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For: Menser C, Smith H. Emergence Agitation and Delirium: Considerations for Epidemiology and Routine Monitoring in Pediatric Patients. Local Reg Anesth 2020;13:73-83. [PMID: 32801855 PMCID: PMC7394591 DOI: 10.2147/lra.s181459] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 06/05/2020] [Indexed: 12/21/2022] Open

For:	Menser C, Smith H. Emergence Agitation and Delirium: Considerations for Epidemiology and Routine Monitoring in Pediatric Patients. Local Reg Anesth 2020;13:73-83. [PMID: 32801855 PMCID: PMC7394591 DOI: 10.2147/lra.s181459] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 06/05/2020] [Indexed: 12/21/2022] Open

Number

Cited by Other Article(s)

Chen YC, Foster J, Rohmah I, Schmied V, Marks A, Wang ML, Chiu HY. Comparative effect of nonpharmacological interventions on emergence delirium prevention in children following sevoflurane general anesthesia: A systematic review and network meta-analysis of randomized controlled trials. Int J Nurs Stud 2025;165:105035. [PMID: 40068447 DOI: 10.1016/j.ijnurstu.2025.105035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 11/16/2024] [Accepted: 02/21/2025] [Indexed: 03/30/2025]

Abstract

BACKGROUND

Children receiving general anesthesia while undergoing surgery have a significantly high incidence of emergence delirium (ED). Nonpharmacological interventions yield beneficial effects on preventing pediatric ED. However, the relative effects of nonpharmacological interventions on pediatric ED prevention based on various perioperative phases remain unknown.

OBJECTIVE

To compare the effects of nonpharmacological interventions on pediatric ED prevention at different surgical phases.

DESIGN

A systematic review and network meta-analysis.

DATA SOURCES

A comprehensive search of five electronic databases (PubMed, CINAHL via EBSCOhost, Embase via Elsevier, Cochrane Trials, and ProQuest Dissertations and theses) for identifying randomized control trials published from inception to October 15, 2023.

METHODS

Two reviewers independently screened, assessed, and extracted data from the eligible studies. A random-effects network meta-analysis was used to determine the comparative effect of nonpharmacological interventions on preventing pediatric ED.

RESULTS

A total of 19 studies involving 2522 children were included in this network meta-analysis. Thirteen studies reported on the prevention of pediatric ED in the preoperative phase, and six studies reported on the prevention of pediatric ED in the intraoperative phases. Multimedia devices (OR 0.39, 95 % CIs 0.20-0.74), a multicomponent program (OR 0.20, 95 % CI 0.14-0.28) significantly reduced the incidence of pediatric ED during the preoperative phase compared with usual care. During the intraoperative phase, listening to regular heartbeat sounds significantly reduced the risk of pediatric ED compared with usual care (OR 0.06, 95 % CI 0.02-0.22), placebo (OR 0.11, 95 % CI 0.03-0.36), acupuncture (OR 0.17, 95 % CI 0.03-0.88), acupuncture with electrical stimulus (OR 0.16, 95 % CI 0.04-0.68), and acupuncture with midazolam (OR 0.04, 95 % CI 0.00-0.41).

CONCLUSIONS

Our study results suggest that the multicomponent program and listening to heartbeat sounds are relatively effective nonpharmacological interventions for preventing pediatric ED during the perioperative phase. This study compared the effectiveness and ranking of various interventions, and the findings can serve as a guide to assist health professionals in choosing the optimal strategy for preventing ED.

REGISTRATION

The study protocol was registered at PROSPERO (CRD42023459541).

TWEETABLE ABSTRACT

Nonpharmacological interventions can reduce the high incidence of pediatric emergence delirium after surgery. Our systematic review highlights the efficacy of multicomponent programs and listening to heartbeat sounds intraoperatively in reducing ED risk. The findings aid health professionals in selecting optimal strategies for pediatric perioperative care.

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Ericksen AM, Kane TD, Tubog TD. Intranasal Dexmedetomidine Compared With Intranasal Midazolam for Pediatric Emergence Delirium: A Systematic Review and Meta-analysis. J Perianesth Nurs 2025:S1089-9472(25)00011-5. [PMID: 40278813 DOI: 10.1016/j.jopan.2025.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Accepted: 01/06/2025] [Indexed: 04/26/2025]

Abstract

PURPOSE

Evaluate the effectiveness of intranasal dexmedetomidine compared with intranasal midazolam in reducing pediatric emergence delirium (ED).

DESIGN

Systematic review and meta-analysis.

METHODS

A comprehensive search was conducted in MEDLINE (PubMed), CINAHL, the Cochrane Review Database, Google Scholar, and gray literature to identify relevant studies. Risk ratios (RR) and standardized mean differences were calculated to estimate the outcomes, using appropriate effect models. The quality of evidence was assessed using the Risk of Bias tool and evaluated according to the Grades of Recommendation, Assessment, Development, and Evaluation approach.

FINDINGS

Twelve studies (N = 1,133) were included in the review. Intranasal dexmedetomidine significantly reduced the incidence of ED (RR 0.52, 95% confidence interval [CI], 0.29 to 0.90, P = .02) compared with midazolam. Intranasal dexmedetomidine also demonstrated significantly improved sedation levels (standardized mean differences -0.48, 95% CI, -0.92 to -0.04, P = .03) compared with midazolam. However, no significant differences were observed in parental separation (RR 1.14, 95% CI, 0.94 to 1.39, P = .19), mask acceptance (RR 1.05, 95% CI, 0.83 to 1.34, P = .67), or postoperative nausea and vomiting (RR 0.84, 95% CI, 0.44 to 1.61, P = .61). The overall quality of evidence was rated as low, primarily due to the small number of studies included.

CONCLUSIONS

Intranasal dexmedetomidine significantly reduces pediatric ED and improves sedation levels compared with midazolam, but both drugs show similar effects on parental separation, mask acceptance, and postoperative nausea and vomiting. Intranasal administration offers a noninvasive, effective option for pediatric sedation. Larger studies are needed to confirm these findings, as current evidence is limited.

