Association of dexmedetomidine use with haemodynamics, postoperative recovery, and cost in paediatric anaesthesia: a hospital registry study.

BACKGROUND: Dexmedetomidine utilisation in paediatric patients is increasing. We hypothesised that intraoperative use of dexmedetomidine in children is associated with longer postanaesthesia care unit length of stay, higher healthcare costs, and side-effects. METHODS: We analysed data from paediatric patients (aged 0-12 yr) between 2016 and 2021 in the Bronx, NY, USA. We matched our cohort with the Healthcare Cost and Utilization Project-Kids' Inpatient Database (HCUP-KID). RESULTS: Among 18 104 paediatric patients, intraoperative dexmedetomidine utilisation increased from 51.7% to 85.7% between 2016 and 2021 (P<0.001). Dexmedetomidine was dose-dependently associated with a longer postanaesthesia care unit length of stay (adjusted absolute difference [ADadj] 19.7 min; 95% confidence interval [CI]: 18.0-21.4 min; P<0.001, median length of stay of 122 vs 98 min). The association was magnified in children aged ≤2 yr undergoing short (≤60 min) ambulatory procedures (ADadj 33.3 min; 95% CI: 26.3-40.7 min; P<0.001; P-for-interaction <0.001). Dexmedetomidine was associated with higher total hospital costs of USD 1311 (95% CI: USD 835-1800), higher odds of intraoperative mean arterial blood pressure below 55 mm Hg (adjusted odds ratio [ORadj] 1.27; 95% CI: 1.16-1.39; P<0.001), and higher odds of heart rate below 100 beats min-1 (ORadj 1.32; 95% CI: 1.21-1.45; P<0.001), with no preventive effects on emergence delirium requiring postanaesthesia i.v. sedatives (ORadj 1.67; 95% CI: 1.04-2.68; P=0.034). CONCLUSIONS: Intraoperative use of dexmedetomidine is associated with unwarranted haemodynamic effects, longer postanaesthesia care unit length of stay, and higher costs, without preventive effects on emergence delirium.

Dexmedetomidine in paediatric anaesthesia: a call for action?

Dexmedetomidine is increasingly used in paediatric anaesthesia practice. In this issue of the British Journal of Anaesthesia, a retrospective hospital registry study in anaesthetised children showed that intraoperative use of dexmedetomidine was dose-dependently associated with a longer postanaesthesia care unit length of stay. Dexmedetomidine administration was also associated with higher total hospital costs and higher odds of unwarranted haemodynamic effects, while the onset of emergence delirium was not reduced. Although these results could curb enthusiasm for paediatric use of dexmedetomidine, they might also trigger discussion about our approach in the postoperative period to children having received dexmedetomidine intraoperatively.

Intravenous MELAtonin for prevention of Postoperative Agitation and Emergence Delirium in children (MELA-PAED): A protocol and statistical analysis plan for a randomized clinical trial.

BACKGROUND: Emergence agitation and delirium in children remain a common clinical challenge in the post-anesthetic care unit. Preoperative oral melatonin has been suggested as an effective preventive drug with a favorable safety profile. The oral bioavailability of melatonin, however, is low. Therefore, the MELA-PAED trial aims to investigate the efficacy and safety of intraoperative intravenous melatonin for the prevention of emergence agitation in pediatric surgical patients. METHODS: MELA-PAED is a randomized, double-blind, parallel two-arm, multi-center, superiority trial comparing intravenous melatonin with placebo. Four hundred participants aged 1-6 years will be randomized 1:1 to either the intervention or placebo. The intervention consists of intravenous melatonin 0.15 mg/kg administered approximately 30 min before the end of surgery. Participants will be monitored in the post-anesthetic care unit (PACU), and the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS) will be performed on days 1, 7, and 14 after the intervention. Serious Adverse Events (SAE) will be assessed up to 30 days after the intervention. RESULTS: The primary outcome is the incidence of emergence agitation, assessed dichotomously as any Watcha score >2 during the participant's stay in the post-anesthetic care unit. Secondary outcomes are opioid consumption in the post-anesthetic care unit and adverse events. Exploratory outcomes include SAEs, postoperative pain, postoperative nausea and vomiting, and time to awakening, to first oral intake, and to discharge readiness. CONCLUSION: The MELA-PAED trial investigates the efficacy of intravenous intraoperative melatonin for the prevention of emergence agitation in pediatric surgical patients. Results may provide further knowledge concerning the use of melatonin in pediatric perioperative care.

