The impact of emergence delirium on hospital length of stay for children who underwent tonsillectomy/adenotonsillectomy: an observational retrospective study

Abstract Background Emergence Delirium (ED) is a combination of disturbance of perception and psychomotor agitation that is common in pediatric patients after general anesthesia, especially at preschool age. Since the effect of ED on the length of stay has been studied in adults but infrequently in children, the aim of this study was to investigate the relationship between ED and length of stay in this population. Methods A single center, retrospective, observational study was carried out in children who underwent tonsillectomy or adenotonsillectomy. The Pediatric Anesthesia Emergence Delirium (PAED) scale was used to assess ED. In addition to the time to hospital discharge (time frame 24 hours), drugs used, comorbidities, early postoperative complications, and pain were investigated if potentially associated with the complication. Results Four hundred sixteen children aged from 1.5 to 10 years (183 female, 233 male) were included. ED occurred in 25.5% of patients (n = 106). Patients were divided into the ED group and the No-ED group. The discharge time was similar in both groups. No significant differences were observed in the frequency of postoperative complications. The use of fentanyl or dexmedetomidine did not affect ED occurrence. The frequency of pain was greater in the ED group, both in the recovery room and in the ward (p= 0.01). Conclusions The occurrence of ED in children after tonsillectomy/adenotonsillectomy did not extend the length of stay.

Effect of seasons on delirium in postoperative critically ill patients: a retrospective analysis

Abstract Background and objectives Postoperative delirium is common in critically ill patients and is known to have several predisposing and precipitating factors. Seasonality affects cognitive function which has a more dysfunctional pattern during winter. We, therefore, aimed to test whether seasonal variation is associated with the occurrence of delirium and hospital Length Of Stay (LOS) in critically ill non-cardiac surgical populations. Methods We conducted a retrospective analysis of adult patients recovering from non-cardiac surgery at the Cleveland Clinic between March 2013 and March 2018 who stayed in Surgical Intensive Care Unit (SICU) for at least 48 hours and had daily Confusion Assessment Method Intensive Care Unit (CAM-ICU) assessments for delirium. The incidence of delirium and LOS were summarized by season and compared using chi-square test and non-parametric tests, respectively. A logistic regression model was used to assess the association between delirium and LOS with seasons, adjusted for potential confounding variables. Results Among 2300 patients admitted to SICU after non-cardiac surgeries, 1267 (55%) had postoperative delirium. The incidence of delirium was 55% in spring, 54% in summer, 55% in fall and 57% in winter, which was not significantly different over the four seasons (p= 0.69). The median LOS was 12 days (IQR = [8, 19]) overall. There was a significant difference in LOS across the four seasons (p= 0.018). LOS during summer was 12% longer (95% CI: 1.04, 1.21; p= 0.002) than in winter. Conclusions In adult non-cardiac critically ill surgical patients, the incidence of postoperative delirium is not associated with season. Noticeably, LOS was longer in summer than in winter.

Efficacy of intravenous lidocaine in controlling emergence agitation in children for surgery under sevoflurane anesthesia: a meta-analysis

BACKGROUND@#Emergence delirium is a state of mental confusion and agitation after wakening from anesthesia that may result in traumatic injuries to the child. Limited drugs have been studied or used to prevent this occurrence.@*OBJECTIVE@#To determine the efficacy and safety of intravenous lidocaine in controlling emergence agitation (EA) in children undergoing surgeries done under general anesthesia compared to placebo or other intravenous anesthetics.@*METHODOLOGY@#This study is a meta-analysis, where published articles were obtained using PubMed, Cochrane Library, Clinical Trials, and Google Scholar up to August 2022. The primary outcome measure includes incidence of emergence delirium while secondary outcomes are postoperative pain and adverse effects comparing lidocaine and other intravenous drugs. The latter includes nausea and vomiting, untoward airway events and local anesthetic toxicity (LAST). Review Manager 5.4 was used for statistical analysis.@*RESULTS@#There were a total of 6 articles included for quantitative and qualitative analysis. The overall incidence of emergence agitation (RR=1.03, 95% CI [0.50, 2.13], P=0.94) and adverse events were higher in the Lidocaine group, although the differences were not significant. Subgroup analysis by comparator showed significant increased risk of developing EA with Lidocaine compared to other intravenous drugs (RR=2.06, 95% CI [1.32, 2.32], P=0.002). The risk for developing postoperative pain is decreased with Lidocaine compared to placebo and other drugs.@*CONCLUSION@#Intravenous lidocaine given to children undergoing general anesthesia with sevoflurane increased their risk for emergence delirium, compared to both placebo and other intravenous anesthetics.