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Liang B, Wu R, Lou Y. Intravenous injection of 0.5 μg/kg dexmedetomidine during plasma resection of tonsil adenoids can reduce the incidence of delirium and hemodynamics in children. Am J Transl Res 2025;17:2188-2196. [PMID: 40226004 PMCID: PMC11982874 DOI: 10.62347/twcy6801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Accepted: 02/27/2025] [Indexed: 04/15/2025]

Abstract

OBJECTIVE

To investigate the effects of different doses of dexmedetomidine on delirium and hemodynamics after plasma resection of adenoids in children.

METHODS

A retrospective analysis was conducted on the clinical data of 80 children who underwent plasma adenoidectomy of tonsil at the Pediatric Hospital of Fudan University from January 2022 to December 2023. The patients were divided into normal saline group, 0.1 μg/kg dexmedetomidine group, and 0.5 μg/kg dexmedetomidine group according to the dose of dexmedetomidine injected intravenously. Hemodynamic changes, modified Yale Preoperative Anxiety Scale (mYPAS-SF) scores, pharyngeal pain (at rest and during swallowing), coagulation function, and postoperative adverse reactions were compared at T0, 10 min after dexmedetomidine pumping (T1), extubation (T2), recovery (T3), 2 h after returning to ward (T4), 12 h after returning to ward (T5) and 24 h after returning to ward (T6), respectively.

RESULTS

There were no significant differences in extubation time, recovery time, or unguardianship time among the three groups (P>0.05). The incidence of postoperative delirium was significantly lower in the 0.1 μg/kg dexmedetomidine group and 0.5 μg/kg dexmedetomidine group compared to the normal saline group (P<0.05), with the 0.5 μg/kg group showing better results. At T2, heart rate (HR) and mean arterial pressure (MAP) levels were significantly lower in 0.1 μg/kg group and 0.5 μg/kg dexmedetomidine group than those in normal saline group (P<0.05). The mYPAS-SF score was significantly lower in the 0.1 μg/kg group and 0.5 μg/kg dexmedetomidine groups than that of the normal saline group at T3, T4 and T5 (P<0.05). The score of pharyngeal pain during swallowing was significantly lower in the 0.5 μg/kg dexmedetomidine group at T5 than that of the normal saline group and 0.1 μg/kg dexmedetomidine group (P<0.05). Coagulation values (PT, APTT, and TT) were significantly altered 36 hours post-surgery, with PT, APTT, and TT increasing, while fibrinogen (FIB) decreased (P<0.05). Postoperative nasopharyngeal hemorrhage occurred in one case and nausea/vomiting in two cases in the saline group. No anesthesia-related adverse reactions were observed in the dexmedetomidine group.

CONCLUSION

Intravenous injection of 0.5 μg/kg dexmedetomidine during plasma resection of tonsillar adenoids can reduce the incidence of postoperative delirium, stabilize hemodynamics, relieve postoperative anxiety and pharyngeal pain, with minimal impacts on coagulation function. Additionally, it reduces the incidence of adverse reactions, making it a promising option for clinical use.

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Rössler J, Abramczyk E, Paredes S, Anusic N, Pu X, Maheshwari K, Turan A, Ruetzler K. Association of Intravenous Neostigmine and Anticholinergics or Sugammadex with Postoperative Delirium: A Retrospective Cohort Study. Anesth Analg 2025;140:110-118. [PMID: 38446705 DOI: 10.1213/ane.0000000000006939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]

Abstract

BACKGROUND

Administration of cholinesterase inhibitors in combination with anticholinergic drugs for reversal of neuromuscular blocks may precipitate delirium through impairment of central cholinergic transmission, which could be avoided by using sugammadex. Therefore, we tested the primary hypothesis that postoperative delirium is less common when neuromuscular block is reversed with sugammadex than with neostigmine combined with glycopyrrolate or atropine.

METHODS

We conducted a single-center retrospective cohort study, analyzing all adult patients having general anesthesia for noncardiac surgery who received neostigmine or sugammadex from January 2016 to March 2022. Inverse propensity score weighting and propensity score calibration were used to adjust for appropriate confounders. Our primary outcome was presence of delirium within the first 4 days after surgery, defined as at least 1 positive brief Confusion Assessment Method (bCAM) screening. The secondary outcome was the presence of early delirium within 24 hours of surgery.

RESULTS

Among 49,468 cases in our analysis, 6881 received sugammadex and 42,587 received neostigmine. After propensity weighting, the incidence of delirium was 1.09% in the sugammadex group and 0.82% in the neostigmine group. The odds of postoperative delirium did not differ between the sugammadex and neostigmine groups, with an estimated odds ratio (95% confidence interval) of 1.33 (0.91-1.95), P = .147. A sensitivity analysis restricted to only include cases with at least 6 bCAM measurements over postoperative day (POD) 1 to 4 had consistent results, as sugammadex compared with neostigmine was associated with an estimated odds ratio for postoperative delirium of 1.20 (0.82-1.77), P = .346. Sugammadex was significantly associated with an increased incidence of early postoperative delirium, with an estimated odds ratio of 1.71 (1.07-2.72), P = .025. Further analysis showed no treatment-by-age interaction for either postoperative delirium ( P = .637) or postoperative early delirium ( P = .904).

CONCLUSIONS

Compared to neostigmine, use of sugammadex for reversal of neuromuscular block was not associated with an increased risk of postoperative delirium in this retrospective single-center study. Though sugammadex was associated with a statistically significant increased risk of postoperative early delirium, the difference was small and not clinically relevant, and may reflect the presence of unknown confounders.

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Henry E, Chen-Lim ML. Does Postanesthesia Forced-Air Warming Affect Emergence Delirium in Pediatric Patients Receiving Daily Anesthesia? J Perianesth Nurs 2024;39:1026-1033.e1. [PMID: 38852105 DOI: 10.1016/j.jopan.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/13/2024] [Accepted: 01/24/2024] [Indexed: 06/10/2024]

Abstract

PURPOSE

To determine if postanesthesia forced-air warming as a nonpharmacologic intervention for emergence delirium (ED)/emergence agitation (EA) decreased the incidence and severity of ED in children aged 18 months to 6 years old.

DESIGN

Prospective nonrandomized controlled trial.