Association between emergence delirium and brain status parameters in children undergoing general anesthesia: A prospective observational study.

INTRODUCTION: Emergence delirium is a common postoperative neurological complication in children after general anesthesia. There is no valid tool to predict emergence delirium. Wavelet index, pain threshold index, anxiety index, and comfort index are real-time brain status parameters extracted from the electroencephalogram, which have recently been developed. The aim is to evaluate the association between real-time brain status parameters during emergence and emergence delirium in children undergoing general anesthesia. METHODS: One hundred and thirty patients between 3 and 6 years of age undergoing dental surgery under general anesthesia were enrolled in the study. Real-time electroencephalogram data were recorded at four different time points from end of anesthetics administration (T1), end of surgery (T2), extubation (T3), and response (eye opening, movement) to verbal stimulation (T4). Each patient was assessed for emergence delirium using the Pediatric Anesthesia Emergence Delirium scale. Receiver operating characteristics curves and the associated areas under the curves were computed to analyze the ability of wavelet index, pain threshold index, anxiety index, and comfort index to predict emergence delirium. RESULTS: One hundred and sixteen patients were included for final analysis. During recovery from general anesthesia, brain status parameters increased significantly from T1 (wavelet index, 59.5 ± 6.2; pain threshold index, 61.7 ± 5.3; anxiety index, 9.2 ± 2.5; comfort index, 21.6 ± 8.7) to T4 (wavelet index, 67.4 ± 9.4; pain threshold index, 73.2 ± 9.1; anxiety index, 38.6 ± 11.2; comfort index, 66.1 ± 16.5; p < .001). To predict emergence delirium, areas under the curves [95% CI] for anxiety index were 0.84 [0.75-0.93] (p < .001), and comfort index was 0.89 [0.81-0.96] (p < .001). The Pediatric Anesthesia Emergence Delirium scale scores of 37 patients were higher than 10 indicating emergence delirium, and the incidence of emergence delirium was 31.90%. The sensitivity and specificity of anxiety index with corresponding cutoff values in predicting emergence delirium were 73.0% and 89.9%, and the sensitivity and specificity of comfort index in predicting emergence delirium were 91.9% and 83.5%. The best cutoff values for anxiety index and comfort index to predict emergence delirium were 46.5 and 68.5, respectively. The areas under the curves [95% CI] of wavelet index to predict emergence delirium were 0.43 [0.31-0.35] (p = .27), while the areas under the curves [95% CI] of pain threshold index to predict emergence delirium were 0.49 [0.37-0.62] (p = .73). DISCUSSION: Both anxiety index and comfort index derived from electroencephalogram wavelet analysis were associated with emergence delirium in pediatric patients undergoing general anesthesia for dental surgery. Wavelet index and pain threshold index were not associated with emergence delirium during general anesthesia for dental surgery in children. CONCLUSIONS: AnXi and CFi might be used to guide anesthesiologists to identify and intervene ED in children.

Global prevalence and risk factors of emergence delirium in pediatric patients undergoing general anesthesia: A systemic review and meta-analysis.

PROBLEM: Emergence delirium (ED) in children post-general anesthesia has been persistently underestimated, impacting the well-being of children, nurses, and even parents. This study employs integrated analysis to establish a comprehensive understanding of ED, including its occurrence and related risk factors, emphasizing the imperative for enhanced awareness and comprehension among pediatric nursing care providers. ELIGIBILITY CRITERIA: A systematic review and meta-analysis were conducted using four electronic databases, namely PubMed, CINAHL via EBSCOhost, Embase via Elsevier, and ProQuest Dissertations and Theses. RESULTS: This meta-analysis included 16 studies involving 9598 children who underwent general anesthesia. The pooled prevalence of ED was 19.2% (95% confidence interval [CI] = 0.12 to 0.29), with younger patients exhibiting a higher prevalence of ED. ED research is scant in Africa and is mostly limited to the Asia Pacific region and Northern Europe. Neck and head surgery (odds ratio [OR] = 2.34, 95% CI = 1.29 to 4.27) were significantly associated with ED risk. CONCLUSIONS: ED should be monitored in children who receive general anesthesia. In this study, ED had a prevalence rate of 19.2%, and head and neck surgery were significantly associated with ED risk. Therefore, healthcare professionals should carefully manage and prevent ED in children undergoing general anesthesia. IMPLICATIONS: A comprehensive understanding of ED's prevalence and risk factors is crucial for enhancing nursing care. Adopting a family-centered care approach can empower parents with information to collaboratively care for their children, promoting a holistic approach to pediatric healthcare.

