Watcha Scale Research Articles

Preoperative Anxiety Scores as Predictors of Postoperative Outcomes in Pediatrics Undergoing Cardiac Surgery: An Observational Study

Abstract Background: Preoperative anxiety has a significant impact on many pediatric surgery patients annually. This study aimed to evaluate the preoperative anxiety scores as predictors of postoperative outcomes in children undergoing cardiac surgery. Subjects and Methods: This cohort study involved 133 children between the ages of 2 and 6 years who underwent cardiac surgery. Preoperative anxiety was evaluated using the happy, relaxed, anxious, distressed scale (HRAD±), Modified Yale Preoperative Anxiety Scale (mYPAS), and Induction Compliance Checklist (ICC) scores. Emergence agitation (EA) was assessed using the Watcha scale at 30 min intervals during the initial 4 h period and again at 24 h. The study’s primary outcome was the correlation between the HRAD± score and postoperative agitation. Secondary outcomes included the correlation between each of the mYPAS and ICC scores and postoperative agitation, as well as the incidence and severity of postoperative agitation. Results: Anxiety was observed in 70.68% of patients. The mean mYPAS score increased after separation, entering the operating room, and during induction of anesthesia compared to the holding area (49.3 ± 5.27, 51.7 ± 4.98, 63.4 ± 5.8 vs. 36.7 ± 4.6). There were significant positive associations between postoperative agitation and preoperative agitation scores, including HRAD±, mYPAS, and ICC scores (P < 0.001). The incidence and severity of EA were high at 0.5 h and then decreased over 24 h postoperatively. Conclusion: Preoperative HRAD±, mYPAS, and ICC scores may predict postoperative agitation in children undergoing cardiac surgery.

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 >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 <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 <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.

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

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

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.

Çocuklarda Obezitenin Postoperatif Derlenme Ajitasyonuna Etkisi

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

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

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

Sleep quality and emergence delirium in children undergoing strabismus surgery: a comparison between preschool- and school-age patients

BackgroundEmergence delirium (ED) is common in pediatric patients undergoing general anesthesia with sevoflurane. Preoperative sleep quality is associated with the risk factors for ED. However, research on the relationship between sleep quality and ED is limited. We aimed to investigate the relationship between ED and preoperative sleep quality in pediatric patients undergoing strabismus surgery.MethodsThis clinical trial included pediatric patients aged 4–12 years who underwent elective strabismus surgery. The patients and their parents were questioned about the patients’ preoperative sleep quality using the Pittsburgh Sleep Quality Index (PSQI) questionnaire. For anesthesia induction, thiopental (5 mg/kg) and rocuronium (0.6 mg/kg) were used, and anesthesia was maintained with sevoflurane (minimum alveolar concentration, 1–1.5). After administration of a reversal drug, extubation was performed, and the patients were transferred to a post-anesthesia recovery unit. At 10 min after extubation, the degree of ED was measured using the pediatric anesthesia emergence delirium (PAED) and Watcha scale scores.ResultsOf the 62 enrolled patients, three pediatric patients were excluded. The overall incidence of ED was 22%. A total of 59 patients were divided into the two groups. The ED group and the non-ED group comprised 13 and 46 patients. Age, height and weight were significantly lower in the ED group than in the non-ED group. Preoperative PSQI and Watcha scale score were significantly higher in the ED group than in the non-ED group. Multivariate analysis showed that age (adjusted OR [95% CI]: 0.490 [0.290–0.828], p = 0.008) and preoperative PSQI score (adjusted OR [95% CI]: 2.149[1.224–3.771], p = 0.008) was associated with ED. In sub-group analysis, PAED scale and Watcha scale scores showed a moderate correlation with preoperative sleep quality in preschool-age patients.ConclusionIn conclusion, the incidence of ED tended to be higher in younger age and poorer preoperative sleep quality in pediatric patients. In particular, the poorer sleep quality score was associated with higher incidence of ED in the preschool-age. Large-scale clinical studies and long-term follow-up studies on ED and sleep quality are required.Trial registrationThis study was registered with Clinicaltrials.gov (NCT03332407) at November 5th 2017.