METHODS

Participants included children aged 18 months to 6 years old receiving general anesthesia within a radiation oncology setting. Status of ED/EA was based on the participants' Pediatric Anesthesia Emergence Delirium (PAED) scale score (two consecutive scores greater than 10 out of 20) or inconsolable agitation behaviors post computed tomography simulation (day 0). Interrater reliability was conducted among the center's perianesthesia care nurses. Participants who scored positive for ED/EA received a forced-air warming blanket for the remainder of treatment with data collection 1 to 14 days postanesthesia. Non-ED/EA participants were followed for 14 days and provided forced-air warming if ED/EA occurred. Data consisted of daily PAED scores and self- or parent-report on the anxiety scale. If the participants received forced-air warming, nurses' clinical observations and parent satisfaction surveys were collected 3 times during the 14-day study period.

FINDINGS

A total of 59 participants completed the study (mean age 3.43 years; 60% male; 63% non-Hispanic White); 16 were identified with ED or EA (mean age 3.56 years; 50% male; 69% non-Hispanic White) with an incidence rate of 28%. For the 16 participants with ED/EA, the primary diagnosis consisted of solid tumors and an American Society of Anesthesia Classification III to IV. Prior to the forced-air warming intervention, all 16 participants exhibited inconsolable ED/EA behaviors, including 8 who had PAED scores greater than 10. ED/EA behaviors expressed included inconsolability, confusion, thrashing, and combativeness. Within the 14-day period, 3 participants received forced-air warming on day 1, while the other 13 received an average of 4.23 days of treatment (range 1 to 11 days; mode 1 day; median 4 days). Comparison of PAED scores pre (mean 4.4) and post (mean 1.8) indicated that the use of forced-air warming was statistically significant (P = .001). ED/EA behaviors and PAED scores after the forced-air warming period decreased in all but one participant. Some agitation behaviors were not captured within the PAED score.

CONCLUSIONS

Forced-air warming impacted PAED scores and agitation behaviors for studied participants, offering a safe, nonpharmacological nursing intervention that may be an effective tool for helping to manage this baffling condition.

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Zhu YF, Yi FY, Qin MH, Lu J, Liang H, Yang S, Wei YZ. Factors influencing agitation during anesthesia recovery after laparoscopic hernia repair under total inhalation combined with caudal block anesthesia. World J Gastrointest Surg 2024;16:3499-3510. [PMID: 39649206 PMCID: PMC11622067 DOI: 10.4240/wjgs.v16.i11.3499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Revised: 09/03/2024] [Accepted: 09/19/2024] [Indexed: 10/30/2024] Open

Abstract

BACKGROUND

Laparoscopic hernia repair is a minimally invasive surgery, but patients may experience emergence agitation (EA) during the post-anesthesia recovery period, which can increase pain and lead to complications such as wound reopening and bleeding. There is limited research on the risk factors for this agitation, and few effective tools exist to predict it. Therefore, by integrating clinical data, we have developed nomograms and random forest predictive models to help clinicians predict and potentially prevent EA.

AIM

To establish a risk nomogram prediction model for EA in patients undergoing laparoscopic hernia surgery under total inhalation combined with sacral block anesthesia.

METHODS

Based on the clinical information of 300 patients who underwent laparoscopic hernia surgery in the Nanning Tenth People's Hospital, Guangxi, from January 2020 to June 2023, the patients were divided into two groups according to their sedation-agitation scale score, i.e., the EA group (≥ 5 points) and the non-EA group (≤ 4 points), during anesthesia recovery. Least absolute shrinkage and selection operator regression was used to select the key features that predict EA, and incorporating them into logistic regression analysis to obtain potential predictive factors and establish EA nomogram and random forest risk prediction models through R software.

RESULTS

Out of the 300 patients, 72 had agitation during anesthesia recovery, with an incidence of 24.0%. American Society of Anesthesiologists classification, preoperative anxiety, solid food fasting time, clear liquid fasting time, indwelling catheter, and pain level upon awakening are key predictors of EA in patients undergoing laparoscopic hernia surgery with total intravenous anesthesia and caudal block anesthesia. The nomogram predicts EA with an area under the receiver operating characteristic curve (AUC) of 0.947, a sensitivity of 0.917, and a specificity of 0.877, whereas the random forest model has an AUC of 0.923, a sensitivity of 0.912, and a specificity of 0.877. Delong's test shows no significant difference in AUC between the two models. Clinical decision curve analysis indicates that both models have good net benefits in predicting EA, with the nomogram effective within the threshold of 0.02 to 0.96 and the random forest model within 0.03 to 0.90. In the external model validation of 50 cases of laparoscopic hernia surgery, both models predicted EA. The nomogram model had a sensitivity of 83.33%, specificity of 86.84%, and accuracy of 86.00%, while the random forest model had a sensitivity of 75.00%, specificity of 78.95%, and accuracy of 78.00%, suggesting that the nomogram model performs better in predicting EA.

CONCLUSION

Independent predictors of EA in patients undergoing laparoscopic hernia repair with total intravenous anesthesia combined with caudal block include American Society of Anesthesiologists classification, preoperative anxiety, duration of solid food fasting, duration of clear liquid fasting, presence of an indwelling catheter, and pain level upon waking. The nomogram and random forest models based on these factors can help tailor clinical decisions in the future.

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Hajdini H, Otey T, Guelbert C, Sanofsky B. Single centre implementation of the Paediatric Anaesthesia Emergence Delirium scale. J Perioper Pract 2024:17504589241299629. [PMID: 39601299 DOI: 10.1177/17504589241299629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2024]

Xiong H, Liu J, Liu G, Zhang Y, Wei Z, Fan L, Jiang F, Zhao Y, Wei W, Li S, Xue R. Effective doses of midazolam oral solution for the prevention of preoperative anxiety in paediatric patients. Int J Paediatr Dent 2024;34:621-629. [PMID: 38243663 DOI: 10.1111/ipd.13162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 01/21/2024]

Abstract

BACKGROUND

More than 60% children exhibit anxiety before undergoing an anesthetic-surgical procedure, particularly among pre-school paediatric patients. Oral midazolam can provide procedural sedation for children prior to anesthesia. However, extemporaneous solutions of midazolam are usually prepared from injectable drug solutions, leading to inconsistent efficacy due to variable preparation methods. Xiaoerjing® is the first commercially available oral formulation of midazolam for procedural sedation in children in China. Despite the recommended dosage range of 0.25-0.5 mg/kg, its effective dose is still largely unknown.