Sufentanil reduces emergence delirium in children undergoing transthoracic device closure of vsd after sevoflurane-based cardiac anesthesia

Abstract Objective: The aim of this study was to evaluate whether sufentanil can reduce emergence delirium in children undergoing transthoracic device closure of ventricular septal defect (VSD) after sevoflurane-based cardiac anesthesia. Methods: From February 2019 to May 2019, 68 children who underwent transthoracic device closure of VSD at our center were retrospectively analyzed. All patients were divided into two groups: 36 patients in group S, who were given sufentanil and sevoflurane-based cardiac anesthesia, and 32 patients in group F, who were given fentanyl and sevoflurane-based cardiac anesthesia. The following clinical data were recorded: age, sex, body weight, operation time, and bispectral index (BIS). After the children were sent to the intensive care unit (ICU), pediatric anesthesia emergence delirium (PAED) and face, legs, activity, cry, consolability (FLACC) scale scores were also assessed. The incidence of adverse reactions, such as nausea, vomiting, drowsiness and dizziness, was recorded. Results: There was no significant difference in age, sex, body weight, operation time or BIS value between the two groups. Extubation time (min), PEAD score and FLACC scale score in group S were significantly better than those in group F (P<0.05). No serious anesthesia or drug-related side effects occurred. Conclusions: Sufentanil can be safely used in sevoflurane-based fast-track cardiac anesthesia for transthoracic device closure of VSD in children. Compared to fentanyl, sufentanil is more effective in reducing postoperative emergence delirium, with lower analgesia scores and greater comfort.

Debería usarse Ketamina para el tratamiento de la agitación/delirio en el ámbito pre-hospitalario /emergencias? / Should Ketamine be used for the treatment of agitation / delirium in the pre-hospital / emergency setting?

DESCRIPCIÓN DE LA TECNOLOGÍA Y TECNOLOGÍAS ALTERNATIVAS: La ketamina se ha utilizado durante más de 50 años para la inducción y el mantenimiento de la anestesia. Tiene propiedades únicas, incluida la capacidad de producir analgesia profunda y amnesia mientras se mantienen reflejos de las vías respiratorias, respiración espontánea y cardiopulmonar estabilidad. Además, produce un estado cataléptico en el que los pacientes pueden tener sus ojos abiertos pero no responde a los comandos. Como tal, la ketamina se ha denominado " anestésico disociativo ". Además de su uso para anestesia, la ketamina se ha utilizado para una gran variedad de indicaciones como el manejo dolor la depresión, tendencias suicidas y más recientemente como agente alternativo para el tratamiento de agitación o delirio. La ketamina ejerce sus acciones a través de interacciones con una variedad de receptores, que incluyen bloqueo de receptores de N-metil-D-aspartato, inhibición de óxido nítrico sintasa e interacciones con múltiples receptores opioides, entre otros. La ketamina se absorbe rápidamente después de administración intramuscular (IM), intravenosa (IV) o intraósea (IO) y es altamente lipofílico, cruzando fácilmente la barrera hematoencefálica. MÉTODOS: Se seleccionó una revisión sistemática (Linder y col 2017) y se evaluó a través de la herramienta AMSTAR 2 con baja confianza. Posteriormente se realizó una búsqueda desde los años 2017 a 2019 que cumpliera con los criterios de búsqueda. Fue incluido en ensayo clínico de tipo "open label" realizado por Cole y col 2016. El mismo fue evaluado a través de la herramienta Rob-2 para valorar el riesgo de sesgo. RECOMENDACIONES Y JUICIOS: Hemos encontrado sólo un ensayo clínico de tipo "open label" que evaluó el uso de Ketamina asociado o no con benzodiacepinas frente a Haloperidol para el tratamiento del delirio o agitación en el contexto de la atención de emergencia en el ámbito pre-hospitalario. El resto de los estúdios son de tipo observacional y son heterogéneos en cuanto a pacientes, intervenciones y desenlaces. Es probable que la Ketamina sea más efectiva frente a Haloperidol para la resolución de la excitación psicomotriz o delirio en la emergencia, así como el tiempo de resolución del delirio se reduce aproximadamente a la mitad. Asimismo, la Ketamina podría no asociarse con mayor mortalidad frente a Haloperidol, hallazgo sustentado en una baja certeza por imprecisión dado el escaso número de eventos. Sin embargo, la Ketamina probablemente se asocie con mayor depresión respiratoria y necesidad de intubación frente al Haloperidol. Por otra parte, el costo directo por paciente asociado del uso de ketamina es 20 veces superior al del Haloperidol, sin tener en cuenta la mayor probabilidad de intubación orotraqueal derivada de la depresión respiratoria asociada con el uso de ketamina así como tampoco la mayor efectividad, que podría reducir el uso de otros fármacos de rescate. No existen meta-análisis en red que evalúen este uso frente al Haloperidol, así como tampoco estudios económicos que valoren el impacto en la costo-efectividad.