EMERGENCE DELIRIUM IN PEDIATRIC PATIENTS UNDERGOING GENERAL ANESTHESIA

Background: Emergence delirium (ED) is described as a transient state of cognitive disturbance and psychomotor agitation, which begins with emergence from anesthesia and continues through the early recovery period. The incidence of ED in the pediatric population remains unclear and ranges from 10 to 80%. The pathophysiology and underlying mechanisms of ED are also uncertain. This study aimed to determine the prevalence of ED, potential risk factors that may contribute to the development of ED and observe behaviour changes related to ED in the late postoperative period. Methods: A prospective observational study was carried out with children aged 1 to 12 years. The child’s behaviour before anesthesia was evaluated using the Pediatric Anesthesia Behavior (PAB) score. Medications used during the perioperative period were registered. The Watcha scale was used to evaluate if children developed ED and the Visual Analogue Scale (VAS) was used to register pain intensity during the first 15 minutes after the awakening. Parents of patients who experienced agitation were asked to assess their child’s behaviour two weeks after the anesthesia. Results: Among 136 observed patients 24 (17.6%) had ED. The duration of anesthesia among ED experienced patients was 45.42 (SD 18.35) min and it was significantly shorter than among children who didn’t develop ED – 60 (SD 29.03) min, p = 0.016. Eighteen (15.5%) patients in a mild pain group (VAS 0 to 3) experienced ED while in a moderate-25 severe pain group (VAS 4-10) there were 6 (37.5%) children who developed ED, p=0.033. However, age, the American Society of Anesthesiologists Classification (ASA) class, surgery type, behaviour before anesthesia induction and perioperative medications were not associated with ED. Conclusions: The prevalence of ED observed during our study, short duration of anesthesia and postoperative pain association with ED coincided with the results specified by other researchers. ED associated behavior changes were reported in the late postoperative period. Our other findings appeared to be not consistent with the results reported in other studies. Thus, the dilemma of ED still remains unresolved.

Oral melatonin as part of multimodal anxiolysis decreases emergence delirium in children whereas midazolam does not: A randomised, double-blind, placebo-controlled study.

Pre-operative anxiety is a risk factor for emergence delirium in children and a multimodal approach including sedatives and nonpharmacological measures is the current strategy to tackle this anxiety. The efficacy of oral melatonin as a component of multimodal anxiolytic strategy to decrease emergence delirium is not well studied. The aim of this study was to evaluate the efficacy of a multimodal anxiolytic strategy including oral melatonin or midazolam to decrease emergence delirium after sevoflurane anaesthesia. A randomised, double-blind, parallel arm, placebo-controlled trial. Tertiary care teaching hospital from July 2019 till January 2020. Children in the age group of 3 to 8 years who received sevoflurane anaesthesia for elective ambulatory procedures. Children were randomised to receive oral premedication with either melatonin 0.3 mg kg-1, midazolam 0.3 mg kg-1 or honey as placebo. All the children received standardised nonpharmacological measures involving multiple techniques to allay anxiety. The anaesthetic plan was also standardised. The primary outcome was the incidence of emergence delirium as assessed by the Watcha scale in the postanaesthesia care unit. The secondary outcomes were pre-operative anxiety assessed using a modified Yale Preoperative Anxiety scale, patient compliance with mask induction using the Induction Compliance Checklist and postoperative sedation. Data from 132 children were analysed. Melatonin significantly reduced the incidence of emergence delirium compared to placebo: 27 vs. 50%, respectively, an absolute risk reduction of 23.3 [95% confidence interval 3.7 to 42.9), P = 0.03]. Melatonin also significantly reduced the risk of emergence delirium compared with midazolam: 27 vs. 56%, respectively, an absolute risk reduction of 29.2 (95% CI 9.5 to 48.8). The midazolam group had a similar incidence of emergence delirium as placebo. Sedation scores were similar in the three groups postoperatively. The incidence and score of pre-operative anxiety as well as the compliance with mask induction were similar in the three groups. A multimodal anxiolytic approach including oral melatonin, as opposed to oral midazolam, significantly reduced emergence delirium after sevoflurane anaesthesia. CTRI/2019/06/019850 in Clinical Trial Registry of India (www.ctri.nic.in).