AIM

To determine the 95% effective dose (ED95) of midazolam oral solution (Xiaoerjing®) for alleviating preoperative anxiety in children prior to mask induction of general anesthesia.

DESIGN

The study included 61 children between the ages of 1 and 6 years undergoing elective surgery under general anesthesia. The first patient received a single dose of 0.5 mg/kg midazolam oral solution, which was adjusted for subsequent patients using the biased coin design method based on their response to the previous dose. Doses were increased or decreased at the rate of 0.1 mg/kg. An effective response was defined as having a modified Ramsay sedation score ≥3a, separation anxiety score ≤2, and mask acceptance score ≤2 during inhalational anesthesia induction.

RESULTS

Fifty-six children were included in the final analysis. Of those, sedation was successful in 50 patients, with a median separation time of 15 (IQR: 25) min. Midazolam oral solution has an ED95 of 0.8254 mg/kg (95% CI: 0.6915-0.8700 mg/kg) for relieving preoperative anxiety in children. No adverse events occurred following drug administration.

CONCLUSION

Midazolam oral solution is a safe and effective medication for relieving preoperative anxiety in children. The ED95 of a single oral dose of midazolam oral solution is 0.8254 mg/kg (95% CI: 0.6915-0.8700 mg/kg).

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Yucedag F, Sezgin A, Bilge A, Basaran B. The effect on perioperative anxiety and emergence delirium of the child or parent's preference for parental accompaniment during anesthesia induction in children undergoing adenotonsillectomy surgery. Paediatr Anaesth 2024;34:792-799. [PMID: 38676358 DOI: 10.1111/pan.14912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/14/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]

Abstract

BACKGROUND

Pediatric emergence delirium (ED) occurs in the early postoperative period and is defined as a complex psychiatric disorder. Non-pharmacological methods of treatment, such as perioperative parental presence, have been the focus of many studies, but the impact on preventing ED of which parent accompanies the child during anesthesia induction has not been identified as yet. Therefore, the aim of this study was to determine whether the selection made by children undergoing adenotonsillectomy of which parent will accompany them during anesthesia induction has the effect of reducing postoperative delirium scores and incidence compared to selections made by the parents.

METHODS

The study included 80 children of both genders, aged 5-12 years, who underwent day-case surgery in the otorhinolaryngology clinic. The patients were separated randomly into two groups of 40. In Group 1, the children were asked to choose which of their parents would accompany them during general anesthesia induction, and in Group 2, the parents were asked to decide who would be the accompanying parent. Evaluation of postoperative delirium was made using the Pediatric Anesthesia Emergence Delirium (PAED) scale. The anxiety level of the children was evaluated with the modified Yale Preoperative Anxiety Scale (mYPAS) both in the preoperative waiting area and during the anesthesia induction. The State-Trait Anxiety Inventory (STAI) was used to evaluate the anxiety level of the parents.

RESULTS

The mean PAED scores were similar in both groups (mean difference [95% CI]: -0.1 [-2.8 to 0.7]). The incidence of emergence delirium was also similar in both groups (risk ratio 0.9 [0.4 to 1.8]). The mean mYPAS scores during the induction of anesthesia of Group 1 was lower than that of Group 2 (mean difference [95% CI]: -8.4 [-15.2 to -1.6]). The mean mYPAS scores evaluated in the preoperative waiting area were found to be similar in the two groups (mean difference [95% CI]: -1.9 [-7.5 to 3.5]). The mean STAI anxiety scores of the parents were similar in both groups, with higher scores obtained by mothers compared to fathers, at all measurement times.

CONCLUSION

The incidence or severity of ED did not decrease significantly even though lower anxiety scores were obtained during anesthesia induction in children who were allowed to make the decision of accompanying parent. Based on these findings, it can be concluded that postoperative delirium is a more complicated process that can be affected by many other variables rather than just the parent-child general interaction.

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Golmohammadi M, Sane S, Ghavipanjeh Rezaei S, Hosseini R, Alwaily ER, Hussien BM, Mohammadpour R, Rahmani N, Kazemi Haki B. Investigating the Effect of Dexmedetomidine in Controlling Postoperative Emergence Agitation in Children under Sevoflurane Anesthesia. Anesthesiol Res Pract 2024;2024:6418429. [PMID: 39105128 PMCID: PMC11300049 DOI: 10.1155/2024/6418429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 05/15/2024] [Accepted: 07/03/2024] [Indexed: 08/07/2024] Open

Abstract

Introduction

Emergence agitation (EA) is one of the common problems during recovery from general anesthesia, especially in children. In this study, we investigated the effect of dexmedetomidine on the control of agitation after anesthesia with sevoflurane in children.

Method

This randomized control-placebo, double-blind prospective clinical trial was conducted on seventy-six children between 2 and 7 years with ASA (American Society of Anesthesiologists) class I who were candidates for elective adenoidectomy surgery and tonsillectomy. Participants were selected by an available sampling method. Patients were randomly placed in one of the two groups D (dexmedetomidine 0.5 μg/kg infusion within ten minutes) or P (placebo: normal saline infusion within ten minutes). A four-point scale evaluated agitation. Pain evaluation was done by FLACC (faces, legs, activity, cry, and consolability). The statistical software was SPSS version 23. P < 0.05 was considered statistically significant.

Results

The level of agitation was significantly lower in the intervention group (P < 0.05), except after 40 minutes in the PACU (Post Anesthesia Care Unit) (P=1.00). Patients in the control group experienced high pain scores when admitted at PACU, 10, 20, and 30 minutes after admission at PACU (P < 0.05). Pethidine and metoclopramide prescriptions in the intervention group were lower than in the control group (P < 0.05). Shivering occurred in five patients in the intervention group and nine in the control groups (P=0.032). Hypotension that required intervention occurred in 3 patients in the intervention group and one in the control group (P=0.024).

Conclusion

Our trial demonstrated that the prescription of 0.5 μg/kg of dexmedetomidine within ten minutes after intubation significantly reduced the EA frequency, pain severity, analgesic consumption, and PONV (postoperative nausea and vomiting). However, it caused delays in the emergence from anesthesia. This trial is registered with IRCT20160430027677N14.

