Effect of dexmedetomidine in children undergoing general anesthesia with sevoflurane: a meta-analysis / Efeito da dexmedetomidina em crianças submetidas à anestesia geral com sevoflurano

Abstract Background and objectives: Sevoflurane is often used in pediatric anesthesia and is associated with high incidence of psychomotor agitation. In such cases, dexmedetomidine (DEX) has been used, but its benefit and implications remain uncertain. We assessed the effects of DEX on agitation in children undergoing general anesthesia with sevoflurane. Method: Meta-analysis of randomized clinical and double-blind studies, with children undergoing elective procedures under general anesthesia with sevoflurane, using DEX or placebo. We sought articles in English in PubMed database using the following terms: Dexmedetomidine, sevoflurane (Methyl Ethers/sevoflurante), and agitation (Psychomotor Agitation). Duplicate articles with children who received premedication and used active control were excluded. It was adopted random effects model with DerSimonian-Laird testing and odds ratio (OR) calculation for dichotomous variables, and standardized mean difference for continuous variables, with their respective 95% confidence interval (CI). Results: Of 146 studies identified, 10 were selected totaling 558 patients (282 in DEX group and 276 controls). The use of DEX was considered a protective factor for psychomotor agitation (OR = 0.17; 95% CI 0.13-0.23; p < 0.0001) and nausea and vomiting in PACU (OR = 0.49; 95% CI 0.35-0.68; p < 0.0001). Wake-up time and PACU discharge time were higher in the dexmedetomidine group. There was no difference between groups for extubation time and duration of anesthesia. Conclusion: Dexmedetomidine reduces psychomotor agitation during wake-up time of children undergoing general anesthesia with sevoflurane.

Resumo Justificativa e objetivos: Sevoflurano é frequentemente usado em anestesia pediátrica e está associado à alta incidência de agitação psicomotora ao despertar. Nesses casos a dexmedetomidina (dex) tem sido usada, porém permanecem incertos seus benefícios e suas implicações. Foram avaliados os efeitos da dex sobre a agitação no despertar de crianças submetidas à anestesia geral com sevoflurano. Método: Metanálise de ensaios clínicos randomizados e duplamente encobertos, com crianças submetidas a procedimentos eletivos sob anestesia geral com sevoflurano, que usaram dex ou placebo. Buscaram-se artigos em língua inglesa na base de dados Pubmed com termos como Dexmedetomidine, sevoflurane (Methyl Ethers/sevoflurane) e agitation (Psychomotor Agitation). Artigos duplicados, com crianças que receberam medicação pré-anestésica e que usaram controle ativo foram excluídos. Adotou-se modelo de efeitos aleatórios com testes de DerSimonian-Laird e cálculo de odds ratio (OR) para variáveis dicotômicas e diferença de média padronizada para variáveis contínuas, com seus respectivos intervalos de confiança de 95% (IC). Resultados: Dos 146 estudos identificados, 10 foram selecionados, com 558 pacientes (282 no grupo dex e 276 controles). O uso da dex foi considerado fator de proteção para agitação psicomotora (OR = 0,17; 95% IC 0,13-0,23; p < 0,0001) e para náuseas e vômitos na SRPA (OR = 0,49; 95% IC 0,35-0,68; p < 0,0001). Tempo para despertar e para alta da SRPA foram maiores no grupo dexmedetomidina. Não houve diferença entre os grupos para tempo de extubação e duração da anestesia. Conclusão: A dexmedetomidina reduz a agitação psicomotora no despertar de crianças submetidas à anestesia geral com sevoflurano.

Effects of micro-Opioid Receptor Gene Polymorphism on Postoperative Nausea and Vomiting in Patients Undergoing General Anesthesia with Remifentanil: Double Blinded Randomized Trial

Association between postoperative nausea and vomiting (PONV) and micro-opioid receptor A118G single nucleotide polymorphism (SNP) is undefined and might underlie inconsistent results of studies on PONV occurrence in patients undergoing general anesthesia with the opioid, remifentanil. Four hundred and sixteen Korean women undergoing breast surgery with general anesthesia were randomized to receive remifentanil 10 ng/mL (plasma-site, Minto model) using a target-controlled infusion device and either propofol for total intravenous anesthesia (T group) or sevoflurane for inhalation anesthesia (I group) with bispectral index values maintained between 40 and 60. Blood specimens were collected after anesthesia induction for A118G SNP analysis. PONV and postoperative pain were evaluated. A118G SNP type distribution among Korean female adults studied was AG (n=195)>AA (n=158)>GG (n=63). Regardless of anesthetic technique, patients with GG types had lower PONV scale on arrival at postoperative care unit (PACU) (P=0.002), while T group showed lower PONV scale than I group up to 6 hr after PACU discharge in AA and AG types. No differences were apparent for postoperative pain among opioid receptor polymorphism. PONV occurrence differs according to opioid receptor polymorphism and anesthetic technique in patients undergoing general anesthesia with remifentanil.

