Quebec 2012

2012 Canadian Journal of Anesthesia  
Emergence delirium (ED) refers to a variety of behavioral disturbances including restlessness, agitation, inconsolability and struggling, commonly seen in children following emergence from anesthesia . The incidence of ED in children may be as high as 40% . Sevoflurane is associated with the highest incidence of ED . Propofol has been shown to reduce ED in children compared with sevoflurane-only anesthesia , but these studies have confounding factors such as sedative pre-medication,
more » ... ve designs and poorly validated ED outcome tools. We used a well-validated ED outcome tool to assess ED after a sevoflurane anesthetic (SEVO) compared with a total intravenous anesthetic (TIVA) using propofol. Pre-op induction behavior and postop pain were also measured. 1 2,3 1 4,5 Methods: Following REB approval in this randomized, double-blind study, we recruited 112 children, ASA I-II, aged 2 and 6 yr, undergoing elective strabismus repair. Subjects were assigned to either the SEVO or TIVA arm and all received an oral pre-med of acetaminophen 20 mg/kg and ibuprofen 10 mg/kg. TIVA subjects received an intravenous (IV) induction of anesthesia with propofol 5-10 mg/kg and remifentanil 2.5-5 g/kg followed by a maintenance infusion of propofol 200 g/kg/min and remifentanil 0.1 g/kg/min, then titrated by the clinician. SEVO subjects received an inhalational induction of anesthesia with 70% N O in 30% O mixture by mask for 60 sec followed by incremental increases in sevoflurane (1-7%) and maintained by titrating sevoflurane to an end tidal value of 2.5%. The airway was maintained using a laryngeal mask airway (LMA). Topical tetracaine and fentanyl 1 mcg/kg IV and were administered for analgesia. Fentanyl 0.5 mcg/kg IV was repeated Q30 min. Induction behaviour was scored using the Perioperative Adult Child Behavior Interaction Scale (PACBIS). Post-op scoring began at LMA removal and continued for 35 min. Every 5 min, a masked investigator assessed ED using the Pediatric Anesthesia Emergence Delirium (PAED) Scale and pain using the face, legs, activity, cry, consolability (FLACC) scale. A positive ED outcome was a PAED 10. 2 2 Results: An interim analysis was performed per protocol. Data are reported for 94 subjects; 18 were excluded (1 failed IV, 17 protocol deviations). Recovery outcomes are reported in Table 1 . Incidence of ED was higher with SEVO (38.3%) vs TIVA (14.9%) (Fisher exact, P=0.02). Based on this result, the trial was discontinued following recruitment of 50% of planned subjects. There was no difference in the median PACBIS score between arms. A higher maximum FLACC score (Mann-Whitney, P=0.033) was seen with SEVO (median 3) vs TIVA (median 1). Subjects experiencing ED had higher maximum FLACC scores (median 7) vs those unaffected by ED (median 1). Discussion: There was a lower incidence of ED after TIVA. Both IV and inhalational inductions were similarly well tolerated without pre-operative anxiolysis. Higher FLACC scores were measured in the SEVO arm. There was a positive correlation between FLACC and PAED scales.
doi:10.1007/s12630-012-9785-6 pmid:23055032 fatcat:puufbogbi5bolazh2kptqew7uq