Sevoflurane Anesthesia In Children Research Articles

Effects of remifentanil maintenance during recovery on emergence delirium in children with sevoflurane anesthesia.

Emergence delirium is a common complication of sevoflurane anesthesia in children. We examined the effects of maintaining remifentanil infusion during the recovery period on the incidence of emergence delirium in preschool-age children undergoing strabismus surgery under sevoflurane anesthesia. Eighty children (aged 3-7years) were randomly assigned to either the control group (group C; intraoperative remifentanil infusion) or the intervention group (group R; intraoperative remifentanil infusion followed by remifentanil maintenance during the recovery phase). Intraoperative remifentanil infusion (0.2μg/kg/min) was discontinued upon surgery completion in the group C, and was maintained until the discharge criteria were met at a dose of 0.05μg/kg/min in the group R. The incidence of emergence delirium was assessed using a five-point agitation scale and the Pediatric Anesthesia Emergence Delirium scale after arrival in the postanesthesia care unit. Postoperative pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale. The incidence of emergence delirium according to the five-point agitation scale (scores≥4) was lower in the group R (33.3%) compared to the group C (68.3%) (odds ratio 0.206; 95% CI 0.080 to 0.531; P=0.002). Similar results were obtained using the Pediatric Anesthesia Emergence Delirium scale (scores>12), with an incidence of 5.1% in the group R and 34.0% in the control group (odds ratio 0.104; 95% CI 0.022 to 0.497; P=0.001). The Children's Hospital of Eastern Ontario Pain Scale scores and occurrence of postoperative adverse events including laryngospasm, desaturation, nausea, and vomiting were similar between the two groups. Maintaining a low dose of remifentanil (0.05μg/kg/min) throughout the recovery phase attenuated the incidence of emergence delirium in children undergoing strabismus surgery under sevoflurane anesthesia.

Electroencephalographic markers of brain development during sevoflurane anaesthesia in children up to 3 years old

BackgroundGeneral anaesthetics generate spatially defined brain oscillations in the EEG that relate fundamentally to neural-circuit architecture. Few studies detailing the neural-circuit activity of general anaesthesia in children have been described. The study aim was to identify age-related changes in EEG characteristics that mirror different stages of early human brain development during sevoflurane anaesthesia. MethodsMultichannel EEG recordings were performed in 91 children aged 0–3 yr undergoing elective surgery. We mapped spatial power and coherence over the frontal, parietal, temporal, and occipital cortices during maintenance anaesthesia. ResultsDuring sevoflurane exposure: (i) slow–delta (0.1–4 Hz) oscillations were present in all ages, (ii) theta (4–8 Hz) and alpha (8–12 Hz) oscillations emerge by ∼4 months, (iii) alpha oscillations increased in power from 4 to 10 months, (iv) frontal alpha-oscillation predominance emerged at ∼6 months, (v) frontal slow oscillations were coherent from birth until 6 months, and (vi) frontal alpha oscillations became coherent ∼10 months and persisted in older ages. ConclusionsKey developmental milestones in the maturation of the thalamo-cortical circuitry likely generate changes in EEG patterns in infants undergoing sevoflurane general anaesthesia. Characterisation of anaesthesia-induced EEG oscillations in children demonstrates the importance of developing age-dependent strategies to monitor properly the brain states of children receiving general anaesthesia. These data have the potential to guide future studies investigating neurodevelopmental pathologies involving altered excitatory–inhibitory balance, such as epilepsy or Rett syndrome.

Effect of Caudal Dexmedetomidine on Prevention of Postoperative Agitation after Sevoflurane Anesthesia in Children: A Prospective Randomized Study