A retrospective evaluation of the efficacy of midazolam and ketamine as premedication for paediatric patients undergoing elective surgery

Background: Preoperative anxiety is common in paediatric patients and is associated with negative postoperative outcomes. Sedative premedication may alleviate some of this anxiety. A new sedation protocol using midazolam and ketamine in combination was instituted at our tertiary hospital. We aimed to evaluate the efficacy and the side effect profile of this regimen. Methods: We conducted a retrospective review of paediatric surgical patients who received oral midazolam (0.25 mg/kg) together with ketamine (3 mg/kg) as premedication, prior to induction of anaesthesia for elective surgery. The Watcha scale was used to assess preoperative and postoperative behaviour. Premedication efficacy was assessed using the Wilson sedation scale together with the 4-point anxiety scale. We further compared the incidence of significant preoperative anxiety with the incidence from a previous study. Results: We included 146 patients in our study. There was optimal sedation (Wilson sedation score = 1/2) in 47.9% of the patients (CI 39.9–56.1) with failed sedation (Wilson sedation score = 0) in 34.9% (CI 27.6–43.1) and over-sedation (Wilson sedation score = 3/4) in 17.1% (CI 11.8–24.2) of the patients. Optimal anxiolysis (4-point anxiety scale = 1) was achieved in 76.0% of the patients (CI 68.4–82.3). Failed anxiolysis (4-point anxiety scale = 2/3/4) occurred in 23.3% of the patients (CI 17.7–31.6). The majority of patients had no side effects (79.5%; CI 72.1–85.3). For those who experienced side effects, the most common was hypersalivation (12.3%; CI 7.9–18.8). The incidence of postoperative delirium was 3.4% (CI 1.4–8.0) and there was significantly less anxiety compared to our previous regimen (5.5%; CI 2.7–10.6 versus 13.5%; p = 0.007). Conclusion: The combination of midazolam and ketamine appears effective in providing safe sedation and reducing preoperative anxiety. Side effects occurred in up to a fifth of patients; predominantly hypersalivation. The combination of midazolam and ketamine for premedication should be considered for ASA I–II patients without contraindications undergoing elective surgery.

The prevalence of emergence delirium and its associated factors among children at a postoperative unit: A retrospective cohort at a Middle Eastern hospital.

Background:Emergence delirium (ED) has been reported among children at a postoperative setting, which delays their recovery and exposes them to traumas. The aim of this study was to determine the prevalence of ED and its associated factors among children who underwent surgeries at a major tertiary healthcare facility in Saudi Arabia.Materials and Methods:Between March and August 2018, a retrospective cohort study was conducted based on a review of 413 medical charts of children (<14 years) who underwent an elective/nonemergency surgery and then were admitted to a Post Anesthesia Care Unit. Patient and surgery-related characteristics were analyzed as potential factors associated with ED. The anxiety level was assessed preoperatively using the Modified Yale Preoperative Anxiety Scale (four domains), while the ED was detected after surgery using the Watcha scale (child is agitated and thrashing around).Results:The leading surgery category was ear, nose, and throat surgeries [184 (44.6%)] and dental surgeries [109 (26.4%)]. Almost one-third received only general anesthesia (31.2%), while 271 (68.8%) received an additional regional block/skin infiltrate. The anxiety domains preop showed that the percentage mean score ± standard deviation of expression of emotions was 37.1 ± 21.6, apparent arousal 33.7 ± 20.4, activeness 30.1 ± 13.5, and vocalization 26.9 ± 20.3. The prevalence of ED among children who underwent surgeries during the 6-month period was 23 (6.6%). Almost 18.8% of those who received opioid analgesics (fentanyl alone) developed ED, while 12% of those who received both opioid and nonopioid analgesics (fentanyl/paracetamol) developed ED. ED was significantly associated with longer recovery duration 69.5 + 27.1 min, P = 0.007. Binary logistics regression analysis showed that participants who did not receive Precedex were adj. odds ratio = 10.3 (2.4–48.9) times more likely to develop ED, compared with those who received it, adj. P = 0.003. Lower preoperative scores of expression of emotions and higher scores of apparent arousal were significantly associated with ED, adj. P = 0.035 and adj. P = 0.023, respectively.Conclusion:ED appears to be inevitable in postoperative settings. It is crucial to address any preoperative anxiety assessment as it is associated with ED. Anxiety remains a modifiable factor that can be managed, as well as to the administration of Precedex and adjunct analgesic treatments.

Three minutes propofol after sevoflurane anesthesia to prevent emergence agitation following inguinal hernia repair in children: a randomized controlled trial.

