before anesthesia. The minimum alveolar concentration for laryngeal mask airway insertion of sevoflurane was determined according to the Dixon's up-and-down method. Emergence delirium was evaluated using the Pediatric Anesthesia Emergence Delirium (PAED) scale in the postanesthesia care unit (PACU). Dexmedetomidine premedication of 1 and 2 μg · kg(-1) was associated with reduction in sevoflurane from 1.92% to 1.53% and 1.23%, corresponding to decrease of 20% and 36%, respectively. The peak PAED scores (median [IQR]) were 9 [8-11.5], 5 [3-5.3], and 3 [2-4] in Group S, Group D1, and Group D2 , respectively. The incidence of emergence delirium (defined as peak PAED score ≥ 10) was significantly lower in Groups D1 and D2 than in Group S (P < 0.001). Simultaneously, the induction qualities and the parent's satisfaction scores were significantly higher in Groups D1 and D2 than in Group S (P < 0.001). Intranasal dexmedetomidine premedication produces a dose-dependent decrease in the minimum alveolar concentration for laryngeal mask airway insertion of sevoflurane and emergence delirium in the PACU.

Emergence delirium is related to the invasiveness of strabismus surgery in preschool-age children.

To investigate the correlation between preoperative anxiety and emergence delirium (ED), and to identify other factors that contribute to ED (such as invasiveness of surgery), in preschool-age paediatric patients undergoing strabismus surgery. This prospective observational study enrolled Korean children (aged 2-5 years), scheduled for strabismus surgery. After completing the modified Yale Preoperative Anxiety Scale, general anaesthesia was induced. Postoperatively, Pediatric Anesthesia Emergence Delirium (PAED) scores (used as an index of the degree of ED) and a four-point delirium scale (ED incidence), were collected and measured every 5 min. Patients were categorized according to the degree of surgical invasiveness: group U-S, single-muscle correction in a unilateral eye; group U-M, multiple-muscle correction in a unilateral eye; group B-S, single-muscle correction in bilateral eyes; group B-M, multiple-muscle correction in bilateral eyes. A total of 90 paediatric patients participated in the study. Maximum PAED scores did not correlate with the presence of preoperative anxiety. The maximum PAED score of group B-M was significantly higher than scores observed in other groups. Preoperative anxiety was not related to ED in preschool-age paediatric patients undergoing strabismus surgery. The incidence and severity of ED was higher in patients who underwent more complicated strabismus surgery, compared with those undergoing simpler procedures.

Efectos de la ketamina y el midazolam sobre la incidencia de agitación postanestesia con sevoflurano en niños sometidos al bloqueo caudal: estudio aleatorizado

Background and objectivesEmergence agitation is a common postanaesthetic problem in children after sevoflurane anaesthesia. We aimed to compare the effects of ketamine and midazolam administered intravenously, before the end of surgery, for prevention of emergence agitation in children who received caudal block for pain relief under sevoflurane anaesthesia. Methods62 American Society of Anesthesiologists patient classification statusi children, aged 2-7years, scheduled for inguinal hernia repair, circumcision or orchidopexy were enrolled to the study. Anaesthesia was induced with sevoflurane 8% in a mixture of 50% oxygen and nitrous oxide. After achieving adequate depth of anaesthesia, a laryngeal mask was placed and then caudal block was performed with 0.75mLkg−1, 0.25% bupivacaine. At the end of the surgery, ketamine 0.25mgkg−1, midazolam 0.03mgkg−1 and saline were given to ketamine, midazolam and control groups, respectively. Agitation was assessed using Paediatric Anaesthesia Emergence Delirium scale and postoperative pain was evaluated with modified Children's Hospital of Eastern Ontario Pain Scale. Results and conclusionsModified Children's Hospital of Eastern Ontario Pain Scale scores were found higher in control group than in ketamine and midazolam groups. Paediatric Anaesthesia Emergence Delirium scores were similar between groups. Modified Children's Hospital of Eastern Ontario Pain Scale and Paediatric Anaesthesia Emergence Delirium scores showed a significant decrease by time in all groups during follow-up in postanaesthesia care unit. The present study resulted in satisfactory Paediatric Anaesthesia Emergence Delirium scores which are below 10 in all groups. As a conclusion, neither ketamine nor midazolam added to caudal block under sevoflurane anaesthesia did show further effect on emergence agitation. In addition, pain relief still seems to be the major factor in preventing emergence agitation after sevoflurane anaesthesia.