AbstractBackground: Sevoflurane commonly used in pediatric anesthesia for inhalational induction and maintenance, however Emergence Agitation (EA) in children after sevoflurane anesthesia is common, with reported incidence up to 80%. Dexmedetomidine is a selective alpha 2 receptor agonist and has sympatholytic, analgesic and sedative properties with minimal respiratory effects.Aim: The aim of this study is to evaluate the effect of caudal dexmedetomidine on prevention of agitation after sevoflurane anesthesia as a primary outcome measure. Also post-operative analgesia will be studied as secondary outcome measures.Material and Methods: This study was carried out on 120 children, 1-6 years, ASA I, scheduled for elective lower abdominal surgery. Patients were randomized into 3 equal groups (40 patients in each group): Group I: Dexmedetomidine group (DEX): Received caudal anesthesia with dexmedeto-midine 1ug/kg and 1ml/kg bupivacaine 0.25%, Group II: Received caudal anesthesia with1ml/kg bupivacaine 0.25%. Group III: Received general anesthesia without caudal block. Hemodynamics: (HR & MAP) and SpO2 before induction and every 10 minutes for 1st 2 hours andat 15-min intervals for 1h. post-operatively, depth of anesthesia, incidence of emergence agitation after extubation and for 10min in the PACU by Aono's four-point scale. at 15-min intervals for 1h. Post-operative pain was assisted by CHIPPS.Results: Hemodynamics (HR & MAP) only significant decrease in MAP and HR in DEX group. EA was significantly lower in DEX group, CHIPPS was significantly lower in Group I, BIS value was low in DEX group, fentanyl require-ment was lower in Group 1.Conclusions: The use of dexmedetomidine (1μg/kg) added to bupivacaine in caudal block in sevoflurane-anaesthetized children significantly decreased the occurrence of EA and prolonged duration of post-operative analgesia.

Prevention of Emergence Delirium in Children - A Randomized Study Comparing Two Different Timings of Administration of Midazolam.

Background:Emergence delirium (ED) is a distressing side effect of sevoflurane anesthesia in children. Midazolam is a widely studied drug for the prevention of ED with conflicting results.Aim, Settings and Design:We designed this prospective randomized double-blind study to compare the effect of 0.03 mg/kg midazolam administered at induction and the same dose administered 10 min before the end of surgery in the prevention of ED in children undergoing sevoflurane anesthesia and also the effect on the time to recovery in both groups.Materials and Methods:Eighty children between 2 and 8 years belonging to patient physical status American Society of Anesthesiologist Classes 1 and 2 undergoing infra-umbilical surgeries under general anesthesia were randomly allocated to receive 0.03 mg/kg midazolam at induction (Group A) and 10 min before the end of surgery (Group B). Caudal block was administered for analgesia after induction. The primary outcome, the incidence of ED was evaluated using the Paediatric Anaesthesia Emergence Delirium Scale from the time of extubation till 30 min postsurgery. The secondary outcome measured was the time to recovery (time from discontinuation of sevoflurane to the time of extubation) and the results were statistically analyzed.Results:The incidence of ED was comparable between the groups (30%, 10%, 5%, and 2.5% at 5, 10, 15, and 20 min, respectively in Group A and 25%, 10%, 5%, and 2.5% of children at 5, 10, 15, and 20 min, respectively in Group B). Recovery was significantly prolonged in Group B (42.5% of patients in Group A recovered within 6 min of discontinuation of sevoflurane in Group A compared to only 20% of patients in Group B).Conclusion:There is no difference in the reduction of incidence of ED following sevoflurane anesthesia when midazolam is administered at induction or the end of surgery. However, the time to recovery was longer when the drug was administered at the end of the surgery.

Effect of age on Narcotrend Index monitoring during sevoflurane anesthesia in children below 2years of age.

In older children, different electroencephalogram-based algorithms for measuring depth of anesthesia displayed a similar performance as in adults, but in infants they have not displayed the same reliability so far. According to the individual developmental state, the Narcotrend distinguishes "differentiated" electroencephalograms, which can be classified using the full Narcotrend Index scale, from "undifferentiated" electroencephalograms, which are classified using a scale with fewer stages. The objective of this prospective clinical observational study was to assess the feasibility and performance of the Narcotrend monitor in children <2years within a clinical setting. Sixty-one children aged 0-24months undergoing general anesthesia with sevoflurane and remifentanil for elective pediatric surgery were studied. We investigated the percentage of differentiated electroencephalograms and the correlation between multiples of minimal alveolar sevoflurane concentration and the Narcotrend Index according to age groups. Prediction probability was used to evaluate the performance of the Narcotrend Index for differentiation between consciousness and unconsciousness and between different sevoflurane concentrations. The percentage of differentiated electroencephalograms increased with increasing age (0-3months: 23.8%, 4-5months: 87.5%, 6-11months: 92.3%, 12-24months: 100%). The overall prediction probability of Narcotrend Index was 1.0 (SE 0.05) for differentiation between awake and loss of consciousness and 1.0 (SE 0.01) for differentiation between anesthetized and return of consciousness. Spearman correlation analysis revealed a significant negative correlation between sevoflurane concentration and the Narcotrend Index (r=-0.78, P<.0001, 95%CI: -0.81 to -0.74). Overall prediction probability of Narcotrend Index to sevoflurane concentration was 0.8 (95%CI: 0.78-0.82). The Narcotrend monitor indicated a Narcotrend Index in most infants and young children starting from 4months with significant correlation to and acceptable prediction probability for minimal alveolar sevoflurane concentration.