BackgroundEmergence agitation (EA) is a common problem after sevoflurane anesthesia among children. There have been mixed results with control of EA using propofol 1 mg/kg bolus following sevoflurane anesthesia. An infusion of 3 mg/kg of propofol over 3 min following sevoflurane anesthesia has been found to be promising in children undergoing magnetic resonance imaging scans. However, no studies have been conducted during surgical procedures. We aimed to examine the efficacy of transition to propofol for 3 min after cessation of sevoflurane anesthesia in children undergoing inguinal hernia repair.MethodsIn this prospective randomized controlled trial, 64 children aged 1–12 years, scheduled for inguinal hernia repair, were randomized to receive either propofol 3 mg/kg over 3 min (propofol group) or no propofol (control group), after the cessation of sevoflurane anesthesia. EA was assessed using the Paediatric Emergence Anesthesia Delirium (PAED) scale and the Watcha scale. Emergence time and the duration of post-anesthesia care unit (PACU) stay were also recorded.ResultsThe incidence of ED was lower in the propofol group on both the PAED (81.3% vs. 15.6%, P < 0.001) and the Watcha (78.1% vs. 15.6%, P < 0.001) scales. The mean emergence time was 6.37 minutes longer in the propofol group with no significant difference in PACU times.ConclusionsTransition to propofol 3 mg/kg over 3 min following sevoflurane anesthesia reduces the incidence of EA and improves the quality of emergence. Although emergence times were longer, the duration of stay in the PACU was similar with propofol use.

Comparison of 0.125% levobupivacaine with dexmedetomidine and 0.25% levobupivacaine in ultrasonography-guided pediatric caudal block: A prospective, randomized, double-blinded study

Background: Caudal anesthesia is a safe and reliable technique for infraumbilical surgeries in pediatric patients. Addition of dexmedetomidine to local anesthetic (LA) in caudal block prolongs the duration of block, but the effect on reducing the concentration of LA drug has not been extensively evaluated. This study was, therefore, designed to evaluate the efficacy of addition of dexmedetomidine to lower concentration of levobupivacaine required for ultrasonography (USG)-guided caudal block. Methods: A total number of 60 children with American Society of Anesthesiologists Grade I and II, aged 2–8 years from both sexes, and undergoing infraumbilical surgeries were recruited in a prospective, double-blinded, randomized controlled study over a duration of 1 year. The study children were allocated into groups A and B (n = 30 each) via computer-generated randomization. Group A children received caudal 0.25% levobupivacaine 0.75 ml/kg with 1 ml of normal saline and Group B children received 0.125% levobupivacaine 0.75 ml/kg with 1 μg/kg dexmedetomidine in 1 ml of normal saline after induction and the insertion of I-gel. Heart rates, blood pressure, and SpO2were monitored perioperatively. Postoperative hemodynamic monitoring; face, legs, activity, cry, and consolability (FLACC) pain score up to 24 h; time to first rescue analgesia; and emergence delirium using Watcha scale and Ramsay sedation score were recorded. Rescue analgesia was administered when FLACC pain score was >4. Any adverse events were noted and documented. Results: The study groups were comparable in terms of demographic characteristics and nature/duration of surgery. The mean FLACC pain scale in Group B was significantly lower compared to Group A. The mean duration of analgesia was statistically prolonged in Group B (P < 0.05) as compared to Group A (1299 ± 145 min in Group B vs. 348 ± 36 min in Group A). Emergence delirium as measured by Watcha scale was significantly lower in Group B (P < 0.05). Perioperative hemodynamic parameters were stable in the two groups, and no clinically significant adverse effects were noted. Conclusion: Addition of 1 μg/kg of dexmedetomidine decreases the effective concentration of levobupivacaine required for USG-guided caudal block, extends the duration of analgesia, and lowers the incidence of emergence delirium among pediatric patients undergoing infraumbilical surgery.

Dexmedetomidine for the reduction of emergence delirium in children undergoing tonsillectomy with propofol anesthesia: A double-blind, randomized study.

Postanesthesia emergence delirium is a motor agitation state complicating pediatric anesthesia. We investigated the efficacy of dexmedetomidine in reducing emergence delirium in children undergoing tonsillectomy with and without adenoidectomy using total intravenous anesthesia with propofol. This was a prospective, single-center, double-blind, randomized study. The primary outcome was the presence or absence of emergence delirium with and without dexmedetomidine. Secondary outcomes were emergence delirium severity, time to extubation, cardiovascular stability, and need for additional postoperative analgesia. Eligible were children 3-14 years of age, ASA I or II, scheduled for tonsillectomy with or without adenoidectomy. Patients were randomized to receive dexmedetomidine 1 mcg kg-1 or a volume matched normal saline solution. Presence of emergence delirium and agitation severity was assessed with the Watcha scale 10, 20, and 30 minutes after arrival in the postanesthesia care unit. Sixty children participated to the study, 31 (51.7%) of them were treated with dexmedetomidine. Their mean age was 6.2 years (SD 5.5). Duration of anesthesia and surgery and blood pressure measurements did not differ between groups. Extubation time was not different between groups. The dexmedetomidine group had a significantly lower frequency of emergence delirium compared with no dexmedetomidine after 20 and 30 minutes in postanesthesia care unit: 16.1% and 12.9% at 20 and 30 minutes in the dexmedetomidine group vs 48.3% and 41.4% in in the no dexmedetomidine group. Dexmedetomidine 1 mcg kg-1 reduces the incidence and severity of emergence delirium after tonsillectomy with propofol anesthesia without prolonging the extubation time.