Non-pharmacological interventions for preventing emergence delirium in children under general anesthesia: A scoping review.

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.

Association of preoperative neutrophil-lymphocyte ratios with the emergence delirium in pediatric patients after tonsillectomy and adenoidectomy: an observational prospective study.

PURPOSE: The study aimed to investigate potential risk factors for emergence delirium (ED) in pediatric patients after tonsillectomy and adenoidectomy (T&A). METHODS: This prospective, single-center observational study enrolled children aged 3-7 years who underwent T&A under general anesthesia. ED was assessed according to DSM-IV or V criteria. Receiver operating characteristic curve analysis was performed to evaluate the predicative and cut-off values of risk factors, including age, preoperative anxiety level, postoperative pain and neutrophil-lymphocyte ratio (NLR) for ED. Univariate and multivariate logistic regression analyses were performed to investigate risk factors for ED. RESULTS: 94 pediatric patients who underwent T&A were enrolled and 19 developed ED (an incidence of 25.3%). Receiver operating characteristic analysis indicated that preoperative NLR was a significant predictor of ED with a cut-off value of 0.8719 and an area under the curve (AUC) of 0.671 (95% confidence interval (CI) 0.546-0.796, P = 0.022). Preoperative NLR (< 0.8719) and postoperative pain were independent risk factors associated with ED (odds ratio: 0.168, 95% CI 0.033-0.858, P = 0.032; odds ratio: 7.298, 95% CI 1.563-34.083, P = 0.011) according to multivariate logistic regression analysis. CONCLUSIONS: Preoperative NLR level and postoperative pain were independent risk factors for ED in pediatric patients undergoing T&A.

Prophylaxis for paediatric emergence delirium in desflurane-based anaesthesia: a network meta-analysis.

PURPOSE: The prevalence of postoperative emergence delirium in paediatric patients (pedED) following desflurane anaesthesia is considerably high at 50-80%. Although several pharmacological prophylactic strategies have been introduced to reduce the risk of pedED, conclusive evidence about the superiority of these individual regimens is lacking. The aim of the current study was to assess the potential prophylactic effect and safety of individual pharmacotherapies in the prevention of pedED following desflurane anaesthesia. METHODS: This frequentist model network meta-analysis (NMA) of randomized controlled trials (RCTs) included peer-reviewed RCTs of either placebo-controlled or active-controlled design in paediatric patients under desflurane anaesthesia. RESULTS: Seven studies comprising 573 participants were included. Overall, the ketamine + propofol administration [odds ratio (OR) = 0.05, 95% confidence intervals (95%CIs) 0.01-0.33], dexmedetomidine alone (OR = 0.13, 95%CIs 0.05-0.31), and propofol administration (OR = 0.30, 95%CIs 0.10-0.91) were associated with a significantly lower incidence of pedED than the placebo/control groups. In addition, only gabapentin and dexmedetomidine were associated with a significantly higher improvement in the severity of emergence delirium than the placebo/control groups. Finally, the ketamine + propofol administration was associated with the lowest incidence of pedED, whereas gabapentin was associated with the lowest severity of pedED among all of the pharmacologic interventions studied. CONCLUSIONS: The current NMA showed that ketamine + propofol administration was associated with the lowest incidence of pedED among all of the pharmacologic interventions studied. Future large-scale trials to more fully elucidate the comparative benefits of different combination regimens are warranted. TRIAL REGISTRATION: PROSPERO CRD42021285200.

Dexmedetomidine - An Alternative to Midazolam in the Treatment of Ketamine-Induced Emergence Delirium: A Systematic Review.