Efeitos de cetamina e midazolam sobre a incidência de agitação pós‐anestesia com sevoflurano em crianças submetidas ao bloqueio caudal: estudo randomizado

Background and objectivesEmergence agitation is a common postanaesthetic problem in children after sevoflurane anaesthesia. We aimed to compare the effects of ketamine and midazolam administered intravenously, before the end of surgery, for prevention of emergence agitation in children who received caudal block for pain relief under sevoflurane anaesthesia. Methods62 American Society of Anesthesiologists patient classification status I children, aged 2–7 years, scheduled for inguinal hernia repair, circumcision or orchidopexy were enrolled to the study. Anaesthesia was induced with sevoflurane 8% in a mixture of 50% oxygen and nitrous oxide. After achieving adequate depth of anaesthesia, a laryngeal mask was placed and then caudal block was performed with 0.75mLkg−1, 0.25% bupivacaine. At the end of the surgery, ketamine 0.25mgkg−1, midazolam 0.03mgkg−1 and saline were given to ketamine, midazolam and control groups, respectively. Agitation was assessed using Paediatric Anaesthesia Emergence Delirium scale and postoperative pain was evaluated with modified Children's Hospital of Eastern Ontario Pain Scale. Results and conclusionsModified Children's Hospital of Eastern Ontario Pain Scale scores were found higher in control group than in ketamine and midazolam groups. Paediatric Anaesthesia Emergence Delirium scores were similar between groups. Modified Children's Hospital of Eastern Ontario Pain Scale and Paediatric Anaesthesia Emergence Delirium scores showed a significant decrease by time in all groups during follow‐up in postanaesthesia care unit. The present study resulted in satisfactory Paediatric Anaesthesia Emergence Delirium scores which are below 10 in all groups. As a conclusion, neither ketamine nor midazolam added to caudal block under sevoflurane anaesthesia did show further effect on emergence agitation. In addition, pain relief still seems to be the major factor in preventing emergence agitation after sevoflurane anaesthesia.

Effects of ketamine and midazolam on emergence agitation after sevoflurane anaesthesia in children receiving caudal block: a randomized trial

Background and objectivesEmergence agitation is a common postanaesthetic problem in children after sevoflurane anaesthesia. We aimed to compare the effects of ketamine and midazolam administered intravenously, before the end of surgery, for prevention of emergence agitation in children who received caudal block for pain relief under sevoflurane anaesthesia. Methods62 American Society of Anesthesiologists patient classification status I children, aged 2–7 years, scheduled for inguinal hernia repair, circumcision or orchidopexy were enrolled to the study. Anaesthesia was induced with sevoflurane 8% in a mixture of 50% oxygen and nitrous oxide. After achieving adequate depth of anaesthesia, a laryngeal mask was placed and then caudal block was performed with 0.75mLkg−1, 0.25% bupivacaine. At the end of the surgery, ketamine 0.25mgkg−1, midazolam 0.03mgkg−1 and saline were given to ketamine, midazolam and control groups, respectively. Agitation was assessed using Paediatric Anaesthesia Emergence Delirium scale and postoperative pain was evaluated with modified Children's Hospital of Eastern Ontario Pain Scale. Results and conclusionsModified Children's Hospital of Eastern Ontario Pain Scale scores were found higher in control group than in ketamine and midazolam groups. Paediatric Anaesthesia Emergence Delirium scores were similar between groups. Modified Children's Hospital of Eastern Ontario Pain Scale and Paediatric Anaesthesia Emergence Delirium scores showed a significant decrease by time in all groups during follow-up in postanaesthesia care unit. The present study resulted in satisfactory Paediatric Anaesthesia Emergence Delirium scores which are below 10 in all groups. As a conclusion, neither ketamine nor midazolam added to caudal block under sevoflurane anaesthesia did show further effect on emergence agitation. In addition, pain relief still seems to be the major factor in preventing emergence agitation after sevoflurane anaesthesia.

Use of ketofol to control emergence agitation in children undergoing adenotonsillectomy

ObjectiveTo assess the efficacy and safety of ketofol administration in controlling emergence agitation (EA) after sevoflurane-based anesthesia in children undergoing adenoidectomy or adenotonsillectomy.Subjects and methodsThis double-blinded randomized study involved 90 children (3–6 years) scheduled for elective adenotonsillectomy or adenoidectomy. They were randomly assigned to receive 10 ml of normal saline (control group, C) or, 1 mg/kg propofol in 10 ml saline (group P) or ketofol as 1 mg/kg propofol and 0.25 mg/kg ketamine in 10 ml saline (group K) 10 min before the end of surgery. In PACU, sedation, behavior, pain and severity of EA were assessed using modified Aldrete score, Aono’s scale, Objective Pain Score (OPS) and Pediatric Anesthesia Emergence Delirium (PAED) scale, respectively.ResultsIn ketofol group, OPS was significantly lower compared to propofol and control groups. Recovery criteria were in favor of ketofol and propofol groups including longer time to eye opening (p < 0.001) and time to Aldrete score ⩾ 9 (p = 0.001). Time to discharge from PACU was comparable in the three groups (p = 0.079). EA was significantly more frequent in the control group (p < 0.001), but comparable in ketofol and propofol groups. PAED score was significantly higher in control group compared to ketofol and propofol groups. Ketofol and propofol preserved hemodynamic stability.ConclusionKetofol provides a promising new option for controlling emergence agitation with adequate postoperative sedative and analgesic effect, good recovery criteria and hemodynamic stability compared to propofol and control groups in children undergoing adenoidectomy or adenotonsillectomy.