Transversus abdominis plane block supplementation during iliac crest bone graft harvesting - Effect on postoperative pain.

Background and Aims:Transversus abdominis plane (TAP) block is a technique proposed to minimise pain after anterior iliac crest bone harvesting. This study aims to evaluate the postoperative pain in patients who receive ultrasound-guided TAP block to supplement routine wound infiltration.Material and Methods:A total of 143 patients aged between 6 and 22 years were randomised into two groups. Patients in group A received supplemental TAP block on the same side. Patients in group B received local anesthetic wound infiltration alone. Pain scores were compared at the first and 24th postoperative hours.Results:TAP block significantly reduced pain and delirium in the immediate postoperative period. The mean FLACC (Face, Legs, Activity, Cry, Consolability) score after 10 min was 0.8 in group A versus 1.8 in group B (P = 0.001). The mean Watcha scale at 10 min was 1.0 in group A versus 1.2 in group B (P = 0.001). After 24 h, 81.7% of patients in group A had no pain versus 59.7% in group B (P = 0.004). The incidence of intolerable pain at 24 h was 5.6% in group B versus 0% in group A (P = 0.04). Cumulative ambulation scores were significantly better in group A (P < 0.05). There was a strong and positive correlation between the analgesia and ability to ambulate comfortably at 24 h postop (Pearson's coefficient 0.95).Conclusion:Supplemental ultrasound-guided TAP block given intraoperatively reduces the postoperative pain. The incidence of emergence delirium was low. These patients were also able to ambulate earlier.

Intraoperative clonidine for prevention of postoperative agitation in children anaesthetised with sevoflurane (PREVENT AGITATION): a randomised, placebo-controlled, double-blind trial

Postoperative agitation is a frequent and stressful condition for a child, their family, and their health-care providers, and prevention would be of benefit. We aimed to assess the effects of intravenous clonidine administered intraoperatively on the incidence of postoperative agitation, pain, and adverse events. We did this randomised, placebo-controlled, double-blind trial (PREVENT AGITATION) at one tertiary-level hospital and two urban-district hospitals in Denmark. Children aged 1-5 years, with an American Society of Anesthesiologists physical classification score of 1-2, who were scheduled for anaesthesia with sevoflurane and fentanyl were randomly assigned (1:1) in blocks of ten by computer-generated centralised randomisation, stratified by age (<2 years or ≥2 years) and site, to receive either intravenous clonidine 3 μg/kg or an equal quantity of isotonic saline in identical vials, administered around 20 min before the completion of surgery. Data were collected from the postoperative care unit (24 h) and at follow-up (30 days). Our primary outcome was the proportion of patients with one or more episodes of postoperative agitation, measured every 15 min in the postoperative care unit (POCU) with the four-point Watcha scale (ie, Watcha >2). We analysed by intention to treat. The trial is registered with ClinicalTrials.gov (number NCT02361476). Between January and December, 2015, of the 379 eligible children, we randomly assigned 191 to receive clonidine treatment and 188 to receive placebo; 75 were girls (20%). Nine were excluded from the primary outcome analysis because of missing data points. 46 (25%) of 187 clonidine participants compared with 86 (47%) of 183 placebo participants had one or more episodes of postoperative agitation (Watcha score >2; relative risk 0·56, 95% CI 0·43-0·73; p<0·0001). 30 (20%) of 150 boys in the clonidine group were agitated compared with 69 (47%) of 147 boys in the placebo group (0·43, 0·30-0·61; p<0·0001). The observed effect was not significant in girls. Incidence of adverse events was similar in the clonidine and placebo groups. On the basis of our results, clonidine might be used to safely prevent postoperative agitation in boys anaesthetised with sevoflurane. Danish Society of Anaesthesia and Intensive Care.