Relationship between emotional states before cardiac valve surgeries with postoperative complications / Relaciones entre el estado emocional antes de la cirugía cardíaca valvar con complicaciones en el post-operatorio / Relações entre o estado emocional antes da cirurgia cardíaca valvar com complicações no pós-operatório

ABSTRACT Objective: To investigate associations between preoperative anxiety and depression symptoms and postoperative complications and the sociodemographic and clinical characteristics of patients undergoing valve repair surgery. Method: Observational, exploratory and prospective study. The consecutive non-probabilistic sample consisted of patients undergoing their first valve repair surgery. Data were collected from September 2013 to September 2015, in a university hospital in the interior of São Paulo, Brazil. Symptoms were assessed using the Hospital Anxiety and Depression Scale and analyzed using Mann-Whitney and Spearman correlation; alpha was established at 5%. Results: Among the 70 participants, depressive symptoms were more frequent among women (p=0.042) and among patients experiencing postoperative agitation (p=0.039) Conclusion: In this study, depressive symptoms were associated with being a woman and postoperative agitation; the same was not true in regard to anxiety symptoms.

RESUMEN Objetivo: Investigar la asociación de los síntomas de ansiedad y depresión preoperatorios con complicaciones en postoperatorio y con características sociodemográficas y clínicas de pacientes sometidos a la corrección quirúrgica de valvopatías. Método: Estudio observacional, exploratorio y prospectivo. Muestra consecutiva y no probabilística fue constituida por pacientes sometidos a la primera cirugía de corrección de valvopatías. Los datos fueron recolectados de septiembre/2013 a septiembre/2015, en un hospital universitario del interior del São Paulo. Los síntomas fueron evaluados por el Hospital Anxiety and Depression Scale. Los datos fueron analizados por las pruebas de Mann-Whitney y Correlación de Spearman, alpha=5%. Resultados: Entre los 70 pacientes, fue encontrado mayor presencia de síntomas depresivos entre las mujeres (p=0,042) y en el grupo con agitación (p=0,039) en el postoperatorio. Conclusión: En el grupo estudiado, los síntomas depresivos se asociaron al sexo femenino y la agitación en el postoperatorio, lo que no ocurrió con los síntomas de ansiedad.

RESUMO Objetivo: Investigar a associação dos sintomas de ansiedade e depressão pré-operatórios com complicações no pós-operatório e com características sociodemográficas e clínicas de pacientes submetidos à correção cirúrgica de valvopatias. Método: Estudo observacional, exploratório e prospectivo. Uma amostra consecutiva e não probabilística foi constituída por pacientes submetidos à primeira cirurgia de correção de valvopatias. Os dados foram coletados de setembro/2013 a setembro/2015, em um hospital universitário do interior paulista. Os sintomas foram avaliados pela Hospital Anxiety and Depression Scale. Os dados foram analisados pelos testes de Mann-Whitney e Correlação de Spearman, alpha de 5%. Resultados: Entre os 70 pacientes, encontrou-se maior presença de sintomas depressivos entre as mulheres (p=0,042) e no grupo com agitação (p=0,039) no pós-operatório. Conclusão: No grupo estudado, sintomas depressivos foram associados ao sexo feminino e a agitação no pós-operatório, o que não ocorreu com os sintomas de ansiedade.

Oral trans-mucosal dexmedetomidine for controlling of emergence agitation in children undergoing tonsillectomy: a randomized controlled trial / Dexmedetomidina transmucosa oral para controle da agitação ao despertar em crianças submetidas a amigdalectomia: ensaio clínico randomizado

Abstract Objectives: Emergence agitation is a negative behavior commonly recorded after pediatric tonsillectomy. We investigated the efficacy of preoperative premedication with oral transmucosal buccal dexmedetomidine on the incidence and severity of emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia. Methods: Ninety patients aged (3-6 years), ASA I‒II were enrolled into three groups (n = 30) to receive oral transmucosal dexmedetomidine 0.5 µg.kg-1 (Group DEX I), 1 µg.kg-1 (Group DEX II) or saline placebo (Group C). Our primary endpoint was the Watcha agitation score at emergence in PACU. Secondary outcomes were preoperative sedation score, intraoperative hemodynamics, postoperative Objective Pain Scale (OPS) and adverse effects. Results: The patients' demographics, preoperative sedation scores and extubation time showed no difference between groups. Significant differences between groups in incidence and frequency distribution of each grade of Watcha score were evident at 5 minutes (p= 0.007), 10 minutes (p= 0.034), 30 minutes (p= 0.022), 45 minutes (p= 0.034) and 60 minutes (p= 0.026), postoperatively with significant differences between DEX I and II groups. DEX groups showed lower OPS scores at 5 minutes (p= 0.011), 10 minutes (p= 0.037) and 30 minutes (p= 0.044) after arrival at PACU, with no difference between DEX I and II groups. Patients in DEX II group exhibited lower intraoperative mean heart rate at 15 min (p= 0.020), and lower mean arterial pressure at 30 minutes, (p= 0.040), 45 minutes (p= 0.002) and 60 minutes (p= 0.006) with no significant differences between groups in other time points. Conclusion: This study demonstrates the clinical advantage and the simple technique of oral transmucosal DEX premedication for emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia compared with saline placebo. Trial registration Clinical Trials.gov trial registry: NCT02720705.