Propofol or sevoflurane anaesthesia does not affect hepatic integrity as assessed by the M30 & M65 cell death markers & liver enzymes.

Background & objectives: General anaesthetics may induce apoptosis. The pro-apoptotic/necrotic markers M30 (caspase-cleaved cytokeratin-18) and M65 (intact cytokeratin-18) have been used to identify early apoptosis in liver disease. The aim of this study was to detect the effect of propofol and sevoflurane anaesthesia on these markers and blood transaminase levels in female patients undergoing elective surgery. Methods: Sixty-seven women undergoing mastectomy or thyroidectomy under general anaesthesia were randomly allocated to the propofol or sevoflurane groups. Venous blood samples for measuring the apoptotic and necrotic markers M30 and M65 as well as for measuring the alanine aminotransferase (ALT) and the aspartate aminotransferase (AST) liver enzymes were collected before induction of anaesthesia, immediately after completion of surgery, and 24 and 48 h postoperatively. Results. The M30 values preoperatively and 0, 24 and 48 h postoperatively were 280±229, 300±244, 267±198 and 254±189 U/l in the propofol group and 237±95, 242±109, 231±94 and 234±127 U/l in the sevoflurane group, respectively. The M30 values did not differ within or between the groups. The M65 levels at the same time intervals were 470±262, 478±271, 456±339 and 485±273 in the propofol group and 427±226, 481±227, 389±158 and 404±144 U/l in the sevoflurane group, respectively. No significant changes were found in the M65 either within or between the propofol and the sevoflurane groups. The ALT and AST levels did not change at these time intervals. Interpretation & conclusions: Under the present study design propofol or sevoflurane anaesthesia did not induce apoptosis or affected the liver function as assessed by the M30, M65 markers and liver enzymes in patients undergoing mastectomy or thyroidectomy under general anaesthesia.

Comparison of Emergence Time in Children Undergoing Minor Surgery According to Anesthetic: Desflurane and Sevoflurane

PURPOSE: In earlier analyses, desflurane has been shown to reduce average extubation time and the variability of extubation time by 20% to 25% relative to sevoflurane in adult patients. We undertook this study to determine which agents prompt less recovery time in pediatric patients undergoing minor surgery. MATERIALS AND METHODS: After obtaining Institutional Review Board approval, we retrospectively reviewed the anesthesia records of 499 patients, with an average age of 5 years, who underwent minor surgeries at Severance Eye and Ear, Nose and Throat Hospital between May 2010 and April 2011. Anesthesia was induced with propofol and rocuronium. Anesthesia was maintained with sevoflurane (n=340) or desflurane (n=159) with 50% air/O2. Time from cessation of anesthetics to recovery of self-respiration, eye opening on verbal command and extubation were compared between the two groups. Additionally, the incidences of postoperative respiratory adverse events were also compared. RESULTS: Times to self-respiration recovery, eye opening on verbal command, and extubation were significantly faster in the desflurane group than the sevoflurane group (4.6+/-2.5 min vs. 6.9+/-3.8 min, 6.6+/-3.0 min vs. 9.2+/-3.6 min, and 6.2+/-2.7 min vs. 9.3+/-3.7 min, respectively, p<0.005). There were no statistically significant differences between the two groups with respect to adverse respiratory events during the peri-operative period (38.2% vs. 34.6%, p=0.468). CONCLUSION: Emergence and recovery from anesthesia were significantly faster in the desflurane group of children undergoing minor surgery. Desflurane did not result in any differences in respiratory adverse events during recovery compared to sevoflurane.