Clinical signs and electroencephalographic patterns of emergence from sevoflurane anaesthesia in children: An observational study.

BACKGROUNDFew studies have systematically described relationships between clinical–behavioural signs, electroencephalographic (EEG) patterns and age during emergence from anaesthesia in young children.OBJECTIVETo identify the relationships between end-tidal sevoflurane (ETsevoflurane) concentration, age and frontal EEG spectral properties in predicting recovery of clinical–behavioural signs during emergence from sevoflurane in children 0 to 3 years of age, with and without exposure to nitrous oxide. The hypothesis was that clinical signs occur sequentially during emergence, and that for infants aged more than 3 months, changes in alpha EEG power are correlated with clinical–behavioural signs.DESIGNAn observational study.SETTINGA tertiary paediatric teaching hospital from December 2012 to August 2016.PATIENTSNinety-five children aged 0 to 3 years who required surgery below the neck.OUTCOME MEASURESTime–course of, and ETsevoflurane concentrations at first gross body movement, first cough, first grimace, dysconjugate eye gaze, frontal (F7/F8) alpha EEG power (8 to 12 Hz), frontal beta EEG power (13 to 30 Hz), surgery-end.RESULTSClinical signs of emergence followed an orderly sequence of events across all ages. Clinical signs occurred over a narrow ETsevoflurane, independent of age [movement: 0.4% (95% confidence interval (CI), 0.3 to 0.4), cough 0.3% (95% CI, 0.3 to 0.4), grimace 0.2% (95% CI, 0 to 0.3); P > 0.5 for age vs. ETsevoflurane]. Dysconjugate eye gaze was observed between ETsevoflurane 1 to 0%. In children more than 3 months old, frontal alpha EEG oscillations were present at ETsevoflurane 2.0% and disappeared at 0.5%. Movement occurred within 5 min of alpha oscillation disappearance in 99% of patients. Nitrous oxide had no effect on the time course or ETsevoflurane at which children showed body movement, grimace or cough.CONCLUSIONSeveral clinical signs occur sequentially during emergence, and are independent of exposure to nitrous oxide. Eye position is poorly correlated with other clinical signs or ETsevoflurane. EEG spectral characteristics may aid prediction of clinical–behavioural signs in children more than 3 months.

The Efficacy of Intraoperative EEG to Predict the Occurrence of Emergence Agitation in the Postanesthetic Room After Sevoflurane Anesthesia in Children

Emergence agitation (EA) is common after sevoflurane anesthesia, but there are no definite predictors. This study investigated whether intraoperative electroencephalography (EEG) can indicate the occurrence of EA in children. A prospective predictive study design was used. EEG-derived parameters (spectral edge frequency 95, beta, alpha, theta, and delta power) were measured at 1.0 minimum alveolar concentration (MAC) and 0.3 MAC of end-tidal sevoflurane (EtSEVO) in 29 patients. EA was evaluated using an EA score (EAS) in the postanesthetic care unit on arrival (EAS 0) and at 15 and 30minutes after arrival (EAS 15 and EAS 30). The correlation between EEG-derived parameters and EAS was analyzed using Spearman correlation, and receiver-operating characteristic curve analysis was used to measure the predictability. EA occurred in 11 patients. The alpha power at 1.0 MAC of EtSEVO was correlated with EAS 15 and EAS 30. The theta/alpha ratio at 0.3 MAC of EtSEVO was correlated with EAS 30. The area under the receiver-operating characteristic curve of percentage of alpha bands at 0.3 MAC of EtSEVO and the occurrence of EA was 0.672. Children showing high-alpha powers and low theta powers (= low theta/alpha ratio) during emergence from sevoflurane anesthesia are at high risk of EA in the postanesthetic care unit.

