Document Type : Original Article
Authors
- . Anindya Mukherjee 1
- . Anjan Das 2
- . Sandip Roy Basunia 2
- . Surajit Chattopadhyay 2
- . Ratul Kundu 3
- . Raghunath Bhattacharyya 2
1 Department of Anaesthesiology, N.R.S Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Anaesthesiology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
3 Department of Anaesthesiology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
Abstract
Objective: Emergence agitation (EA), a short‑lived, self‑limiting phenomenon, arises
frequently after the use of inhalational agents and hampers the implementation of pediatric
ambulatory surgery in spite of using so many drugs with variable efficacy.
Methods: In this prospective, double‑blinded, parallel group study (2008–2009), 80 children
of both sex aged 3–7 years, with American Society of Anesthesiologists (ASA) physical status
grade I-II, undergoing sevoflurane‑based general anesthesia for elective day care surgery
were randomly assigned into groups C or D. Group C received 4 µg/kg intranasal clonidine,
whereas group D received 1 µg/kg intranasal dexmedetomidine, 45 min before induction of
anesthesia. In postanesthesia care unit (PACU), the incidence of EA was assessed with Aonos
four‑point scale and the severity of EA was assessed with pediatric anesthesia emergence
delirium scale upon admission (T0), after 5 min (T5), 15 min (T15), and 25 min (T25).
Extubation time, emergence time, duration of PACU stay, dose and incidence of fentanyl
use for pain control were noted.
Findings: Based on comparable demographic profiles, the incidence and severity of EA
were significantly lower in group D as compared to group C at T0, T5, T15, and T25. But
time of regular breathing, awakening, extubation, and emergence were significantly delayed in
group D than C. The number and dose of fentanyl used in group C were significantly higher
than group D. PACU and hospital stay were quite comparable between groups.
Conclusion: Intranasal dexmedetomidine 1 µg/kg was more effective than clonidine
4 µg/kg in decreasing the incidence and severity of EA, when administered 45 min before the
induction of anesthesia with sevoflurane for pediatric day care surgery. Dexmedetomidine
also significantly reduced fentanyl consumption in PACU.
Keywords
- Sikich N, Lerman J. Development and psychometric evaluation
of the pediatric anesthesia emergence delirium scale.
Anesthesiology 2004;100:1138‑45.
2. Tomal CR, Silva AG, Yamashita AM, Andrade PV, Hirano MT,
Tardelli MA, et al. Assessment of induction, recovery, agitation
upon awakening, and consumption with the use of two brands
of sevoflurane for ambulatory anesthesia. Rev Bras Anestesiol
2012;62:154‑72.
3. Welborn LG, Hannallah RS, Norden JM, Ruttimann UE,
Callan CM. Comparison of emergence and recovery
characteristics of sevoflurane, desflurane, and halothane in
pediatric ambulatory patients. Anesth Analg 1996;83:917-20.
4. Silva LM, Braz LG, Módolo NS. Emergence agitation in
pediatric anesthesia: Current features. J Pediatr (Rio J)
2008;84:107-13.
5. Veyckemans F. Excitation phenomena during sevoflurane
anaesthesia in children. Curr Opin Anaesthesiol 2001;14:339-43.
6. Kim D, Doo AR, Lim H, Son JS, Lee JR, Han YJ, et al. Effect
of ketorolac on the prevention of emergence agitation in
children after sevoflurane anesthesia. Korean J Anesthesiol
2013;64:240‑5.
7. Sajedi P, Baghery K, Hagibabie E, Mehr AM. Prophylactic use
of oral acetaminophen or IV dexamethasone and combination
of them on prevention emergence agitation in pediatric after
adenotonsillectomy. Int J Prev Med 2014;5:721‑7.
8. Inomata S, Maeda T, Shimizu T, Satsumae T, Tanaka M.
Effects of fentanyl infusion on tracheal intubation and
emergence agitation in preschool children anaesthetized with
sevoflurane. Br J Anaesth 2010;105:361‑7.
9. Lee JR, Kim MS, Moon BE, Kim H. Comparison of propofol
and fentanyl for preventing emergence agitation in children.
Br J Anaesth 2013;111:121-2.
10. Tazeroualti N, De Groote F, De Hert S, De Villé A,
Dierick A, Van der Linden P. Oral clonidine vs midazolam in
the prevention of sevoflurane‑induced agitation in children.
A prospective, randomized, controlled trial. Br J Anaesth
2007;98:667-71.
11. Ali MA, Abdellatif AA. Prevention of sevoflurane
related emergence agitation in children undergoing
adenotonsillectomy: A comparison of dexmedetomidine and
propofol. Saudi J Anaesth 2013;7:296-300.
12. Kulka PJ, Bressem M, Tryba M. Clonidine prevents
sevoflurane-induced agitation in children. Anesth Analg
2001;93:335-8.
13. Bock M, Kunz P, Schreckenberger R, Graf BM, Martin E,
Motsch J. Comparison of caudal and intravenous clonidine
in the prevention of agitation after sevoflurane in children.
Br J Anaesth 2002;88:790-6.