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Yahya CQ, Andriyanto L, Priyadi YA. Dexmedetomidine as a total intravenous anesthetic in pediatric patients undergoing cleft lip and palate surgery: a case series. J Med Case Rep 2024;18:342. [PMID: 39010154 PMCID: PMC11251124 DOI: 10.1186/s13256-024-04645-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 06/19/2024] [Indexed: 07/17/2024] Open

Li Y, Li Q, Zhao G, Zhang H, Zhong H, Zeng Y. Nalbuphine in Pediatric Emergence Agitation Following Cochlear Implantation: A Randomized Trial. Drug Des Devel Ther 2024;18:2837-2845. [PMID: 39006192 PMCID: PMC11244056 DOI: 10.2147/dddt.s451089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/30/2024] [Indexed: 07/16/2024] Open

Chen YC, Foster J, Wang ML, Rohmah I, Tseng YH, Chiu HY. Global prevalence and risk factors of emergence delirium in pediatric patients undergoing general anesthesia: A systemic review and meta-analysis. J Pediatr Nurs 2024;77:74-80. [PMID: 38479065 DOI: 10.1016/j.pedn.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/01/2023] [Accepted: 03/06/2024] [Indexed: 07/07/2024]

Shi X, Su L, Sun Y, Ma C, Wang Z. Non-pharmacological interventions for preventing emergence delirium in children under general anesthesia: A scoping review. J Pediatr Nurs 2024;77:e38-e53. [PMID: 38523049 DOI: 10.1016/j.pedn.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/26/2024]

Abstract

PROBLEM

The phenomenon of emergence delirium in pediatric patients undergoing general anesthesia has garnered increasing attention in the academic community. While formal non-pharmaceutical interventions have demonstrated efficacy in mitigating this phenomenon, the diversity of intervention types and their varying degrees of effectiveness necessitate further discussion. A scoping review was conducted to identify and explicate the categorization, content elements, and outcomes measures of non-pharmacological interventions utilized to forestall the onset of emergence delirium in children undergoing general anesthesia.

ELIGIBILITY CRITERIA

This review was conducted in accordance with the Arksey and O'Malley's methodology framework and PRISMA-ScR. It encompassed experimental and quasi-experimental studies that involved any non-pharmacological interventions during the perioperative period to prevent emergence delirium in children aged 0 to 18 years undergoing general anesthesia for elective surgery.

SAMPLE

Thirty-two articles met the inclusion criteria, of which 29 were randomized controlled trials. The total sample size of the population was 4633.

RESULTS

The scoping review revealed 10 non-pharmacological interventions, that included distraction intervention, visual preconditioning, virtual reality, parental participation, maternal voice, light drinking, acupuncture, auditory stimulation, monochromic light and breathing training. Emergence delirium, preoperative anxiety, and postoperative pain were the primary outcomes, and four assessment instruments were employed to measure the extent and incidence of emergence delirium.

CONCLUSION

Numerous non-pharmacological interventions have been employed to prevent emergence delirium. Nevertheless, the effectiveness of some interventions is not yet evident.

IMPLICATIONS

The utilization of visual preconditioning and distraction interventions appears to be an emerging area of interest.

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Kim K, Jeong JH, Choi EK. Non-pharmacological interventions for delirium in the pediatric population: a systematic review with narrative synthesis. BMC Pediatr 2024;24:108. [PMID: 38347509 PMCID: PMC10863154 DOI: 10.1186/s12887-024-04595-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 01/25/2024] [Indexed: 02/15/2024] Open

Abstract

BACKGROUND

Delirium is a serious complication experienced by hospitalized children. Therefore, preventive management strategies are recommended for these patients. However, comprehensive analyses of delirium interventions in children remain insufficient. Specifically, this systematic review aimed to summarize non-pharmacological interventions for pediatric delirium, addressing the urgent need for a comprehensive understanding of effective strategies. We also explored frequently measured outcome variables to contribute evidence for future research on delirium outcomes in children.

METHODS

This systematic review searched articles from PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medica databases. The eligibility criteria were formed under the population, intervention, comparator, outcome, and study design framework. Studies were included if they involved (1) children aged under 18 years receiving hospital care, (2) non-pharmacological delirium interventions, (3) comparators involving no intervention or pharmacological delirium interventions, and (4) outcomes measuring the effectiveness of non-pharmacological delirium interventions. Only peer-reviewed articles published in English were included.

RESULTS

Overall, 16 studies were analyzed; of them, 9 assessed non-pharmacological interventions for emergence delirium and 7 assessed interventions for pediatric delirium. The intervention types were grouped as follows: educational (n = 5), multicomponent (n = 6), and technology-assisted (n = 5). Along with pediatric and emergence delirium, the most frequently measured outcome variables were pain, patient anxiety, parental anxiety, pediatric intensive care unit length of stay, agitation, analgesic consumption, and postoperative maladaptive behavior.

CONCLUSIONS

Non-pharmacological interventions for children are effective treatments without associated complications. However, determining the most effective non-pharmacological delirium intervention for hospitalized children based on current data remains challenging.

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López Segura M, Busto-Aguirreurreta N. Postoperative agitation or delirium in paediatric patients. What we know and how to avoid it. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023;70:467-472. [PMID: 37678453 DOI: 10.1016/j.redare.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/10/2022] [Indexed: 09/09/2023]

Xu H, Shen Z, Gu Y, Hu Y, Jiang J, Li X, Zhao Y, Zhu M, Li J. Nasal splinting and mouth breathing training reduce emergence delirium after endoscopic sinus surgery: a randomized controlled trial. BMC Anesthesiol 2023;23:302. [PMID: 37679665 PMCID: PMC10483790 DOI: 10.1186/s12871-023-02262-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/28/2023] [Indexed: 09/09/2023] Open

Liang HH, Lu YW, Ou XX, Shi H, She YJ, Zhang MX. Effect of ice popsicle treatment on emergence agitation in children undergoing oral surgery with sevoflurane anaesthesia: A prospective randomized controlled study. J Pediatr Nurs 2023;72:9-15. [PMID: 37030043 DOI: 10.1016/j.pedn.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 04/10/2023]