PURPOSE: Analyze the effectiveness of dexmedetomidine compared to midazolam for the treatment of ketamine-induced emergence delirium in noncardiac surgical patients. DESIGN: Systematic review. METHODS: Guidelines outlined in the Preferred Reporting Items For Systematic Reviews and Meta-analyses (PRISMA)22 were used for this review. PubMed, Cumulative Index To Nursing And Allied Health Literature (CINAHL), MEDLINE, The Cochrane Library, EBSCOhost, National Institute of Health clinical trials, Google Scholar, and gray literature were searched for relevant studies. Only peer-reviewed nonexperimental studies, quasi-experimental studies, and randomized control trials with or without meta-analysis were included. The evidence was assessed using the Johns Hopkins Nursing Evidence-Based Practice guidelines for quality ratings and evidence level. FINDINGS: Five blinded randomized controlled trials, three quasi-experimental studies, and two retrospective nonexperimental studies comprised of 1,024 subjects were evaluated for this review. Dexmedetomidine was more effective at reducing ketamine-induced delirium in adult patients, although midazolam attenuated the psychomimetic effects of ketamine better in pediatric patients. Furthermore, postanesthesia care unit discharge times were similar between patients treated with dexmedetomidine and midazolam. The studies in this review were categorized as Level I, Level II, or Level III and rated Grade A, implying strong confidence in the actual effects of dexmedetomidine in all outcome measures of the review. CONCLUSIONS: The current evidence suggests that dexmedetomidine is an effective alternative for alleviating ketamine-induced delirium in noncardiac adult surgical patients. Multiple studies in this review noted improved hemodynamics and reduced postoperative analgesic requirements after administration of dexmedetomidine in conjunction with ketamine.

The Impact of Parental Presence on Emergence Delirium in Pediatric Patients After General Anesthesia: A Systematic Review and Meta-analysis.

PURPOSE: This study reviewed existing literature on parental presence in cases of pediatric patients after general anesthesia and explored its effect on emergence delirium (ED) in the postanesthesia care unit (PACU). DESIGN: Systematic review and meta-analysis. METHODS: After protocol registration, we searched the PubMed, EMBASE, CINHAL, Web of Science, SCOPUS, and CENTRAL databases. Two authors independently searched and selected the relevant studies, assessed their risk of bias, and abstracted the data. The primary outcome was ED, and the additional outcome was pain. We provided the narrative synthesis and meta-analysis results. FINDINGS: Of the 296 articles retrieved, 6 were included in the narrative synthesis, and 5 were used for the meta-analysis. Four studies were randomized controlled trials, and two studies were nonrandomized controlled trials. There were 348 pediatric patients in the parental presence group and 314 pediatric patients in the usual care group. Parental presence effectively reduced the ED score (mean difference, -0.58; 95% confidence interval [CI], -0.84 to -0.31; P < .001). The ED incidence rate (log odds ratio, -0.58; 95% CI, -1.24 to 0.09; P = .090) and pain score (standardized mean difference, -0.24; 95% CI, -0.57 to 0.10; P = .163) were lower in the parental presence group than in the usual care group. However, the differences were not statistically significant. CONCLUSIONS: The presence of parents in the PACU can reduce ED in pediatric patients. Therefore, parental presence may be a useful intervention in the PACU.

Does Postanesthesia Forced-Air Warming Affect Emergence Delirium in Pediatric Patients Receiving Daily Anesthesia?

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.

The Effect of Different Propofol-Ketamine Combinations on Emergence Delirium in Children Undergoing Adenoidectomy and Tonsillectomy Surgery.