Resumo Objetivos: A agitação ao despertar da anestesia é um comportamento negativo comumente registrado após amigdalectomia pediátrica. Avaliamos a eficácia da pré-medicação com dexmedetomidina via transmucosa oral no pré-operatório sobre a incidência e gravidade da agitação ao despertar em crianças pré-escolares submetidas à amigdalectomia sob anestesia com sevoflurano. Métodos: Noventa pacientes entre três e seis anos e estado físico ASA I-II foram incluídos em três grupos (n = 30) para receber 0,5 µg.kg-1 ou 1 µg.kg-1 de dexmedetomidina via transmucosa oral (Grupo DEX I e Grupo DEX II, respectivamente) ou solução salina (Grupo C). O desfecho primário foi o escore de agitação ao despertar medido com a escala de Watcha na SRPA. Os desfechos secundários foram escore de sedação pré-operatória, hemodinâmica intraoperatória, escore OPS (Objective Pain Scale) e efeitos adversos no pós-operatório. Resultados: A demografia dos pacientes, os escores de sedação pré-operatória e o tempo de extubação não apresentaram diferença entre os grupos. Diferenças significativas entre os grupos na distribuição da incidência e frequência de cada grau do escore de Watcha foram evidentes aos 5 minutos (p = 0,007), 10 minutos (p = 0,034), 30 minutos (p = 0,022), 45 minutos (p = 0,034) e 60 minutos (p = 0,026) no pós-operatório, com diferenças significativas entre os grupos DEX I e II. Os grupos DEX apresentaram escores OPS mais baixos aos 5 minutos (p = 0,011), 10 minutos (p = 0,037) e 30 minutos (p = 0,044) após a chegada à SRPA, sem diferença entre os grupos DEX I e II. Os pacientes do grupo DEX II apresentaram menor frequência cardíaca média aos 15 minutos de intraoperatório (p = 0,020) e menor pressão arterial média aos 30 minutos, (p = 0,040), 45 minutos (p = 0,002) e 60 minutos (p = 0,006), sem diferenças significativas entre os grupos em outros momentos. Conclusão: Este estudo demonstra a vantagem clínica e a técnica simples da pré-medicação com DEX por via transmucosa oral para agitação ao despertar em crianças pré-escolares submetidas à amigdalectomia sob anestesia com sevoflurano, comparado à solução salina. Registro do estudo: Clinical Trials.gov trial registry: NCT02720705.

Emergence delirium following sevoflurane anesthesia in adults: prospective observational study / Delirium do despertar após anestesia com sevoflurano em adultos: estudo observacional prospectivo

Abstract Background and objectives: Emergence delirium after general anesthesia with sevoflurane has not been frequently reported in adults compared to children. This study aimed to determine the incidence of emergence delirium in adult patients who had anesthesia with sevoflurane as the volatile agent and the probable risk factors associated with its occurrence. Design & methods: A prospective observational study was conducted in adult patients who had non-neurological procedures and no existing neurological or psychiatric conditions, under general anesthesia. Demographic data such as age, gender, ethnicity and clinical data including ASA physical status, surgical status, intubation attempts, duration of surgery, intraoperative hypotension, drugs used, postoperative pain, rescue analgesia and presence of catheters were recorded. Emergence delirium intensity was measured using the Nursing Delirium Scale (NuDESC). Results: The incidence of emergence delirium was 11.8%. The factors significantly associated with emergence delirium included elderly age (>65) (p = 0.04), emergency surgery (p = 0.04), African ethnicity (p = 0.01), longer duration of surgery (p = 0.007) and number of intubation attempts (p = 0.001). Factors such as gender, alcohol and illicit drug use, and surgical specialty did not influence the occurrence of emergence delirium. Conclusions: The incidence of emergence delirium in adults after general anesthesia using sevoflurane is significant and has not been adequately reported. Modifiable risk factors need to be addressed to further reduce its incidence.