Kidney Function in Living Donors Undergoing Nephrectomy by Sevoflurane or Desflurane Anesthesia

PURPOSE: Although there is no clinical evidence of nephrotoxicity with the volatile anesthetics currently used in general anesthesia, a better agent should be needed in terms of preserving postoperative renal function in living kidney donors who have only single remaining kidney. The purpose of the current retrospective, single-center study was to evaluate and compare renal function of living kidney donors after nephrectomy under either sevoflurane or desflurane anesthesia. MATERIALS AND METHODS: From January 2006 through December 2011, a total of 228 donors undergoing video assisted minilaparotomy surgery nephrectomy for kidney donation were retrospectively enrolled in the current study. The donors were categorized into a sevoflurane group or desflurane group based on the type of volatile anesthetic used. We collected laboratory data from the patients preoperatively, immediately after the operation, on the first postoperative day and on the third postoperative day. We also compared renal function of the kidney donors after donor nephrectomy by comparing creatinine level and estimated glomerular filtration rate (eGFR). RESULTS: The decrease in renal function after surgery in both groups was the most prominent on the first postoperative day. There were no significant differences between the two groups in postoperative changes of creatinine or eGFR. CONCLUSION: Sevoflurane and desflurane can be used safely as volatile anesthetics in donors undergoing nephrectomy.

Sudden Cardiac Arrest during Anesthesia in a 30-Month-Old Boy with Syndactyly: A Case of Genetically Proven Timothy Syndrome

Timothy syndrome, long QT syndrome type 8, is highly malignant with ventricular tachyarrhythmia. A 30-month-old boy had sudden cardiac arrest during anesthesia induction before plastic surgery for bilateral cutaneous syndactyly. After successful resuscitation, prolonged QT interval (QTc, 0.58-0.60 sec) and T-wave alternans were found in his electrocardiogram. Starting beta-blocker to prevent further tachycardia and collapse event, then there were no more arrhythmic events. The genes KCNQ1, KCNH2, KCNE1 and 2, and SCN5A were negative for long QT syndrome. The mutation p.Gly406Arg was confirmed in CACNA1C, which maintains L-type calcium channel depolarization in the heart and other systems.

Movimientos convulsivos durante la inducción inhalatoria con sevoflurano / Convulsive movements during inhalational induction with sevoflurane

La inducción inhalatoria con sevoflurano se ha asociado con actividad epileptógena y movimientos convulsivos. Se diseñó un estudio para determinar la incidencia de movimientos convulsivos durante la inducción inhalatoria con sevoflurano y sus posibles factores de riesgo. Para llevar a cabo estos objetivos, desde marzo a julio de 2011 se solicitó a los anestesiólogos de Clínica Dávila registrar la ocurrencia de movimientos convulsivos en todo paciente en que se realizara inducción inhalatoria con sevoflurano, en el período comprendido entre la etapa III de la anestesia y la inyección de drogas endovenosas. El tamaño muestral calculado fue de 400 pacientes para obtener un intervalo de confianza de 95 por ciento con un error menor a 2,5 por ciento. Se obtuvo información de 405 pacientes con una mediana de edad de 4 años (rango: 2 días a 16 años de edad), predominantemente hombres y ASA I. La incidencia de convulsiones fue de 3,5 por ciento (IC 95 por ciento: 1,9 por ciento; 5,7 por ciento) y fueron más frecuentes en mujeres (5,9 por ciento versus 2 por ciento en hombres, p = 0,039). En conclusión, la incidencia de convulsiones durante la inducción inhalatoria con sevoflurano fue de 3,5 por ciento y su único factor de riesgo fue pertenecer al género femenino...

Introduction: Mask induction with Sevoflurane has been associated with epileptic form changes of the EEG and sometimes with tonic-clonic movements. Objectives: To determine the incidence rate of convulsive movements during the induction of anesthesia with Sevoflurane and its risk factors. Methods: From march 1st to july 31st 2011, we asked to the anesthesiologists of our institution to watch the occurrence of tonic-clonic movements during Sevoflurane induction, after the loss of eyelash reflex and before the injection of intravenous drugs. The sample size was calculated in 400 patients to obtain a 95 percent confidence interval with an error lesser than 2.5 percent. Results: We obtain data from 405 patients with a median age of 4 years old (range 2 days to 16 years old), predominantly males and ASA physical status I. The incidence rate of convulsions was 3.5 percent (CI 95 percent 1.9; 5.7), more frequent in females (5.9 percent versus 2.0 percent in males, p = 0.039). Conclusions: The incidence rate of convulsions during inhalatory induction with Sevoflurane was 3.5 percent and associated to female gender...