Wang CM, Zhang Y, Chen WC, Lin S, He HF. Effects of Pharmacological Intervention on Recovery After Sevoflurane Anesthesia in Children: a Network Meta-analysis of Randomized Controlled Trials. Mol Neurobiol 2023;60:4488-4501. [PMID: 37115403 DOI: 10.1007/s12035-023-03349-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/13/2023] [Indexed: 04/29/2023]

Van Wicklin SA. Caring for Pediatric Patients Undergoing Plastic Surgical Procedures. PLASTIC AND AESTHETIC NURSING 2023;43:114-121. [PMID: 37389624 DOI: 10.1097/psn.0000000000000516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]

Tsivitis A, Wang A, Murphy J, Khan A, Jin Z, Moore R, Tateosian V, Bergese S. Anesthesia, the developing brain, and dexmedetomidine for neuroprotection. Front Neurol 2023;14:1150135. [PMID: 37351266 PMCID: PMC10282145 DOI: 10.3389/fneur.2023.1150135] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/18/2023] [Indexed: 06/24/2023] Open

Wang N, Hao J, Zhang J, Du J, Luo Z. Risk factors for emergence agitation during the awakening period in elderly patients after total joint arthroplasty: a retrospective cohort study. BMJ Open 2023;13:e068284. [PMID: 37164475 PMCID: PMC10174031 DOI: 10.1136/bmjopen-2022-068284] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open

Abstract

OBJECTIVES

This study aimed to explore the incidence and risk factors for emergence agitation (EA) in elderly patients who underwent total joint arthroplasty (TJA) under general anaesthesia, and to assess their predictive values.

DESIGN

Single-centre retrospective cohort study.

SETTING

A 1600-bed general tertiary hospital in China.

PARTICIPANTS

This study enrolled 421 elderly patients scheduled for elective primary TJA under general anaesthesia.

PRIMARY AND SECONDARY OUTCOME MEASURES

EA was assessed using the Richmond Agitation Sedation Scale during the awakening period after surgery in the post-anaesthesia care unit. Risk factors for EA were identified using univariate and multivariable logistic analyses. The receiver operating characteristic (ROC) curve was used to assess the predictive values of the risk factors for EA.

RESULTS

The incidence of EA in elderly patients who underwent TJA was 37.6%. According to the multivariable logistic analysis, postoperative pain (95% CI: 1.951 to 3.196), male sex (95% CI: 1.781 to 6.435), catheter-related bladder discomfort (CRBD) (95% CI: 4.001 to 15.392) and longer fasting times for solids (95% CI: 1.260 to 2.301) and fluids (95% CI: 1.263 to 2.365) were independent risk factors for EA. As shown by the ROC analysis, postoperative pain and fasting times for solids and fluids had good predictive values, with areas under the ROC curve equalling 0.769, 0.753 and 0.768, respectively.

CONCLUSIONS

EA is a common complication after TJA in elderly patients. Some risk factors, including postoperative pain, male sex, CRBD and longer fasting times, can increase the incidence of EA. These risk factors may contribute to identifying high-risk patients, which facilitates the development of effective strategies to prevent and treat EA.

TRIAL REGISTRATION NUMBER

ChiCTR1800020193.

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Na HS, Kim SY, In Park J, Lee S, Hwang JW, Shin HJ. The effect of intranasal dexmedetomidine administration on emergence agitation or delirium in pediatric patients after general anesthesia: A meta-analysis of randomized controlled trials. Paediatr Anaesth 2023. [PMID: 37128675 DOI: 10.1111/pan.14689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/09/2023] [Accepted: 04/11/2023] [Indexed: 05/03/2023]

Abstract

BACKGROUND

Emergence agitation or delirium can occur in pediatric patients after anesthesia. Dexmedetomidine is known to reduce the impairment of postoperative cognitive function.

AIMS

This study aimed to identify the role of intranasal administration of dexmedetomidine in lowering the development of emergence agitation or emergence delirium in pediatric patients after general anesthesia.

METHODS

Electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, were searched to identify studies. The primary outcome was the proportion of patients who underwent emergence agitation or emergence delirium after the surgery. Secondary outcomes included emergence time and incidence of postoperative nausea and/or vomiting. We estimated the odds ratio and mean difference with 95% confidence intervals for the determination of effect size using a random-effects model.

RESULTS

In total, 2103 pediatric patients from 20 randomized controlled trials were included in the final analysis. The incidence of emergence agitation or emergence delirium was 13.6% in the dexmedetomidine group and 33.2% in the control group. The pooled effect size revealed that intranasal dexmedetomidine administration significantly reduced the incidence of postoperative emergence agitation or emergence delirium in pediatric patients undergoing surgery under general anesthesia (odds ratio 0.25, 95% confidence interval 0.18-0.34; p = .0000; I² = 37.74%). Additionally, significant difference was observed in emergence time between the two groups (mean difference 2.42, 95% confidence interval 0.37-4.46; p = .021; I² = 98.40%). Children in the dexmedetomidine group had a significantly lower incidence of postoperative nausea and/or vomiting than those in the control group (odds ratio 0.39, 95% confidence interval 0.24-0.64; p = .0002; I² = 0.00%).

CONCLUSIONS

Intranasal dexmedetomidine reduced the incidence of emergence agitation or emergence delirium in pediatric patients after general anesthesia.

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Zhang Y, Zhang Q, Xu S, Zhang X, Gao W, Chen Y, Zhu Z. Association of volatile anesthesia exposure and depth with emergence agitation and delirium in children: Prospective observational cohort study. Front Pediatr 2023;11:1115124. [PMID: 37033193 PMCID: PMC10076635 DOI: 10.3389/fped.2023.1115124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/09/2023] [Indexed: 04/11/2023] Open

Abstract

Background

Sevoflurane anesthesia is widely used in pediatric ambulatory surgery. However, emergency agitation (EA) and emergency delirium (ED), as major complications following sevoflurane anesthesia in children, pose risks to surgery and prognosis. Identifying the high risk of EA/ED, especially anesthesia exposure and the depth of anesthesia, may allow preemptive treatment.