Resumo Justificativa e objetivos: O delirium do despertar após a anestesia geral com sevoflurano não tem sido relatado com frequência em adultos como nas crianças. Este estudo teve como objetivo determinar a incidência de delirium do despertar em pacientes adultos submetidos à anestesia com sevoflurano como agente volátil e os prováveis fatores de risco associados à sua ocorrência. Desenho e métodos: Um estudo observacional prospectivo foi conduzido com pacientes adultos sem distúrbios neurológicos ou psiquiátricos submetidos à anestesia geral para procedimentos não neurológicos. Dados demográficos como idade, sexo, etnia e dados clínicos, inclusive estado físico ASA, estado cirúrgico, tentativas de intubação, tempo de cirurgia, hipotensão intraoperatória, drogas usadas, dor pós-operatória, analgesia de resgate e presença de cateteres, foram registrados. A intensidade do delirium do despertar foi medida com a Escala de Triagem de Delirium em Enfermagem (Nursing Delirium Scale - NuDESC). Resultados: A incidência de delirium do despertar foi de 11,8%. Os fatores significativamente associados ao delirium do despertar incluíram idade avançada (> 65) (p = 0,04), cirurgia de emergência (p = 0,04), descendência africana (p = 0,01), tempo maior de cirurgia (p = 0,007) e número de tentativas de intubação (p = 0,001). Fatores como sexo, uso de álcool e drogas ilícitas e especialidade cirúrgica não influenciaram a ocorrência de delirium do despertar. Conclusões: A incidência de delirium do despertar em adultos após a anestesia geral com sevoflurano é significativa e não tem sido relatada adequadamente. Fatores de risco modificáveis precisam ser abordados para reduzir ainda mais sua incidência.

Caracterización de los episodios de agitación durante la emergencia de la anestesia general en pediatría / Characterization of agitation episodes during the emergence from general anesthesia in Pediatrics

RESUMEN Introducción: la agitación durante la emergencia de la anestesia general es una complicación frecuente en pediatría que puede causar daños físicos, retrasar el alta y aumentar los costos. Objetivo: caracterizar los episodios anestesia general en el paciente pediátrico. Materiales y métodos: se realizó un estudio descriptivo, prospectivo, longitudinal de 246 pacientes que presentaron anestesia general en el Hospital "Eliseo Noel Caamaño" entre septiembre de 2015 y diciembre de 2018. Se estudiaron las variables: edad, género, ASA, tiempo quirúrgico y tiempo anestésico, tipo de cirugía, método de anestesia, agentes usados para la inducción y el mantenimiento, severidad de los episodios y necesidad de tratamiento. Resultados: la mayoría de los pacientes que presentaron anestesia general tenían entre 2 y 6 años (63,4%), eran masculinos (67,9%), ASA I (78,1%) y fueron operados de excéresis de lesiones de partes blandas (27,6%). El tiempo quirúrgico fue de 31,2 ± 10,4 minutos y el anestésico 43,5±8,8 minutos. El método anestésico más indicado fue la anestesia balanceada (84,2%), como inductor el propofol (86,2%) y para el mantenimiento isoflurano (34,1%) y sevoflurano (26,4%). Predominaron los episodios severos (51,2%) y el 56,9% necesitó intervención farmacológica. Conclusiones: esta anestesia fue más frecuente en los menores de seis años, masculinos, sanos, a los cuales se les realizaron procederes cortos, con anestesia balanceada, se usó propofol para la inducción e isoflurano y sevoflurano para el mantenimiento de la anestesia. Prevalecieron los episodios severos y la mayoría requirió tratamiento farmacológico.

ABSTRACT Introduction: agitation during the emergence from general anesthesia is a frequent complication in Pediatrics that can cause physical damages, delay discharge and increase costs. Objective: to characterize the episodes of general anesthesia in the pediatric patient. Materials and methods: a descriptive, prospective, longitudinal study was carried out with 246 patients who presented general anesthesia in the Hospital "Eliseo Noel Caamaño" from September 2015 to December 2018. The studied variables were age, gender, ASA, surgical time, anesthetic time, kind of surgery, anesthetic method, agents used for the induction and maintenance, episodes severity and treatment necessity. Results: most of patients treated with general anesthesia were aged 2-6 years (63.4 %), male (67.9 %), ASA I (78.1 %), and underwent the removal of soft parts lesions (27.6 %). The average surgical time was 31,2 ± 10,4 minutes and the anesthetics one was 43,5±8,8 minutes. The most used anesthetics method was balanced anesthesia (84.2 %), the most used inductor was propofol (86.2 %) and for the maintenance isoflurane (34,1%) and sevoflurane (26,4%). Severe episodes (51,2%) predominated, and 56.9 % needed pharmacologic intervention. Conclusions: this kind of anesthesia is more frequently used in children aged less than 6 years, male, healthy, who underwent short procedures with balanced anesthesia and the use of propofol for the induction and isoflurane and sevoflurane for maintaining it. Severe episodes predominated, and most of them required pharmacologic treatment.