Avaliação da indução, recuperação, agitação ao despertar e consumo com uso de duas marcas de sevoflurano para anestesia ambulatorial / Assessment of induction, recovery, agitation upon awakening, and consumption with the use of two brands of sevoflurane for ambulatory anesthesia / Evaluación de la inducción, recuperación, agitación al despertar y consumo con el uso de dos marcas de sevoflurano para la anestesia ambulatorial

JUSTIFICATIVA E OBJETIVOS: O sevoflurano por suas características farmacológicas é o anestésico ideal para procedimentos de curta duração. Existem duas marcas de sevoflurano no mercado brasileiro, o Sevocris® e Sevorane®, com diferentes formulações e envasamento. O objetivo deste estudo foi analisar se existem diferenças entre os dois anestésicos na indução, manutenção, recuperação e consumo. MÉTODO: Foram incluídas 130 crianças dividas em dois grupos segundo a marca do agente utilizado: Grupo 1 sevoflurano da Cristália® e Grupo 2 da Abbott®. Foram analisados os seguintes parâmetros: frequência cardíaca, pressão arterial sistólica e diastólica, fração inspirada e expirada de sevoflurano, valores de BIS, temperatura timpânica, tempos de indução e recuperação, agitação ao despertar pela escala PAED e consumo do anestésico por pesagem dos vaporizadores. A indução foi realizada com 1 CAM e incrementadas a cada três movimentos respiratórios em 0,5 CAM, até no máximo 3 CAM. RESULTADO: Não houve diferença entre os grupos quanto ao tempo de procedimento e de anestesia e nos parâmetros avaliados na indução. No Grupo 1, o número de crianças que necessitaram bolus adicionais de sevoflurano na manutenção da anestesia foi maior que no 2 (p < 0,05). A fração inspirada e expirada de sevoflurano no final do procedimento foi menor no Grupo 1 (p < 0,001). No momento do despertar o valor do BIS foi menor no Grupo 1 (p = 0,045). Outros parâmetros avaliados na recuperação não mostraram diferença entre os grupos. O consumo de anestésico foi semelhante entre os grupos.

BACKGROUND AND OBJECTIVES: Due to its pharmacological characteristics, sevoflurane is the ideal anesthetic for short-duration procedures. There are two brands of sevoflurane in the Brazilian market, Sevocris® and Sevorane®, with different formulations and packaging. The objective of this study was to assess whether there are differences between the two anesthetics regarding induction, maintenance, recovery, and consumption. METHODS: One hundred and thirty children were included, divided into two groups according to the brand used: Group 1 was assigned to sevoflurane Cristália® and Group 2 to sevoflurane Abbott®. The following parameters were assessed: heart rate, systolic and diastolic blood pressure, fraction of inspired and expired sevoflurane, BIS values, tympanic temperature, induction and recovery time, agitation upon awakening measured by the PAED scale, and anesthetic consumption by weighing the vaporizers. Anesthesia was induced with 1 MAC and increased every three breaths at 0.5 MAC, up to 3 MAC. RESULTS: There was no difference between groups regarding the duration of the procedure, the anesthesia, and the parameters evaluated at induction. In Group 1, the number of children who required additional bolus of sevoflurane for anesthesia maintenance was higher than in Group 2 (p < 0.05). The fraction of inspired and expired sevoflurane at the end of the procedure was lower in Group 1 (p < 0.001). Upon awakening, BIS value was lower in Group 1 (p = 0.045). Other parameters evaluated in recovery showed no difference between groups. The use of anesthesia was similar between groups.

JUSTIFICATIVA Y OBJETIVOS: El sevoflurano, por sus características farmacológicas, es el anestésico ideal para procedimientos de corta duración. Existen dos marcas de sevoflurano en el mercado brasileño, el Sevocris® y el Sevorane®, con diferentes formulaciones y envases. El objetivo de este estudio, fue analizar si existen diferencias entre los dos anestésicos en la inducción, mantenimiento, recuperación y consumo. MÉTODO: Se incluyeron 130 niños divididos en dos grupos según la marca del agente utilizado: Grupo 1 sevoflurano de Cristália® y Grupo 2 de Abbott®. Se analizaron los siguientes parámetros: frecuencia cardíaca, presión arterial sistólica y diastólica, fracción inspirada y espirada de sevoflurano, valores de BIS, temperatura timpánica, tiempos de inducción y recuperación, agitación al despertar por la escala PAED, y consumo del anestésico por pesaje de los vaporizadores. La inducción fue realizada con 1 CAM e incrementada a cada tres movimientos respiratorios en 0,5 CAM, hasta el máximo de 3 CAM. RESULTADO: No hubo diferencia entre los grupos en cuanto al tiempo de procedimiento y de anestesia y en los parámetros evaluados en la inducción. En el Grupo 1, el número de niños que necesitaron bolos adicionales de sevoflurano en el mantenimiento de la anestesia, fue mayor que en el 2 (p < 0,05). La fracción inspirada y espirada de sevoflurano al final del procedimiento fue menor en el Grupo 1 (p < 0,001). Al momento del despertar, el valor del BIS fue menor en el Grupo 1 (p = 0,045). Otros parámetros evaluados en la recuperación no arrojaron diferencia entre los grupos. El consumo de anestésico fue similar entre los grupos.