Methods

A total of 137 patients were prospectively enrolled in this single-center observational cohort study to assess the incidence of EA or ED. Multivariable logistic regression analyses were used to test the association between volatile anesthesia exposure and depth with EA or ED. The Richmond Agitation and Sedation Scale (RASS), Pediatric Anesthesia Emergence Delirium Scale (PAED) and Face, Legs, Activity, Cry, and Consolability (FLACC) behavioural pain scale was used to assess the severity of EA or ED severity and pain. Bispectral index (BIS) to monitor the depth of anesthesia, as well as Time_LOW-BIS/Time_ANES %, EtSevo (%) and EtSevo-time AUC were included in the multivariate logistic regression model as independent variables to analyze their association with EA or ED.

Results

The overall prevalence of EA and ED was 73/137 (53.3%) and 75/137 (54.7%) respectively, where 48/137 (35.0%), 19/137 (13.9%), and 6/137 (4.4%) had mild, moderate, and severe EA. When the recovery period was lengthened, the prevalence of ED and extent of FLACC decreased and finally normalized within 30 min in recovered period. Multivariable logistic regression demonstrated that intraoperative agitation [2.84 (1.08, 7.47) p = 0.034], peak FLACC [2.56 (1.70, 3.85) p < 0.001] and adverse event (respiratory complications) [0.03 (0.00, 0.29) p = 0.003] were independently associated with higher odds of EA. Taking EtSevo-time AUC ≤ 2,000 as a reference, the incidence of EA were [15.84 (2.15, 116.98) p = 0.002] times and 16.59 (2.42, 113.83) p = 0.009] times for EtSevo-time AUC 2,500-3,000 and EtSevo-time AUC > 3,000, respectively. Peak FLACC [3.46 (2.13, 5.62) p < 0.001] and intraoperative agitation [5.61 (1.99, 15.86) p = 0.001] were independently associated with higher odds of developing ED. EtSevo (%), intraoperative BIS value and the percentage of the duration of anesthesia at different depths of anesthesia (BIS ≤ 40, BIS ≤ 30, BIS ≤ 20) were not associated with EA and ED.

Conclusions

For pediatrics undergoing ambulatory surgery where sevoflurane anesthesia was administered, EA was associated with surgical time, peak FLACC, respiratory complications, and "EtSevo-time AUC" with a dose-response relationship; ED was associated with peak FLACC and intraoperative agitation.

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Emergence delirium after intracranial neurosurgery- a prospective cohort study. J Clin Neurosci 2022;104:12-17. [PMID: 35933784 DOI: 10.1016/j.jocn.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/18/2022] [Accepted: 08/01/2022] [Indexed: 11/24/2022]

Liu W, Luo T, Wang F, Zhang D, Liu T, Huang J, Xu S. Effect of Preoperative Thoracic Paravertebral Blocks on Emergence Agitation During Tracheal Extubation: A Randomized Controlled Trial. Front Med (Lausanne) 2022;9:902908. [PMID: 35814746 PMCID: PMC9257130 DOI: 10.3389/fmed.2022.902908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/19/2022] [Indexed: 11/13/2022] Open

Abstract

Objective

This study aims to compare the effects of preoperative thoracic paravertebral blocks (TPVB) with intercoastal nerve blocks (ICNB) on emergence agitation (EA) during tracheal extubation in patients who underwent thoracoscopic lobectomy.

Design, Setting, and Participants

A randomized clinical trial was conducted in patients undergoing thoracoscopic lobectomy at Beijing Chest Hospital between June 2019 and December 2020.

Interventions

Patients were randomly assigned 1:1 to receive either ultrasound-guided preoperative TPVB or ICNB.

Main Outcomes and Measures

The primary outcome was the occurrence of emergency agitation, which was evaluated by Aono’s four-point scale (AFPS). Secondary outcomes included hemodynamics [mean arterial pressure (MAP) and heart rate (HR)]; and post-operative pain intensity [visual analog scale (VAS), Ramsay sedation score (RSS), and patient-controlled analgesia (PCA) demand times].

Results

Among the 100 patients aged 55–75 years old, 50 were randomized to each group; 97 patients completed the trial. Compared to the ICNB group, the occurrence of EA in the TPVB group was significantly lower [31.3% (15/48) vs. 12.2% (6/49), relative risk = 1.276, 95% CI: 1.02–1.60, P = 0.028]. For patients in the TPVB group, the MAP and HR at 5, 10, and 30 min after extubation were significantly lower; the intraoperative details including emergence time, extubation time, and consumption of sufentanil were significantly shorter than that in the ICNB group. Additionally, patients in the TPVB group showed significantly lower VAS at rest or coughing and significantly lower RSS at 60 and 240 min after extubation than patients in the ICNB group (all P < 0.05).

Conclusion

Preoperative TPVB was associated with less EA during tracheal extubation when compared with ICNB in patients undergoing thoracoscopic lobectomy.

Clinical Trial Registration

[http://www.chictr.org.cn/index.aspx], identifier [ChiCTR1900023852].

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Heshmati M, Bruchas MR. Historical and Modern Evidence for the Role of Reward Circuitry in Emergence. Anesthesiology 2022;136:997-1014. [PMID: 35362070 PMCID: PMC9467375 DOI: 10.1097/aln.0000000000004148] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]

Koo CH, Koo BW, Han J, Lee HT, Lim D, Shin HJ. The effects of intraoperative magnesium sulfate administration on emergence agitation and delirium in pediatric patients: A systematic review and meta-analysis of randomized controlled trials. Paediatr Anaesth 2022;32:522-530. [PMID: 34861083 DOI: 10.1111/pan.14352] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/25/2021] [Accepted: 11/22/2021] [Indexed: 02/06/2023]

Abstract

BACKGROUND

The role of intraoperative magnesium for the prevention of emergence agitation or delirium is unclear as there have been conflicting results reported by several randomized controlled trials.

AIMS

The aim of this study was to investigate the effect of magnesium sulfate on emergence agitation or emergence delirium in pediatric patients.

METHODS

Electronic databases, including PubMed, EMBASE, CENTRAL, CINAHL, Scopus, and Web of Science, were searched to identify studies which evaluated the effects of magnesium on postoperative emergence agitation or emergence delirium. The primary outcome was the incidence of emergence agitation or emergence delirium during the post-anesthesia stay. The secondary outcome was the agitation or delirium score upon admission to the post-anesthesia care unit. We estimated the odds ratio and standardized mean difference using a random-effect model.