Effect of oral midazolam in preventing postoperative emergence agitation in children

Introduction: Emergence from general anaesthesia can be complicated by the presence of agitation in children and thus presents a challenging situation for postanesthesia care providers. Several factors are associated with emergence agitation (EA). These include pain, preoperative anxiety, young age, poor adaptability, short time to recovery, among others. Objective: This study aimed to determine the effect of oral midazolam inpreventing postoperative EA in children. Materials and Methods: This was a case­control study carried out among 80 healthy children aged 1­10 years scheduled for day­case surgery. The children were randomly assigned to receive either a syrup of paracetamol 10 mg/kg with injectable midazolam 0.5 mg/kg added to the syrup (Group A) or a placebo in the form of paracetamol syrup (Group B) at a dose of 10 mg/kg 30 min before induction of anesthesia. Patients' state of agitation was assessed every 5 min for the 1st h by means of an EA scale. Children with an agitation score of 3 or 4 were classified as agitated.Prolonged agitation was defined as a score of ≥3 lasting 15 min after arrival in the recovery room. Data were analyzed using the Statistical Software for Social Sciences version 20. Results: Eighty children aged 1­10 years were enrolled in the study. Majority of the procedures were circumcisions (48.75%), while urethral dilatation, examination under anesthesia, and tongue release were the least (1.25%). There was no statistically significant difference in the agitation state of the two groups (P = 0.60). Conclusion:Premedication with oral midazolam 0.5 mg/kg administered 30 min preoperatively does not prevent EA in all cases

Risk factors associated with anesthesia emergence delirium in children undergoing outpatient surgery / Fatores de risco associados a delírio no despertar da anestesia em crianças submetidas à cirurgia ambulatorial

Abstract Introduction: Anesthesia emergence delirium is a self-limiting clinical phenomenon very common in children. Although pathophysiology is still uncertain, some factors seem to be involved, such as rapid awakening in an unknown environment, agitation during anesthetic induction, preoperative anxiety, environmental disorders, use of preanesthetic medication, use of inhalational anesthetics, and postoperative pain. Objective: To determine the prevalence and risk factors associated with anesthesia emergence delirium in children undergoing outpatient surgery. Methods: A prospective observational study was carried out with 100 children aged 2-10 years, who underwent surgery on an outpatient basis. The study variables were: anesthesia emergence delirium and the associated risk factors (preoperative anxiety, child impulsive behavior, use of pre-anesthetic medication, traumatic induction, type of anesthesia, and postoperative pain). Multivariate Poisson's logistic regression was used to analyze the possible explanatory variables, where the prevalence ratios were estimated with the respective 95% confidence intervals, considering a significance level of 5%. Results: Delirium and pain were observed in 27% and 20% of children, respectively. Only postoperative pain after Poisson's regression, was shown to be associated with anesthesia emergence delirium, with a prevalence ratio of 3.91 (p < 0.000). Conclusion: The present study showed 27% prevalence of anesthesia emergence delirium in the study population. The incidence of anesthesia emergence delirium was higher in children who had postoperative pain.

Resumo Introdução Delírio ao despertar anestésico é um fenômeno clínico autolimitado muito comum em crianças. Apesar de fisiopatologia ainda incerta, alguns fatores parecem estar envolvidos, como despertar rápido em um ambiente desconhecido, agitação durante a indução anestésica, ansiedade pré-operatória, perturbações ambientais, uso de medicação pré-anestésica, uso de anestésicos inalatórios e dor pós-operatória. Objetivo Determinar a prevalência e os fatores de risco associados ao delírio ao despertar anestésico em crianças submetidas à cirurgia ambulatorial. Métodos Estudo observacional prospectivo, envolveu 100 crianças entre dois e 10 anos, submetidos à cirurgia em caráter ambulatorial. As variáveis de estudo foram: delírio ao despertar anestésico e os fatores de risco associados (ansiedade pré-operatória, comportamento impulsivo da criança, uso de medicação pré-anestésica, indução traumática, tipo de anestesia e dor pós-operatória). Foi feita a regressão multivariada de Poisson para análise das possíveis variáveis explanatórias, na qual foram estimadas as razões de prevalência com os respectivos intervalos de confiança de 95%, considerou-se o nível de significância de 5%. Resultados Delírio e dor foram observados em 27% e 20% das crianças respectivamente. Apenas a dor no pós-operatório, após a regressão de Poisson, mostrou ter uma associação com o delírio ao despertar anestésico, cuja razão de prevalência foi 3,91 (p < 0,000). Conclusão O presente estudo evidenciou uma prevalência de delírio ao despertar anestésico de 27% na população estudada. A incidência de delírio ao despertar anestésico foi maior em crianças que apresentaram dor no pós-operatório.

¿Existe relación entre la concentración de inducción anestésica de sevofluorano y la incidencia de agitación postanestésica en niños? / Is there a relationship between the concentration of sevofluoran anesthetic induction and the incidence of post-anesthetic agitation in children?