The Effects of a Single Bolus of Remifentanil on Corrected QT Interval Change during Sevoflurane Induction

PURPOSE: Opioids may affect changes in the corrected QT interval (QTc) during anesthetic induction. This study examine whether a single bolus of remifentanil would prolong QTc after laryngeal mask airway (LMA) insertion during sevoflurane induction. MATERIALS AND METHODS: Forty women of American Society of Anesthesiologists physical status 1 (ASA PS1) undergoing gynecological surgery were studied. All patients were induced using three vital capacity inhalation inductions with 5% sevoflurane. Two minutes after induction, the inspiratory concentration of sevoflurane was reduced to 2%. Using double-blinded randomization, patients were allocated into one of two groups, receiving either saline (placebo group, n = 20) or 0.25 microg.kg-1 remifentanil (remifentanil group, n = 20) over a period of thirty seconds. Sixty seconds later, LMA insertion was performed. Recordings were taken with a 12-lead electrocardiogram at baseline, 2 min after induction and 1 and 3 min after LMA insertion. QTc was calculated by Bazett's formula. The mean arterial pressure (MAP) and heart rate (HR) were also measured at each time point. RESULTS: The QTc interval was significantly prolonged in the placebo group as compared to the remifentanil group at 1 min after LMA insertion (467.8 +/- 16.5 vs. 442.7 +/- 21.3 ms, p < 0.001). However, there was no significant difference in QTc at 3 min after LMA insertion between the two groups. MAP and HR were significantly higher in the placebo group (p < 0.001). CONCLUSION: A single bolus of remifentanil is safe method to attenuate prolonged QTc associated with insertion of LMA.

The effects of volatile induction and maintenance of anesthesia and selective spinal anesthesia on QT interval, QT dispersion, and arrhythmia incidence

OBJECTIVE: The effects of sevoflurane general anesthesia and bupivacaine selective spinal anesthesia on QT dispersion (QTd) and corrected QT (QTc) interval were investigated. METHODS AND MATERIALS: This prospective, randomized, double-blind study was conducted between July and September 2009 in the Urology and General Surgery operating rooms. Forty ASA I-II patients undergoing noncardiac surgery were randomized into two groups: Group R (n=20) and Group V (n=20). In Group R, 5 mg bupivacaine was administered into the spinal space. Anesthesia induction in Group V was established with sevoflurane + 0.1 mg/kg vecuronium using the maximum vital capacity technique. Anesthesia was maintained with 2-3 percent sevoflurane + 50 percent N2O/O2 inhalation. All patients were tested with a 24-hour Holter ECG device. QT, QTc, and QTd intervals were measured using 12-lead ECG records at 1 and 3 minutes during preinduction, postinduction, postincision and postextubation periods. Mean arterial pressure (MAP), heart rate and ECG records were measured simultaneously. RESULTS: None of the patients displayed arrhythmia. There was no significant difference between the groups with regard to QTd values (p>0.05). However, QTc was longer in Group V than in Group R after the induction of anesthesia at 3 minutes, after the intubation at 1 and 3 minutes, and after the incision at 1 and 3 minutes. MAP and heart rate were generally higher in Group V (p<0.05). CONCLUSION: Although Volatile Induction and Maintenance of Anesthesia (VIMA) with sevoflurane might prolong the QTc interval and did not result in arrhythmia, selective spinal anesthesia with bupivacaine was not associated with alterations in the QT interval or arrhythmia.

Sevoflurane causes less arrhythmias than desflurane after off-pump coronary artery bypass grafting: A pilot study.