Effect of intranasal dexmedetomidine on emergence agitation after sevoflurane anesthesia in children undergoing tonsillectomy and/or adenoidectomy.

Background:Emergence agitation (EA) after sevoflurane anesthesia is common in children during recovery from general anesthesia and may result in postoperative complications. This study investigated safety and effectiveness of intranasal dexmedetomidine in reducing the incidence and severity of EA.Methods:This prospective, randomized double-blinded controlled trial included 86 patients scheduled for the tonsillectomy and/or adenoidectomy under general anesthesia with sevoflurane. They were randomly allocated into two groups. Group D received intranasal dexmedetomidine at 1 μg/kg, and Group C received intranasal saline 0.9% after the induction of general anesthesia. Four-point agitation scale and Face, Legs, Activity, Cry and Consolability (FLACC) scale for pain assessment were measured at six time points (after extubation, leaving the operating room, on arrival to postanesthesia care unit [PACU], 10, 20, and 30 min after arrival in PACU). Extubation, emergence, and discharge times were recorded in addition to any adverse effects.Results:There was a significant difference in the incidence of EA between Groups D and C (6.98% and 58%, respectively, with P = 0.001). The median four-point agitation scales and the median scores of FLACC pain scales of Group D were significantly lower than those of Group C at the all six time points with P < 0.05. Extubation, emergence, and discharge times were comparable in both groups, and none of the subjects reported any adverse effects.Conclusion:This study demonstrates that a 1 μg/kg dose of intranasal dexmedetomidine administered after the induction of anesthesia reduces post-sevoflurane incidence and severity of EA in children undergone tonsillectomy and/or adenoidectomy with no adverse effects and smooth recovery profile.

μ-Opioid agonists for preventing emergence agitation under sevoflurane anesthesia in children: a meta-analysis of randomized controlled trials.

Emergence agitation (EA) is an adverse effect after sevoflurane anesthesia in pediatric patients. The effectiveness of prophylactic μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil in preventing EA is debatable. A literature search was conducted to identify clinical trials that observed the effect of μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil on preventing EA in pediatric patients under sevoflurane anesthesia. The statistical software RevMan 5.3 was used for meta-analysis. Data from each study were combined using the relative ratio (RR), weighted mean differences, and their associated 95% confidence intervals. I(2) was used to evaluate heterogeneity. Subgroup analysis was conducted to investigate the possible influences of patient age, adenotonsillectomy, premedication, N2 O, propofol, and regional block/local anesthetics on preventing EA with prophylactic administration of μ-opioid agonists. Publication bias was checked using funnel plots and Begg's test. This meta-analysis showed the inclusion of 19 randomized controlled trials with 1528 patients (857 patients received μ-opioid agonists therapy and 671 patients had placebo). The pooled data indicated that prophylactic μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil significantly decreased the incidence of EA [RR = 0.49 (0.38, 0.64), I(2) = 42%, P = 0.04; RR = 0.57 (0.33, 0.99), I(2) = 37%, P = 0.19; RR = 0.18 (0.08, 0.39), I(2) = 0%, P = 0.98; and RR = 0.56 (0.40, 0.78), I(2) = 6%, P = 0.34, respectively]. All subgroup analyses strengthened the proof for lower incidence of EA under sevoflurane anesthesia after fentanyl administration. A possibility of publication bias was detected in the fentanyl group. This meta-analysis suggested that prophylactic μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil could significantly decrease the incidence of EA under sevoflurane anesthesia in children compared to placebo. Considering the limitations of the included studies, more clinical studies are required.

Effects of Fentanyl on Emergence Agitation in Children under Sevoflurane Anesthesia: Meta-Analysis of Randomized Controlled Trials.