Introducción. La inducción anestésica con sevofluorano se asocia con agitación postanestésica (APA) en niños. Concentraciones de sevofluorano mayores a 6% producen actividad cerebral epileptiforme, la que podría estar relacionada a APA. El propósito de este estudio fue comparar el efecto de dos diferentes concentraciones de inducción anestésica con sevofluorano sobre la incidencia de APA, en niños sometidos a cirugía infraumbilical. Método. Estudio prospectivo y doble ciego, en pacientes de 2 a 7 años, operados de fimosis o hernia inguinal con anestesia general y bloqueo epidural caudal. Los pacientes fueron aleatorizados para recibir sevofluorano 5 por ciento (grupo S5) o sevofluorano 8 por ciento (grupo S8). Se registraron variables demográficas, signos vitales, profundidad anestésica utilizando índice biespectral (BIS) y respuesta motora durante distintos momentos de la anestesia. Se evaluó la presencia de agitación en pabellón y recuperación utilizando la escala de APA pediátrica (PAED). Análisis estadístico: t-test o Mann-Whitney y test Chi-cuadrado o Fisher, p < 0,05 considerada significativa. Resultados. Se reclutaron 33 pacientes, 16 en el grupo S5 y 17 en el grupo S8. Ambos grupos fueron comparables en cuanto a variables demográficas, signos vitales, respuesta motora y valores de BIS. No hubo diferencias significativas en la incidencia de APA en pabellón (S5: 31,3 por ciento y S8: 35,3 por ciento) y en recuperación (S5: 43,8 por ciento y S8: 41,2 por ciento), entre los grupos. Conclusión. No habría relación entre la concentración de inducción anestésica de sevofluorano y la incidencia de APA en niños sometidos a cirugía infraumbilical con anestesia general y bloqueo caudal. (AU)

Introduction. Induction of anesthesia with sevoflurane is associated with post-anesthetic agitation (PAA) in children. Sevoflurane concentration greater than 6% produces epileptiform brain activity, which could be related to PAA. The aim of this study was to compare the effect of two different sevoflurane concentrations for anesthesia induction on the incidence of PAA in children undergoing infraumbilical surgery. Method. Prospective, double blind study, performed in patients 2 to 7 years of age, undergoing circumcision or inguinal hernia repair under general anesthesia and epidural caudal block. Patients were randomized to receive sevoflurane 5 percent (S5 group) or sevoflurane 8 percent (S8 group), during anesthesia induction. Demographic variables, vital parameters, anesthesia depth using bispectral index (BIS) and motor responses during different moments of anesthesia were recorded. The presence of agitation in the operating room and recovery room were determined using the pediatric PAA scale (PAED). Statistical analysis: t-test or Mann-Whitney, and Chi-square or Fisher test, p < 0.05 considered significant. Results. Thirty-three patients were enrolled, 16 in the S5 group and 17 in the S8 group. Demographic variables, vital parameters, motor responses and BIS values were comparable between both groups. There were no significant differences in the incidence of PAA in the operating room (S5: 31.3 percent percent and S8: 35.3 percent) or in the recovery room (S5: 43,8 percent and S8: 41.2 percent), between both groups. Conclusion. Sevoflurane concentration used for induction of anesthesia would not be related to the incidence of PAA in children undergoing infraumbilical surgery under general anesthesia and epidural caudal block. (AU)

Dexmedetomidine improves surgical field in cochlear implant surgery: a randomized, double-blind, placebo-controlled trial

Objectives: Sympatholytic properties of dexmedetomidine have many advantages to use in general anesthesia especially in pediatric age group undergoing cochlear implant surgeries. This study is designed to compare the effects of bolus dose of dexmedetomidine followed by infusion with placebo in cochlear implant surgeries for quality of hypotensive anesthesia with hemodynamic stability and incidence of complications in pediatric age group particularly emergence delirium with sevoflurane

Methodology: 60 pediatric patient of ASA grade I or II with congenital or acquired deafness of age ranging from 2 to 8 years scheduled for cochlear implant surgery were included in this study. Group D were administered dexmedetomidine 0.5 micro g/kg in 100 ml 0.9% NaCI over 10 min followed by infusion of dexmedetomidine at 0.5 micro g/kghr[-1] and Group P was given placebo only i.e. 0.9% NaCl 100 ml over 10 min followed by infusion at 2 ml.hr[-1]. Heart rate [HR] and mean arterial pressure [MAP] at different time interval, intraoperative fentanyl and propofol consumption, surgeons' satisfaction score and complications, particularly incidences of emergence delirium were recorded

Statistical analysis: Mean with standard deviation of various parameters of both groups was compared using student's t test were analyzed

Result: statistical significant lowering of MAP, HR, opioid consumption and rate of complications were lower in dexmedetomidine group compared to placebo group

Conclusion: Intraoperative administration of dexmedetomidine provides better surgical field and subsequently higher surgeon's satisfaction score leading to reduced surgery time with better recovery profile

Comparison of caudal dexmedetomidine and fentanyl combined with bupivacaine in pediatric patients undergoing urogenital surgery