PURPOSE: Emergence delirium (ED) after sevoflurane anesthesia remains a serious issue in children. We aimed to compare different ratios of propofol-ketamine combinations to determine a better option for preventing ED. DESIGN: A prospective, randomized clinical trial. METHODS: In this study, 112 children aged between 3 and 12 years who underwent adenoidectomy and tonsillectomy were recruited. Propofol 1 mg kg-1 + ketamine 1 mg kg-1 (1:1 ratio), propofol 1.5 mg kg-1 + ketamine 0.75 mg kg-1 (2:1 ratio), propofol 2 mg kg-1 + ketamine 0.66 mg kg-1 (3:1 ratio), and propofol 3 mg kg-1 were applied at induction of anesthesia for Groups I, II, III, and IV, respectively. Fentanyl 1 mcg kg-1 and rocuronium 0.6 mg kg-1 were applied at induction, and anesthesia was maintained with sevoflurane and O2/N2O mixture for all participants. Intravenous morphine 0.1 mg kg-1 was applied for postoperative analgesia in the last 10 minutes of surgery. ED was defined as a Watcha score of ≥3. Demographics, hemodynamics, extubation time, Watcha scores, the Face, Legs, Activity, Cry, and Consolability scores, length of stay in the postanesthesia care unit (PACU), rescue analgesic requirement, and postoperative complications were recorded. FINDINGS: ED was significantly higher at 10 and 20 minutes in Group IV. Eighteen children experienced ED in PACU, (3, 2, 2, and 11 children in Groups I, II, III, and IV, respectively). Face, Legs, Activity, Cry, and Consolability scores were significantly different at all times. Rescue analgesics were required by 3 children (10.7%) in Group I, 2 (7.1%) in Group II, 2 (7.1%) in Group III, and 10 (35.7%) in Group IV (P = .012). The PACU stay was 21.9 ± 6.4 in Group I, 18.7 ± 6.3 in Group II, 16.7 ± 5.8 in Group III, and 17.4 ± 5.8 in Group IV. Nystagmus was observed in three children in Group I. CONCLUSIONS: To addition of ketamine to propofol during the induction of sevoflurane anesthesia can reduce the ED and analgesic requirements in children. A propofol-to-ketamine ratio of 3:1 provided better postoperative recovery with less pain and ED, without prolonging the PACU length of stay.

Effect of video distraction on preoperative anxiety scores in pediatric patients undergoing general anesthesia in ophthalmic daycare procedures: A randomized controlled trial.

Background and Aims: Parental separation, fear, and exposure to the operating room environment lead to stress and anxiety in pediatric patients. This study aims to identify the research gaps in the effect of video distraction on pediatric patients of Indian origin. We hypothesized that video distraction along with parental presence would reduce preoperative anxiety in pediatric patients undergoing ophthalmic procedures under general anesthesia compared with parental presence alone. Material and Methods: In this prospective randomized trial, 145 patients aged 2-8 years, ASA I-II, with at least one functional eye undergoing elective ophthalmic daycare procedures were enrolled. They were randomly allocated to two Groups: Group V had distraction by watching a video/playing a video game together with parental presence, whereas control Group C had parental presence alone without any video distraction. The primary objective of the study was to compare preoperative anxiety using the Modified Yale Preoperative Anxiety score (mYPAS) and heart rate (HR), whereas the secondary objective was to compare child fear, emergence delirium, and parental satisfaction between the two groups. The three time points for intergroup comparisons were the preoperative holding area 10 min before induction (T0), transport of the child to the operating room (T1), and face mask introduction (T2). Results: There was a statistically significant difference between mYPAS score in groups V and C at all time points (P = 0.036, P = 0.0001, P = 0.0000), parental satisfaction score at all three time points (P = 0.0049, P = 0.0000, P = 0.0000), and Child Fear Score at T1 and T2 (P = 0.0001, P = 0.0001, respectively). However, there was no statistically significant difference in the emergence of delirium between the two groups. Conclusions: Video distraction together with parental presence has a promising role for implementation in hospitals with heavy workload settings where pharmacological intervention would not be feasible, to alleviate preoperative anxiety in children. However, preoperative anxiety may not translate into increased postoperative emergence delirium as was earlier believed.

Risk of esketamine anesthesia on the emergence delirium in preschool children after minor surgery: a prospective observational clinical study.

Emergence delirium (ED) is a common mental complication during recovery from anesthesia. However, studies on the effects of esketamine, an intravenous anesthetic for pediatrics, on ED are still lacking. This study aimed to investigate the effects of a single-dose of esketamine during anesthesia induction on ED after minor surgery in preschool children. A total of 230 children (aged 2-7 years) completed the study. The exposed group (0.46 mg kg-1: average dose of esketamine) was associated with an increased incidence of ED and a higher maximum Pediatric Anesthesia Emergence Delirium score than the non-exposed group. The length of post-anesthesia care unit stay was longer in the exposed group than the non-exposed group. In contrast, extubation time, face, legs, activity, cry, and consolability (FLACC) scores, and the proportions of rescue analgesics were comparable between the two groups. Furthermore, five factors, including preoperative anxiety scores, sevoflurane and propofol compared with sevoflurane alone for anesthesia maintenance, dezocine for postoperative analgesia, FLACC scores, and esketamine exposure, were associated with ED. In conclusion, a near-anesthetic single-dose of esketamine for anesthesia induction may increase the incidence of ED in preschool children after minor surgery. The use of esketamine in preschool children for minor surgery should be noticed during clinical practice.