Background: Volatile anesthetics provide myocardial protection during cardiac surgery. Sevoflurane and desflurane are both efficient agents that allow immediate extubation after off-pump coronary artery bypass grafting (OPCABG). This study compared the incidence of arrhythmias after OPCABG with the two agents. Materials and Methods: Forty patients undergoing OPCABG with immediate extubation and perioperative high thoracic analgesia were included in this controlled, double-blind study; anesthesia was either provided using 1 MAC of sevoflurane (SEVO-group) or desflurane (DES-group). Monitoring of perioperative arrhythmias was provided by continuous monitoring of the EKG up to 72 hours after surgery, and routine EKG monitoring once every day, until time of discharge. Patient data, perioperative arrhythmias, and myocardial protection (troponin I, CK, CK-MB-ratio, and transesophageal echocardiography examinations) were compared using t-test, Fisher's exact test or two-way analysis of variance for repeated measurements; P < 0.05. Results: Patient data and surgery-related data were similar between the two groups; all the patients were successfully extubated immediately after surgery, with similar emergence times. Supraventricular tachycardia occurred only in the DES-group (5 of 20 patients), atrial fibrillation was significantly more frequent in the DES group versus SEVO-group, at five out of 20 versus one out of 20 patients, respectively. Myocardial protection was equally achieved in both groups. Discussion: Ultra-fast track anesthesia using sevoflurane seems more advantageous than desflurane for anesthesia, for OPCABG, as it is associated with significantly less atrial fibrillation or supraventricular arrhythmias after surgery.

A comparison of the effects of desflurane, sevoflurane and propofol on QT, QTc, and P dispersion on ECG.

The aim of this prospective, randomized, and double-blinded study was to compare the effects of desflurane, sevoflurane, propofol on both atrial and ventricular wall function by measurement of QT dispersion (QTd), corrected QT dispersion (QTcd), and P dispersion (Pd) on electrocardiogram (ECG). Forty-six patients from the American Society of Anesthesiologists class I−II undergoing noncardiac surgery, were enrolled in this study. Patients were randomly allocated to receive desflurane, sevoflurane or propofol anesthesia. ECG recordings were taken before and after 5 minutes of drug administration. Induction with desflurane significantly increased the QTd compared to baseline (38 ± 2 ms vs. 62 ± 6 ms, P < 0.05). Sevoflurane and propofol anesthesia was not associated with any changes in QTd. QTcd was increased with desflurane induction and decreased with sevoflurane and propofol induction, but this decrease was only significant in the propofol group (67 ± 5 ms vs. 45 ± 3 ms, P < 0.05). Pd was significantly increased after induction with desflurane (34 ± 3 vs. 63 ± 6 ms, P < 0.05). There was a significant increase in QTd and Pd in desflurane group, but this increment did not cause any dangerous arrhythmias. QTcd significantly decreased in propofol group. We believe that further investigations are required for using desflurane as safe as sevoflurane and propofol in noncardiac surgery patients who have high cardiac arrhythmia and ischemia risk.

Sevoflurane for central venous catheterization in non-intubated neonates.

OBJECTIVE: Sedation in neonates undergoing invasive prodedures as central venous catheterization (CVC) remains contro versial. Sevoflurane is an inhaled anesthetic whose periods of action and elimination are very short. The objective of this study was to evaluate the use of sevoflurane for sedation for central venous catheterization (CVC) in non-intubated neonates and preterms. METHODS: Thirty three (33) consecutive patients (range: 1-31 days old, 26 to 40 weeks GA, weighing 580 to 3200 g) were included over a 4 months period. Sevoflurane was progressively increased, until loss of consciousness and motor response to stimulation. FiO(2), heart rate (HR), mean arterial pressure (MAP), duration of the procedure and the ease of the procedure were recorded. RESULTS: HR was very stable, but MAP dropped significantly. No patient required intubation. The ease of the procedure was scored as average 13 times and excellent 20 times. CONCLUSION: The use of sevoflurane in neonates for CVC is feasible and achieve the goals of procedural sedation. The pharmacokinetic of sevoflurane enabled rapid adjustment of the depth of sedation. Sevoflurane appears to be a new agent at the disposal of neonatologists. Its use does not come without risks, especially for smaller preterms, which the treating clinician must anticipate.