Introduction: Caudal epidural block is one of the most popular, reliable, and safe techniques in pediatric patients that can provide analgesia for a variety of supra- and infra-umblical surgical procedures. This study aimed to compare the efficacy of dexmedetomidine-bupivacaine, fentanyl-bupivacaine mixture and bupivacaine alone on duration of postoperative analgesia, sedation, emergence agitation, duration of sensory and motor block, hemodynamic stability and side effects

Methodology: After approval from ethical committee 90 pediatric patients of age 2-7 y were enrolled. The children were randomly allocated to three equal groups of 30 each using a computer generated randomization list. Caudal block was given after induction of general anesthesia for urogenital surgery. General anesthesia was maintained with sevoflurane at a concentration adjusted to maintain BIS between 40-60. Hemodynamic parameters, Pediatric Anaesthesia Emergence Delirium [PAED] score, Richmond agitation sedation scale [RASS], and Children's Hospital of Eastern Ontario Pain Scale [CHEOPS] were recorded immediate postoperatively and then regularly every hour for the next 12 hours

Results: PAED score was less in group BD than group B and BF from baseline. RASS Score was less in Group BD than Group BF from base line to 12 h except at 240 min and Group BF is less than Group B from base line to 12 h. Group BD was less than B from base line to 12 h. CHEOP score was less in Group BD than Group BF and Group B from base line to 12 h

Conclusion: Dexmedetomidine [1 micro g/kg] added to bupivacaine in caudal block increases the duration of postoperative analgesia, provides arousable sedation, and decreases emergence delirium with stable hemodynamics and minimal side effects in pediatric patients

Effectiveness of dexmedetomidine for emergence agitation in infants undergoing palatoplasty: a randomized controlled trial / Eficácia de dexmedetomidina para o surgimento de agitação em lactentes submetidos à palatoplastia: estudo clínico randomizado

OBJECTIVES: In infants, there is a high incidence of emergence agitation (EA) after sevoflurane (Sev) anesthesia. This study aimed to test the hypothesis that dexmedetomidine (Dex) administration would reduce the incidence and severity of EA after Sev-based anesthesia in infants undergoing palatoplasty. METHODS: A prospective randomized clinical trial was conducted with 70 patients undergoing palatoplasty, aged 10-14 months. Infants were randomly allocated into two groups: Dex (n = 35) and saline (n = 35). In the Dex group, Dex (6 µg/kg/h) was administered approximately 10 min before the end of the surgery for 10 min, followed by 0.4 µg/kg/h until 5 min after extubation. In the saline group, an equivalent amount of saline was administered in a similar manner. After the surgery, patients were transferred to the postanesthetic care unit (PACU). The infant's behavior and pain were assessed with scoring system for EA (5-point rating scale) and pain scale (PS; 10-point rating scale), respectively. EA and PS were estimated at six time points (after extubation, leaving the operating room, 0, 30, 60, and 120 min after arrival in PACU). RESULTS: EA and PS scores were significantly lower in the Dex group than in the saline group from extubation to 120 min after arrival in PACU. CONCLUSIONS: Dex administration has the advantage of a reduced EA and PS without any adverse effects. Dex provided satisfactory recovery in infants undergoing palatoplasty.

OBJETIVOS: Em crianças, é elevada a incidência de surgimento de agitação (SA) em seguida à anestesia com sevoflurano (Sev). Este estudo teve como objetivo testar a hipótese de que a administração de dexmedetomidina (Dex) reduziria a incidência e a gravidade do SA após anestesia com Sev em lactentes submetidos à palatoplastia. MÉTODOS: Estudo clínico prospectivo randomizado, feito com 70 pacientes submetidos a uma palatoplastia, com 10-14 meses. As crianças foram divididas randomicamente em dois grupos: Dex (n = 35) e solução salina (n = 35). No grupo de Dex, Dex (6 µg/kg/h) foi administrada cerca de 10 minutos antes do fim da cirurgia durante 10 minutos, seguida de 0,4 µg/kg/h até 5 minutos após a extubação. No grupo de solução salina, uma quantidade equivalente de salina foi administrada com o mesmo esquema de dosagem. Após a cirurgia, os pacientes foram transferidos para a unidade de cuidados pós-anestésicos (UCPA). O comportamento e a dor dos bebês foram avaliados com um sistema de pontuação para SA (escala de classificação de 5 pontos) e com uma escala de dor (ED; escala de classificação de 10 pontos), respectivamente. SA e ED foram estimados em seis pontos cronológicos (após a extubação, ao deixar a sala de cirurgia e 0, 30, 60 e 120 minutos após a chegada à UCPA). RESULTADOS: Os escores SA e ED foram significativamente menores no grupo Dex versus grupo salina, desde a extubação até 120 minutos após a chegada à UCPA. CONCLUSÕES: A administração de Dex tem a vantagem de uma redução no SA e na ED, sem quaisquer efeitos adversos. Dex proporcionou uma recuperação satisfatória em lactentes submetidos à palatoplastia.