Nasal splinting and mouth breathing training reduce emergence delirium after endoscopic sinus surgery: a randomized controlled trial.

BACKGROUND: Emergence delirium (ED) is generally occurred after anesthesia associated with increased risks of long-term adverse outcomes. Therefore, this study aimed to evaluate the efficacy of preconditioning with nasal splint and mouth-breathing training on prevention of ED after general anesthesia. METHODS: This randomized controlled trial enrolled 200 adult patients undergoing ESS. Patients were randomized to receive either nasal splinting and mouth breathing training (n = 100) or standard care (n = 100) before surgery. The primary outcome was the occurrence of ED within 30 min of extubation, assessed using the Riker Sedation-Agitation Scale. Logistic regression identified risk factors for ED. RESULTS: Totally 200 patients were randomized and 182 aged from 18 to 82 years with 59.9% of males were included in the final analysis (90 in C-group and 92 in P-group). ED occurred in 16.3% of the intervention group vs. 35.6% of controls (P = 0.004). Male sex, smoking and function endoscopic sinus surgery (FESS) were independent risk factors for ED. CONCLUSIONS: Preoperative nasal splinting and mouth breathing training significantly reduced the incidence of emergence delirium in patients undergoing endoscopic sinus surgery. TRIAL REGISTRATION: ChiCTR1900024925 ( https://www.chictr.org.cn/index.aspx ) registered on 3/8/2019.

A successful awake pediatric neurosurgery procedure following, 3 months after, a previous failure due to an emergence agitation: a case report.

Awake neurosurgery in children may sometimes require conversion to general anesthesia. We present here the case of a first failed awake procedure for epilepsy surgery. After adapting the anesthesia protocol (sedation + hypnosis) and acceptance by the patient, the surgeons operated the child in good conditions a few months later. We believe that it is possible to retry awake neurosurgery after a first failure if its analysis showed modifiable causes.

Comparison of intravenous and inhalation anesthesia on postoperative behavior changes in children undergoing ambulatory endoscopic procedures: A randomized clinical trial.

BACKGROUND: Early and delayed behavioral changes are well recognized after anesthesia. Intravenous anesthesia may prevent emergence delirium. However, it has not been evaluated as a preventive strategy for delayed postoperative behavior changes. AIMS: We aimed to determine whether intravenous anesthesia is effective at reducing postoperative behavior changes in children undergoing ambulatory endoscopic procedures when compared to inhalation anesthesia. METHODS: This randomized, double-blinded controlled trial was approved by the local IRB. Children aged 1-12 years who underwent ambulatory endoscopic procedures were recruited. Preoperative anxiety was evaluated through the modified Yale Preoperative Anxiety Scale. All children underwent face mask inhalation induction with sevoflurane. After a peripheral line was placed, each child was allocated to sevoflurane or propofol maintenance. Emergence delirium was evaluated through the Pediatric Anesthesia Emergence Delirium scale. The child was discharged home, and behavioral changes were assessed through the Posthospitalization Behavior Questionnaire for Ambulatory Surgery on Days 1, 7, and 14. RESULTS: Overall, 175 children were enrolled. On Day 1 after the procedure, 57 children presented at least one negative behavior. On Days 7 and 14, 49 and 44 children presented at least one negative behavior, respectively. The median number of negative behaviors was similar between the groups. Post hoc analyses showed a moderate correlation between emergence delirium and negative postoperative behavior on Day 7 (r = .34; p = <.001) and an increase of 3.31 (95% CI 1.90; 4.36 p < .001) points in the mean summed score of new negative behaviors for individuals with emergence delirium. CONCLUSION: The incidence of postoperative behavior changes in children undergoing ambulatory endoscopic procedures was similar when comparing intravenous with inhalation anesthesia. Children who experience emergence delirium might show a greater incidence of negative postoperative behavior changes.

The effect of intranasal dexmedetomidine administration on emergence agitation or delirium in pediatric patients after general anesthesia: A meta-analysis of randomized controlled trials.