Combination effect of low dose fentanyl and propofol on emergence agitation in children following sevoflurane anesthesia

To investigate the combination effect of low dose fentanyl and subhypnotic dose of propofol on emergence agitation in children receiving sevoflurane for adenotonsillectomy procedure. After ethical approval, a prospective, randomized, clinical study was performed in Saad Specialist Hospital, Al-Khobar, Kingdom of Saudi Arabia in 2007-2008. One hundred and twenty children in physical status of I according to the American Society of Anesthesiologists, aged 2-6 years, scheduled for adentonsillectomy under general anesthesia were allocated into 3 groups randomly. Anesthesia was induced and maintained by sevoflurane in all groups. Children received 0.1 ml.kg-1 normal saline at the end of surgery in group C [n=40], 1.5 mcg.kg-1 fentanyl during induction, and 0.1 ml.kg-1 normal saline at the end of surgery in group F [n=40], and 1.5 mcg.kg-1 fentanyl during induction and 1 mg.kg-1 propofol at the end of surgery in group FP [n=40]. Postoperative agitation was recorded, if any, for the first postoperative hour. Three groups were comparable with regard to demographic data. Twenty-one patients [53%] in the control group, 14 patients [35%] in group F and 7 [18%] patients in group FP experienced postoperative agitation. The combination of low dose fentanyl before surgery and propofol at the end of surgery decreases the incidence and level of emergence agitation in children after adenotonsillectomy procedure under sevoflurane anesthesia

Hepatocellular integrity during sevoflurane anesthesia with induced hypotension

The effect of sevoflurane anesthesia with or without induced hypotension on hepatocellular integrity was studied. Forty adult consented patients scheduled for various urological procedures were allocated randomly to either NTG group [nitroglycerin-induced hypotension] or a control group of twenty patients each. Anesthesia was induced and maintained by fentanyl, sevoflurane and vecuronium in both groups. In NTG group, nitro-glycerin infusion was adjusted to maintain mean arterial pressure [MAP] of 50-65 mm Hg. Specific and sensitive hepatic biomarkers; alpha [alpha] and pi [pi] glutathione S-transferases [GST] and hyaluronic acid [HA], also traditional liver enzymes; aspartate [AST] and alanine [ALT] aminotransferases were measured at: TO [pre-induction], T1, T2, T3 [15, 30 and 60 minutes after MAP stabilization respectively] and T4 [24 hours after anesthesia end]. Plasma alpha-GST significantly increased at T3 in control group [p < 0.05] and in NTG group [p < 0.01] compared to T0 in same group. In NTG group, hyaluronic acid con-centrations was significantly increased at T1, T2 [p < 0.05] and T3 [p < 0.01] from T0. Compared to control group, alpha- GST and HA concentrations showed significant increases in NTG group at T3 with p < 0.05 then returned back to normal range at T4. But, pi-GST, AST and ALT showed no significant changes throughout the study in both groups

Incidence and risk factors of emergence agitation in pediatric patients after general anesthesia.

OBJECTIVE: To study the incidence and evaluate factors associated with emergence agitation (EA) in pediatrics after general anesthesia. MATERIAL AND METHOD: A prospective observational study was conducted in 250 pediatric patients aged 2-9 years, who received general anesthesia for various operative procedures in Maharaj Nakorn Chiang Mai Hospital between October 2006 and September 2007. The incidence of EA was assessed Difficult parental-separation behavior, pharmacologic and non-pharmacologic interventions, and adverse events were also recorded Univariate and multivariate analysis were used to determine the factors associated with EA. A p-value of less than 0.05 was considered significant. RESULTS: One hundred and eight children (43.2%) had EA, with an average duration of 9.6 +/- 6.8 minutes. EA associated with adverse events occurred in 32 agitated children (29.6%). From univariate analysis, factors associated with EA were difficult parental-separation behavior, preschool age (2-5 years), and general anesthesia with sevoflurane. However; difficult parental-separation behavior; and preschool age were the only factors significantly associated with EA in the multiple logistic regression analysis with OR = 3.021 (95% CI = 1.680, 5.431, p < 0.001) and OR = 1.857 (95% CI = 1.075, 3.206, p = 0.026), respectively. CONCLUSION: The present study indicated that the incidence of EA was high in PACU. Preschool children and difficult parental-separation behavior were the predictive factors of agitation on emergence. Therefore, anesthesia personnel responsible for pediatric anesthesia should have essential skills and knowledge to effectively care for children before, during, and after an operation, including implementing the methods that minimize incidence of EA.