Prevention and Therapy of Pediatric Emergence Delirium: A National Survey.

INTRODUCTION: Although pediatric emergence delirium (ED) is common, preventive and therapeutic pharmacological treatment is the matter of an international controversial discussion and evidence on different options is partially vague. OBJECTIVE: We therefore examined clinical routine in prevention strategies and postoperative therapy of ED with respect to clinical experience in pediatric anesthesia. METHODS: A web-based survey was developed investigating routine management (prevention and treatment) of ED, facility structure, and patient population. The link was sent to all enlisted members of the German Society of Anesthesiology. RESULTS: We analyzed 1229 questionnaires. Overall, 88% reported ED as a relevant clinical problem; however, only 5% applied assessment scores to define ED. Oral midazolam was reported as standard premedication by 84% of respondents, the second largest group was 'no premedication' (5%). The first choice prevention strategy was to perform total intravenous (propofol) anesthesia (63%). The first choice therapeutic pharmacological treatment depended on clinical experience. Therapeutic propofol was preferentially chosen by more experienced anesthesiologists (5 to >20 patients per week, n = 538), while lesser experienced colleagues (<5 patients per week, n = 676) preferentially applied opioids. Dexmedetomidine (1%) and non-pharmacological (2%) therapy were rarely stated. The highest satisfaction levels for pharmacological therapy of ED were attributed to propofol. CONCLUSIONS: Propofol is the preferred choice for pharmacological prevention and treatment of ED among German anesthesiologists. Further therapy options as well as alternatives to a midazolam-centered premedication procedure are underrepresented.

Combined vs. Isoflurane/Fentanyl anesthesia for major abdominal surgery: Effects on hormones and hemodynamics.

BACKGROUND: Combination of epidural and general anesthesia (combined anesthesia) avoids the intraoperative use of intravenous analgesics and may reduce the surgical stress response during major abdominal surgery. This study examines the differences in intraoperative hemodynamic stability, cortisol levels and activity of cardiovascular hormones between combined anesthesia and isoflurane/fentanyl anesthesia. MATERIAL/METHODS: Sixty ASA I-II patients were prospectively randomized to receive either combined anesthesia, i.e, isoflurane anesthesia combined with thoracic epidural analgesia (bolus of 12 ml 0.2% ropivacaine containing 1 microg/ml sufentanil 30 min before incision, followed by continuous infusion at 6 ml/h) or isoflurane/fentanyl anesthesia (IV fentanyl as required) for major abdominal surgery. Depth of anesthesia was monitored using Bispectral Index. Administration of fluids and of vasopressors was directed by a standardized protocol. Blood samples for angiotensin II, vasopressin, catecholamines, and cortisol were drawn before anesthesia, after induction (but before using the epidural catheter), and 40 min after skin incision. RESULTS: After induction of anesthesia, mean arterial pressure decreased by 12-20 mmHg in both groups and angiotensin-II concentrations increased. Vasopressin increased predominantly after opening the abdomen in both groups. Under combined anesthesia, intraoperative epinephrine and cortisol concentrations were considerably lower. Intraoperative crystalloid fluid substitution, blood loss and urine output did not differ between groups. There were more hypotensive periods and the demand for colloids and low-dose continuous norepinephrine was greater under combined anesthesia. CONCLUSIONS: Combined anesthesia reduces the intraoperative stress response, but moderate hemodynamic instability is relatively common and has to be compensated for by adequate volume replacement and vasopressor support.