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.

Monitoring anesthesia depth with patient state index during pediatric surgery.

BACKGROUND: Monitoring anesthesia depth in children is challenging. Pediatric anesthesiologists estimate general anesthesia depth using indirect methods such as pharmacokinetic models and neurovegetative reflexes. The application of processed electroencephalography may help to identify the correct anesthesia depth (i.e., patient state index between 25 and 50). AIMS: To determine the median values of patient state index and spectral edge frequency 95% in children undergoing general anesthesia conducted according to indirect evaluation of depth. The relationships between patient state index and spectral edge frequency 95% and indirect monitoring of anesthesia depth, type of anesthesia, age subgroups, and postoperative delirium were also assessed. METHODS: A prospective observational study on children (aged 1-18 years) undergoing surgery longer than 60 min. The SedLine monitor and the novel SedLine pediatric sensors (Masimo Inc., Irvine California) were applied. Patient state index levels were recorded for the duration of the anesthesia until the discharge to the ward at predefined time points. RESULTS: In the 111 enrolled children, median patient state index level at the end of anesthesia induction was 25 (22-32) and ranged from 26 (23-34) to 28 (25-36) in the maintenance phase. Patient state index at extubation was 48 (35-60) and 69 (62-75) at discharge from the operatory room. Median right/left spectral edge frequency 95% values at the end of induction were 10 (6-14)/9 (5-14) Hz and median right/left spectral edge frequency 95% values in the maintenance phase ranged from 10 (6-14) to 12 (11-15) Hz in both hemispheres. At extubation, right/left spectral edge frequency 95% levels were 18 (15-21)/17 (15-21) Hz. We observed 39 episodes of burst suppression in 20 patients (19%). Median patient state index levels were not different between patients undergoing inhalational and intravenous anesthesia and between those undergoing general anesthesia and general anesthesia added to locoregional anesthesia. Children <2 years displayed significantly higher patient state index levels than older patients (p = .0004). The presence of a burst suppression episode was not associated with PAED levels (OR 1.58, 95% CI 0.14-16.74, p` = .18). CONCLUSIONS: NonpEEG-guided anesthesia in children led to median patient state index levels at the low range of recommended unconsciousness values with frequent episodes of burst suppression. Patient state index levels were generally higher in children below 2 years.

Effects of virtual tour on perioperative pediatric anxiety.

BACKGROUND: There is a high incidence of perioperative anxiety in the pediatric population, with adverse side effects, such as emergency delirium and maladaptive postoperative behaviors. AIMS: The study's objective was to compare the level of preoperative anxiety in children after standard preparation plus a virtual tour of the operating room vs. standard preparation alone. PATIENTS/METHODS: This was a prospective single-center, randomized, controlled, blinded trial with parallel assignment, registered as NCT04043663. Eligible subjects were healthy children (ASA I-II) aged 4-12, scheduled for outpatient surgery. Five visits were conducted during the study, two at the hospital and three over the phone. Variables assessed were child's anxiety through the modified Yale Perioperative Anxiety Scale, demographic data, cooperation with induction through the Induction Compliance Checklist, preoperative parental anxiety through the State-Trait Anxiety Inventory and Anxiety Visual Analog Scale, the postoperative delirium degree through the Pediatric Anesthesia Emergence Delirium Scale, the presence of behavioral changes through the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery, and the overall parental satisfaction. RESULTS: A total of 125 participants were included; 61 (48.8%) of them were randomized to the Virtual Tour Group (VT+) and 64 (51.2%) to the Non-virtual Tour Group (VT-). Yale Preoperative Anxiety Scale results in VT+ vs. VT- were mean 27.26 vs. 32.57, and median 23.4 (CI 95% 23.4-23.4) vs. 23.4 (CI 95% 23.4-33.4), (p = .0086). In the VT+ group, satisfaction was higher for questions one (p = .0213), three (p = <.0001), and four (p = .0130). Throughout the study, we observed a significant reduction in perioperative anxiety in the VT+ group, facilitating anesthetic induction in perfect (p = .018) and moderate compliance (p = .0428). The other variables did not show statistically significant differences. CONCLUSION: Our study confirms previous studies that found virtual tours for perioperative patients may reduce perioperative anxiety and improve satisfaction. We found no impact on longer-term outcomes.