The Association between Preoperative Parental Anxiety and Emergence Agitation in Preschoolers

Introduction: The preoperative distress and anxiety experienced by preschoolers are associated with an increased incidence of troubled recovery from anesthesia. However, influences of parental anxiety on children at different stages of the surgical processes are not clear. The aim of this study was to evaluate any existing association between preoperative parental anxiety and emergence agitation in a pediatric surgery population. Materials and Methods: A total of 60 children ASA class I or II, aged 3 - 12 years old, undergoing adenotonsillectomy with sevoflurane, were included in the study. Before surgery, we used State-Trait Anxiety Inventory S-T (STAI S-T) to assess parental anxiety. Emergence agitation of the children was assessed with Watcha scale and recorded every 10 min of first 30 min of the postoperative period. Parents were contacted 24 hours after the surgery to evaluate their satisfaction, post operative pain and any side effect observed in the children. Results: Preoperatively, the mean STAI-S scores of mothers were significantly higher than those of fathers (p 0.05). The children had the highest agitation scores at 10th postoperative minutes with an incidence of 73.9%. There was no correlation between parental anxiety and emergence agitation. Logistic regression analysis showed that low educational level of the parent was the only independent factor for state anxiety (OR: 8.96, 95% CI: 1.50 - 40.35, p = 0.030). Discussion: In this study, we observed that education level of the parents might affect their preoperative anxiety. The factors influential in parental anxiety were not correlated with pediatric emergence agitation in this study.

Ketofol versus sevoflurane for maintenance of aesthesia in paediatric cardiac catheterization: A prospective double blind study

BackgroundPediatric cardiac anesthesia involves anaesthetizing very small children with complex congenital heart disease. Sevoflurane provides the advantage of rapid induction of anesthesia with short recovery time. Ketofol is a neologism coined to refer to the combination of ketamine and propofol mixed together in one syringe. Ketamine and propofol have opposing influences on blood pressure, heart rate, and SVR.Aim of the workTo compare the effectiveness and side effects of ketofol versus sevoflurane for maintenance of aesthesia in pediatric cardiac catheterization.MethodsThis double blinded randomized study was carried on 90 pediatric patients ASA II and III undergoing cardiac catheterization. Induction was accomplished with titration of 3–5% sevoflurane. Patients were randomly assigned to one of the two study groups. Group K received ketofol mixture (propofol, 4 mg/mL, and ketamine, 2 mg/mL) infusion rate propofol 25–50 mic/kg/min and ketamine 12.5–25 mic/kg/min for maintenance. Group S received sevoflurane 0.5–1 MAC. Changes in recovery time, hemodynamic variables and the incidence of adverse effects were measured.ResultsDiastolic blood pressure showed significant difference between the study groups at induction p (0.001), 5 min after induction p(0.04), on recovery 0.037, 5 min postoperatively p(0.016), and 10 min postoperatively. The need for vasopressor and MAP decrease >20% compared with baseline did not show significant difference p(0.832). Recovery time was shorter in group S p(.000). The incidence of nausea and vomiting was significantly more in group S p(.000). Emergence agitation was observed in group S in 12(26.6) patients. Watcha scale was significantly lower in group K at 10 min postoperatively p(.001).ConclusionsBoth propofol–ketamine and sevoflurane provided effective sedation and analgesia during pediatric cardiac catheterization. But propofol–ketamine combination was superior to sevoflurane because the incidence of agitation, nausea and vomiting in patients given sevoflurane was significantly higher than in ketofol group.

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.

Paediatric emergence delirium

A child with emergence delirium (ED) is in a ‘dissociated state of consciousness in which the child is irritable, uncompromising, uncooperative, incoherent, and inconsolably crying, moaning, kicking, or thrashing’. ED can disrupt the surgical repair, be distressing for parents and staff and may cause parental dissatisfaction with their child’s care. Many scales have been proposed to evaluate the incidence and severity of ED, and a variety of scales are used in clinical practice and for research purposes. Agitation due to pain is a significant confounding factor for the evaluation of the presence or measurement of the degree of ED. The Cravero scale (Table 1) has five steps from obtunded and unresponsive to wild thrashing behaviour requiring restraint. A score of 4 (from crying and difficult to console to wild thrashing) for a 5 or more min duration despite active calming efforts is regarded as indicative of ED. The Paediatric Anaesthesia Emergence Delirium (PAED) scale (Table 2) is validated but is difficult to use in routine clinical practice. The Watcha scale (Table 3) is a simpler tool to use in clinical practice and may have a higher overall sensitivity and specificity than the PAED and Cravero scales. It is more practical to use a simple scale to detect delirium and then use the PAED scale to measure its degree.