RESULTS

A total of 712 pediatric patients from 10 randomized controlled trials were included in the final analysis. The incidence of emergence agitation or emergence delirium was 29.7% in the magnesium group and 50.5% in the control group. The pooled effect size revealed that the administration of magnesium sulfate significantly reduced the incidence of postoperative emergence agitation or emergence delirium in pediatric patients undergoing surgery with general anesthesia (Odds ratio, 0.31; 95% confidence interval, 0.15 to 0.64; p = .002). Additionally, children in the magnesium group reported significantly lower agitation or delirium scores than those in the control group (standardized mean difference, -0.70; 95% confidence interval, -1.15 to -0.24; p = .003).

CONCLUSION

The administration of magnesium sulfate reduced the incidence and severity of emergence agitation or emergence delirium in pediatric patients after the use of general anesthesia during surgery.

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The use of the Safeguard pressure-assisted device for maintenance of hemostasis following angiography in children. J Vasc Interv Radiol 2022;33:1084-1088. [DOI: 10.1016/j.jvir.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/29/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open

Emergence agitation in paediatric day case surgery: A randomised, single-blinded study comparing narcotrend and heart rate variability with standard monitoring. Eur J Anaesthesiol 2021;39:261-268. [PMID: 34923564 DOI: 10.1097/eja.0000000000001649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]

Abstract

BACKGROUND

Postoperative emergence agitation remains a significant challenge in paediatric anaesthesia. Although short-lived, it may cause harm to the patient and negative experiences for all. Differentiating agitation, delirium and pain is difficult. Electroencephalography allows precise titration of anaesthetic depth, and heart rate variability monitoring permits immediate intervention regarding nociception and pain. We examined if one of these measures could be used to reduce postoperative agitation in an unselected paediatric day surgical population.

OBJECTIVE

The primary outcome was postoperative agitation with a Richmond Agitation-Sedation Scale greater than 0. Secondary outcomes were: length of stay, postoperative nausea and vomiting, fentanyl and propofol consumption, pain scores and use of postoperative analgesics.

DESIGN

A randomised, single-blinded study constituting children aged 1 to 6 years, undergoing minor general day surgical procedures.

SETTING

Paediatric day surgical department 29th March 2019 to 12th June 2020.

PATIENTS

Ninety-eight children (ASA 1 or 2) were enrolled, and 93 children were included in the final analysis.

INTERVENTIONS

Children received standard monitoring (n=31), standard monitoring plus either Narcotrend (n=31), or Anaesthesia Nociception Index monitoring (n=31). Sevoflurane or fentanyl was titrated immediately according to monitor thresholds.

RESULTS

Kaplan-Meier analysis yielded a statistically significant difference between the groups (P = 0.016) with the lowest agitation levels in the Anaesthesia Nociception Index group, intermediate levels in the control group and the highest agitation levels in the Narcotrend monitored group. Intergroup pairwise comparison however, showed no difference. The Anaesthesia Nocioception Index group received slightly more fentanyl (P = 0.277). The control group patients had the highest pain scores despite receiving more caudal blocks and the Narcotrend group had more sevoflurane adjustments. Other secondary outcomes were comparable.

CONCLUSION

Children in the Anaesthesia Nociception Index group were the least agitated with the highest fentanyl doses, without increasing the length of stay in the PACU or postoperative nausea and vomiting.

CLINICAL REGISTRATION

The study was registered in RedCAP online trial database 1/11/2018 trial registration nr. OP720. https://open.rsyd.dk/OpenProjects/openProject.jsp?openNo=720&lang=da.

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Wang Q, Zhou J, Liu T, Yang N, Mi X, Han D, Han Y, Chen L, Liu K, Zheng H, Zhang J, Lin X, Li Y, Hong J, Li Z, Guo X. Predictive Value of Preoperative Profiling of Serum Metabolites for Emergence Agitation After General Anesthesia in Adult Patients. Front Mol Biosci 2021;8:739227. [PMID: 34746231 PMCID: PMC8566542 DOI: 10.3389/fmolb.2021.739227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/20/2021] [Indexed: 12/27/2022] Open

Analgesic Efficacy of Quadratus Lumborum Block in Infants Undergoing Pyeloplasty. SURGERIES 2021. [DOI: 10.3390/surgeries2030028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open

Apai C, Shah R, Tran K, Pandya Shah S. Anesthesia and the Developing Brain: A Review of Sevoflurane-induced Neurotoxicity in Pediatric Populations. Clin Ther 2021;43:762-778. [PMID: 33674065 DOI: 10.1016/j.clinthera.2021.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/14/2020] [Accepted: 01/25/2021] [Indexed: 11/18/2022]

Abstract

PURPOSE

For over 150 years of anesthetic practice, it was believed that the effects of general anesthetics were temporary and not adverse. A growing number of studies over the past 2 decades, however, have identified structural and cognitive abnormalities, especially in the developing brain. Despite the growing evidence of anesthetic-induced neurotoxicity in animal studies, the evidence to date in humans has been inconsistent and unclear. Sevoflurane, a commonly used inhalational agent in pediatric anesthesia, is an agent of choice for inhalational induction due to its rapid activity and low blood-gas solubility. With evaluation of the current literature, improved considerations can be made regarding the widespread use of sevoflurane as an anesthetic.

METHODS

PubMed database was searched for article published between 1969 through 2020. The reference lists of identified articles were searched manually for additional papers eligible for inclusion. This review addressed the tolerability of sevoflurane in specific populations, particularly pediatrics, and is divided into 3 parts: (1) the history of sevoflurane use in anesthetic practice and the pharmacokinetic properties that make it advantageous in pediatric populations; (2) proposed mechanisms of anesthesia-induced neurotoxicity; and (3) considerations due to potential adverse effects of sevoflurane in both short and long procedures.

FINDINGS

There is reason for concern regarding the neurotoxic effects of sevoflurane in both the pediatric and elderly populations, as spatial memory loss, developmental deficits, and an enhanced risk for Alzheimer disease have been linked with the use of this popular inhalational agent.

IMPLICATIONS

The duration and dose of sevoflurane may need to be altered, especially in longer procedures in pediatric populations. This may change how sevoflurane is administered, thus indicating a greater demand for an understanding of its limitations as an anesthetic agent.

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