Background and ObjectivesThe goal of this meta-analysis study was to assess the effects of fentanyl on emergence agitation (EA) under sevoflurane anesthesia in children.Subjects and MethodsWe searched electronic databases (PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials) for articles published until December 2014. Randomized controlled trials (RCTs) that assessed the effects of fentanyl and placebo on EA under sevoflurane anesthesia in children that the outcome were the incidence of EA, postoperative pain, emergence time or adverse effects were included in this meta-analysis.ResultsA total of 16 studies, including 1362 patients (737 patients for the fentanyl group and 625 for the placebo group), were evaluated in final analysis. We found that administration of fentanyl decreased the incidences of EA (RR = 0.37, 95% CI 0.27~0.49, P<0.00001) and postoperative pain (RR = 0.59, 95% CI 0.41~0.85, P = 0.004) but increased the incidence of postoperative nausea and vomiting (PONV) (RR = 2.23, 95% CI 1.33~3.77, P = 0.003). The extubation time (WMD = 0.71 min, 95% CI 0.12~1.3, P = 0.02), emergence time (WMD = 4.90 min, 95% CI 2.49~7.30, P<0.0001), and time in the postanesthesia care unit (PACU) (WMD = 2.65 min, 95% CI 0.76~4.53, P = 0.006) were slightly increased. There were no significant differences in the time to discharge of day patients (WMD = 3.72 min, 95% CI -2.80~10.24, P = 0.26).ConclusionOur meta-analysis suggests that fentanyl decreases the incidence of EA under sevoflurane anesthesia in children and postoperative pain, but has a higher incidence of PONV. Considering the inherent limitations of the included studies, more RCTs with extensive follow-up should be performed to validate our findings in the future.

Neonatal exposure to sevoflurane may not cause learning and memory deficits and behavioral abnormality in the childhood of Cynomolgus monkeys.

Results of animal studies have raised a significant concern that commonly used general anesthetics may induce neurotoxicity in children. It may be difficult to resolve this concern with human studies because randomizing children only for testing anesthetic toxicity may not be feasible. We randomized 6-day old male Cynomolgus monkeys to receive or not to receive sevoflurane anesthesia at surgical plane for 5 h. Sevoflurane is the most commonly used general anesthetic in children in the U.S.A. Here, we showed that sevoflurane anesthesia did not affect the behavior evaluated by holding cage method when the monkeys were 3 and 7 months old. However, there was an age-dependent decrease in the frequency of stress events and environmental exploration behavior during the test. Sevoflurane also did not affect the learning and memory of the monkeys when they were assessed from the age of 7 months. Finally, sevoflurane did not affect the expression of multiple neuron-specific proteins in the hippocampus and cerebral cortex of 10-month old monkeys after all behavioral and cognitive tests were completed. These results suggest that exposure of neonatal monkey to sevoflurane may not affect cognition, behavior and neuronal structures in childhood, indicating the safety of sevoflurane anesthesia in children.

Effect of ramosetron on the QT interval during sevoflurane anaesthesia in children

We investigated the effects of concomitant administration of sevoflurane and ramosetron on the QT interval, the interval between the peak and end of the T wave (Tpe) and Tpe/QT ratio in children. To compare the effects of concomitant administration of ramosetron and sevoflurane on heart rate corrected interval with Bazett's formula (QTc), Tpe interval and Tpe/QT ratio. A prospective observational study. Elective orthopaedic surgery with patient-controlled analgesia. Forty children aged between 3 and 12 years. ECG recordings were collected before induction (BASE), before sevoflurane administration (SEVO) and after the administration of ramosetron (SEVO and R). The heart rate corrected interval with Bazett's formula (QTc), Tpe interval and Tpe/QT ratio were calculated and the changes were analysed using repeated-measures analysis of variance (ANOVA). The QTc interval at BASE was 388.5 ± 29.3 ms. It increased with sevoflurane anaesthesia to 414.9 ± 21.4 ms and did not change with the administration of ramosetron (418.2 ± 23.0 ms). The Tpe interval and Tpe/QT ratio did not differ between measurements. No ventricular arrhythmias occurred during the study. Ramosetron was not associated with prolongation of the QTc interval when it was given concomitantly with sevoflurane in children. No ventricular arrhythmias or other adverse effects occurred during the study.

Does a prophylactic dose of propofol reduce emergence agitation in children receiving anesthesia? A systematic review and meta-analysis.