14. Ibacache ME, Muñoz HR, Brandes V, Morales AL. Single-dose
dexmedetomidine reduces agitation after sevoflurane
anesthesia in children. Anesth Analg 2004;98:60-3.
15. Guler G, Akin A, Tosun Z, Ors S, Esmaoglu A, Boyaci A.
Single-dose dexmedetomidine reduces agitation and provides
smooth extubation after pediatric adenotonsillectomy.
Paediatr Anaesth 2005;15:762‑6.
16. Isik B, Arslan M, Tunga AD, Kurtipek O. Dexmedetomidine
decreases emergence agitation in pediatric patients after
sevoflurane anesthesia without surgery. Paediatr Anaesth
2006;16:748‑53.
17. Shukry M, Clyde MC, Kalarickal PL, Ramadhyani U. Does
dexmedetomidine prevent emergence delirium in children
after sevoflurane‑based general anesthesia? Paediatr Anaesth
2005;15:1098‑104.
18. Saklad M. Grading of patients for surgical procedures.
Anesthesiology 1941;2:281-4.
19. Aldrete JA. The post-anesthesia recovery score revisited. J Clin
Anesth 1995;7:89‑91.
20. Davis PJ, Cohen IT, McGowan FX Jr, Latta K. Recovery
characteristics of desflurane versus halothane for maintenance
of anesthesia in pediatric ambulatory patients. Anesthesiology
1994;80:298-302.
21. Aono J, Ueda W, Mamiya K, Takimoto E, Manabe M.
Greater incidence of delirium during recovery from
sevoflurane anesthesia in preschool boys. Anesthesiology
1997;87:1298-300.
22. Dahmani S, Stany I, Brasher C, Lejeune C, Bruneau B,
Wood C, et al. Pharmacological prevention of sevoflurane‑
and desflurane-related emergence agitation in children:
A meta-analysis of published studies. Br J Anaesth
2010;104:216-23.
23. Maze M, Tranquilli W. Alpha-2 adrenoceptor agonists:
Defining the role in clinical anesthesia. Anesthesiology
1991;74:581‑605.
24. Verner L, Hartmann M, Seitz W. Clonidine supplemented
analgesia and sedation in prevention of postoperative
delirium. Anasth Intensivther Notfallmed 1990;25:274‑80.
25. Ip Yam PC, Forbes A, Kox WJ. Clonidine in the treatment of
alcohol withdrawal in the intensive care unit. Br J Anaesth
1992;68:106-8.
26. Almenrader N, Passariello M, Coccetti B, Haiberger R,
Pietropaoli P. Steal-induction after clonidine premedication:
A comparison of the oral and nasal route. Paediatr Anaesth
2007;17:230-4.
27. Huang R, Hertz L. Receptor subtype and dose dependence
of dexmedetomidine-induced accumulation of [14C]
glutamine in astrocytes suggests glial involvement in its
hypnotic‑sedative and anesthetic‑sparing effects. Brain Res
2000;873:297-301. - 28. Yuen VM, Irwin MG, Hui TW, Yuen MK, Lee LH. A double-blind,
crossover assessment of the sedative and analgesic effects of
intranasal dexmedetomidine. Anesth Analg 2007;105:374‑80.
29. Srivastava U, Sarkar ME, Kumar A, Gupta A,
Agarwal A, Singh TK, et al. Comparison of clonidine and
dexmedetomidine for short-term sedation of intensive care
unit patients. Indian J Crit Care Med 2014;18:431-6.
30. Di M, Huang C, Chen F, Zeng R, Yu C, Shangguan W, et al.
Effect of single‑dose dexmedetomidine on recovery profiles
after sevoflurane anesthesia with spontaneous respiration
in pediatric patients undergoing cleft lip and palate repair.
Zhonghua Yi Xue Za Zhi 2014;94:1466-9.
31. Ham SY, Kim JE, Park C, Shin MJ, Shim YH. Dexmedetomidine
does not reduce emergence agitation in adults following
orthognathic surgery. Acta Anaesthesiol Scand 2014;58:955‑60.
32. Zhang C, Hu J, Liu X, Yan J. Effects of intravenous
dexmedetomidine on emergence agitation in children under
sevoflurane anesthesia: A meta-analysis of randomized
controlled trials. PLoS One 2014;9:e99718.
33. Sun L, Guo R, Sun L. Dexmedetomidine for preventing
sevoflurane-related emergence agitation in children:
A meta-analysis of randomized controlled trials. Acta
Anaesthesiol Scand 2014;58:642‑50.
34. Heinmiller LJ, Nelson LB, Goldberg MB, Thode AR. Clonidine
premedication versus placebo: Effects on postoperative
agitation and recovery time in children undergoing strabismus
surgery. J Pediatr Ophthalmol Strabismus 2013;50:150‑4.
35. Malviya S, Voepel‑Lewis T, Ramamurthi RJ, Burke C, Tait AR.
Clonidine for the prevention of emergence agitation in young
children: Efficacy and recovery profile. Paediatr Anaesth
2006;16:554‑9
)