Emergence agitation (EA) is common after sevoflurane anesthesia in children, and can lead to distressing inconsolability, agitation, crying, and injury. Use of a single dose of the short-acting sedative-hypnotic agent propofol at the end of a procedure has shown promise for preventing EA, but evidence evaluating the efficacy and safety of this approach has not been formally summarized. The objective of this review was to assess the effects of a prophylactic dose of propofol vs placebo on the incidence and severity of EA in children age 0-13 years receiving general inhalational anesthesia. We searched PubMed (1946-2013) via Medline, CENTRAL (1898-2013), and Web of Science (1900-2013) without limits or language restrictions; we also searched ClinicalTrials.gov and reference lists. We reviewed abstracts from the 2012 and 2013 Society for Pediatric Anesthesia meetings and pediatric anesthesia-related abstracts from the 2012 and 2013 International Anesthesia Research Society meetings. We assessed randomized, double-blind trials evaluating the efficacy of a prophylactic dose of propofol (1 mg·kg(-1) ) vs placebo given at the end of inhalational anesthesia to prevent EA in pediatric patients. Studies were required to follow patients through recovery and report at least one prespecified outcome. Two authors independently assessed trial quality and extracted data from included studies. We contacted study authors regarding any missing data. We used the random effects models to calculate pooled relative risks (RR) and weighted mean differences (WMD). We collected Pediatric Anesthesia Emergence Delirium (PAED) scale scores from included studies. PAED scale scores can range from 0 to 20. Of 276 studies screened, nine trials involving 997 children met all inclusion criteria. All were considered low risk of bias. For one non-English trial, we obtained a full-text translation and for one non-English trial, we used the English-language abstract, tables, and figures. Based on available evidence, prophylactic propofol was associated with both decreased incidence of EA (29% vs 58%, RR 0.50, 95% confidence intervals [CI] 0.41, 0.61, I(2) = 37%, seven studies), and reduced severity of EA as assessed by mean PAED scale score (WMD -2.08 points, 95% CI -3.20, -0.96, I(2) = 0%, three studies), when compared to placebo. In addition, though prophylactic propofol did lengthen the time to awakening (WMD 4.07 min, 95% CI 2.22, 5.91, I(2) = 82%, six studies), it did not increase recovery time (WMD 2.91 min, 95% CI -0.59, 6.41, I(2) = 82%, six studies) when compared to placebo. No significant adverse events were reported in either arm. Based on high quality evidence, prophylactic propofol appears to be effective for reducing the incidence and severity of EA in children emerging from general anesthesia.

Transition to propofol after sevoflurane anesthesia to prevent emergence agitation: a randomized controlled trial.

Emergence agitation (EA) is a common behavioral disturbance after sevoflurane anesthesia in children. Propofol 1 mg · kg(-1) bolus at the end of sevoflurane anesthesia has had mixed results in reducing the incidence of EA, whereas propofol infusion throughout anesthesia maintenance seems effective but is more complex to administer. If a simple, short transition to propofol anesthesia was found to be effective in reducing EA, this could enhance the recovery of children following sevoflurane anesthesia. We therefore aimed to determine whether transition to propofol over 3 min at the end of sevoflurane anesthesia reduces the incidence of EA in children. In this prospective randomized controlled trial, 230 children aged 1-12 years, undergoing magnetic resonance imaging (MRI) scans under sevoflurane anesthesia were randomized to receive either propofol 3 mg · kg(-1) over 3 min (propofol group), or no propofol (control group), at the end of sevoflurane anesthesia. EA was assessed by a blinded assessor using the Pediatric Emergence Anesthesia Delirium (PAED) scale and the Watcha scale until 30 min after emergence. EA on the PAED scale was defined as a PAED score >12. EA on the Watcha scale was defined as a score ≥ 3. Times to emergence, postanesthesia care unit (PACU) discharge, and discharge home were also recorded. Data were analyzed for 218 children. The incidence of EA was lower in the propofol group on both PAED (29% vs 7%; relative risk = 0.25; 95% confidence interval 0.12-0.52; P < 0.001) and Watcha (39% vs 15%; relative risk = 0.37; 95% confidence interval 0.22-0.62; P < 0.001) scales. Duration and severity of EA were also reduced in the propofol group. Preplanned subgroup analyses for midazolam premedication, preexisting cognitive or behavioral disturbance, and age group did not alter our findings. Emergence time and time in PACU were both increased by a mean of 8 min in the propofol group (P < 0.001) with no difference in time to discharge home. Transition to propofol at the end of sevoflurane anesthesia reduces the incidence of EA and improves the quality of emergence. There is a small increase in recovery time, but no delay in discharge home.

Effect of dexemeditomedine and propofol on the prevention of emergence agitation following sevoflurane anesthesia in Egyptian children.

This study evaluated the effect of dexemeditomedine and propofol on the prevention of emergence agitation following sevoflurane anesthesia in children. Sixty children, aged 4-6 years, ASA I, who were undergoing inguinal hernia repair were enrolled after written informed consents were obtained from parents of all participants. The results showed that the incidence of EA showed statistical significant reduction in dexemedetomedine group (1.5%) than propofol group (20%) and much reduction than saline group (60%) with no difference in the discharge time, FLACC scale was clinically but not statistically lower in dexemedetomedine group than propofol group and much lower than saline group at all times with no significant difference in the number of patients administered fentanyl, Ramsay's sedation scale was clinically higher in dexemeditomedine group than propofol group and much higher than saline group at all times but Without statistical difference, inspired sevoflurane concentration was statistically lower in dexemeditomedine group than the other two groups at all times except at T7, where it was reduced in both dexemeditomedine and propofol groups but the reduction was more in dexemeditomedine group and heart rate (HR) and mean arterial pressure (MAP) showed statistical significant reduction in dexemedetomedine group than the other two groups at all times compared to baseline value (TO) except at T7, where they were reduced in both dexemedetomedine and propofol groups. In dexemedetomedine group, eight cases (40%) showed reduction in HR and four cases (20%) showed reduction in MAP but only one case (5%) required atropine and other one (5%) required ephedrine while in propofol group, one case (5%) showed reduction in HR and other case (5%) showed reduction in MAP but did not require atropine or ephedrine respectively.

Dexmedetomidine for preventing sevoflurane‐related emergence agitation in children: a meta‐analysis of randomized controlled trials

Emergence agitation (EA) is a common problem after sevoflurane anesthesia in children. Prophylactic dexmedetomidine has been directed at this issue; however, the efficacy remains controversial. We therefore conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the effectiveness of dexmedetomidine on the incidence of sevoflurane-related EA. A comprehensive literature search was performed to identify RCTs that compared dexmedetomidine with placebo about the reduction in the incidence of sevoflurane-related EA for children. Heterogeneity between studies was anticipated; therefore, random effects models were chosen to calculate the pooled risk ratio (RR) and 95% confidence interval (CI), and I(2) statistics were used to assess statistical heterogeneity. The funnel plot and Egger test were used to assess potential publication bias. Subgroup analysis was run to explore the possible effects of age, surgical procedure, regional block/local anesthetics, supplemental analgesic, propofol, N2O, pre-medication and methodological quality on the incidence of EA using dexemedetomidine. Totally, 15 RCTs were included (518 patients received dexmedetomidine and 413 had placebo). Dexmedetomidine reduced the incidence of sevofurane-related EA (pooled RR = 0.351; 95% CI: 0.275-0.449; P = 0.965; heterogeneity test, I(2) = 0.0%), and it also resulted in a lower incidence of severe EA (pooled RR = 0.119; 95% CI: 0.033-0.422; P = 0.962; heterogeneity test, I(2) = 0.0%). All subgroup analyses for potential sources of heterogeneity showed a lower incidence of sevoflurane-related EA after dexmedetomidine administration. This meta-analysis demonstrated that dexemedetomidine was effective in reducing the incidence of sevoflurane-induced EA in children as compared with placebo.

Influence of the Sevoflurane Concentration on the Occurrence of Epileptiform EEG Patterns

Objectives and AimThis study was performed to analyse the effects of different sevoflurane concentrations on the incidence of epileptiform EEG activity during induction of anaesthesia in children in the clinical routine.BackgroundIt was suggested in the literature to use sevoflurane concentrations lower than 8% to avoid epileptiform activity during induction of anaesthesia in children.Methods100 children (age: 4.6±3.0 years, ASA I–III, premedication with midazolam) were anaesthetized with 8% sevoflurane for 3 min or 6% sevoflurane for 5 min in 100% O2 via face mask followed by 4% sevoflurane until propofol and remifentanil were given for intubation. EEGs were recorded continuously and were analysed visually with regard to epileptiform EEG patterns.ResultsFrom start of sevoflurane until propofol/remifentanil administration, 38 patients (76%) with 8% sevoflurane had epileptiform EEG patterns compared to 26 patients (52%) with 6% (p = 0.0106). Epileptiform potentials tended to appear later in the course of the induction with 6% than with 8%. Up to an endtidal concentration of 6% sevoflurane, the number of children with epileptiform potentials was similar in both groups (p = 0.3708). The cumulative number of children with epileptiform activity increased with increasing endtidal sevoflurane concentrations. The time from start of sevoflurane until loss of consciousness was similar in patients with 8% and 6% sevoflurane (42.2±17.5 s vs. 44.9 s ±14.0 s; p = 0.4073). An EEG stage of deep anaesthesia with continuous delta waves <2.0 Hz appeared significantly earlier in the 8% than in the 6% group (64.0±22.2 s vs. 77.9±20.0 s, p = 0.0022).ConclusionThe own analysis and data from the literature show that lower endtidal concentrations of sevoflurane and shorter administration times can be used to reduce epileptiform activity during induction of sevoflurane anaesthesia in children.

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.

Effect of caudal clonidine on emergence agitation and postoperative analgesia after sevoflurane anaesthesia in children: Randomised comparison of two doses.

Background and Aims:Sevoflurane, a popular inhalational anaesthetic for children, has been associated with significant emergence agitation in the recovery phase. This study was intended to compare two doses of caudal clonidine added to ropivacaine 0.2% in order to decide on the optimal dose for prevention of sevoflurane induced emergence agitation (EA) and to get a meaningful prolongation of postoperative analgesia with minimal side effects.Methods:Sixty-one children aged 1–7 years (American Society of Anaesthesiologists physical status I-II) received standardized general anaesthesia with inhaled sevoflurane and caudal epidural block with 0.2% ropivacaine 1 ml/kg for sub-umbilical surgeries. They were assigned randomly to two groups: (I) clonidine 1 μg/kg added to caudal ropivacaine; (II) clonidine 2 μg/kg added to caudal ropivacaine. EA and postoperative analgesia were assessed using pain/discomfort scale score and face, legs, activity, cry, consolability (FLACC) score respectively.Results:EA was observed in 8 children (26.6%) in group I when compared to only 2 children (6.4%) in group II after first 15 min postoperatively. Incidences of EA at 15 min, as well as total incidence of agitation, were both significantly lower in group II when compared to group I with P < 0.05. Duration of analgesia in group I (12 [8–20] h) and group II (16 [8–20] h) was statistically comparable (P > 0.05). There was no difference in the incidence of sedation or complications.Conclusion:Caudal clonidine 2 μg/kg added to 0.2% ropivacaine 1 ml/kg is suggested to be the optimal dose, for prevention of EA and meaningful prolongation of postoperative analgesia with minimal side-effects.

Premedication with dexmedetomidine decreases emergence agitation after sevoflurane anesthesia in children

Background Diagnostic procedures such as bone marrow aspiration and biopsy have increased in recent years. The pain during such procedures is too much for most children to tolerate, and therefore general anesthesia with sevoflurane is the only choice. Emergence agitation (EA) is described as a mental disturbance during the recovery from general anesthesia. The aim of this study is to test the hypothesis that, because of its sedative effects, the use of dexmedetomidine decreases EA and improves parents and nurses' satisfaction after sevoflurane-based anesthesia in children. Patients and methods A total of 200 children aged 2-6 years, scheduled for bone marrow aspirations and biopsies, in a hospital procedure room, were enrolled. Patients were randomized into two groups: group D, receiving dexmedetomidine (2 μg/kg) in 10 ml saline over 2 min; and group S, receiving 10 ml saline over 2 min. Procedure duration, recovery time, and discharge time were recorded. Agitation score and parents and nurses' satisfaction scores were assessed. Results There were no significant differences between groups in the duration of the procedure or the time of discharge. The recovery time was longer in group D. Both parents and nurses' satisfaction scores were significantly lower in group D. Both agitation score and percent of patients who had agitation were significantly lower in group D. The mean arterial blood pressure and heart rate were significantly lower in group D. Conclusion Dexmedetomidine is an effective drug to reduce EA in pediatric patients after sevoflurane anesthesia without prolongation in the time of discharge, and provide better parents and nurses' satisfaction scores, which may allow better performance of the nurses.