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Departments of Anesthesiology and Pediatrics, Children’s National Medical Center and George Washington University Medical Center, Washington, DC
Address correspondence and reprint requests to Ira Todd Cohen, MD, Department of Anesthesiology, Children’s National Medical Center, 111 Michigan Ave., NW, Washington, DC 20010. Address e-mail to icohen{at}cnmc.org
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Abstract |
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IMPLICATIONS: The concurrent use of fentanyl in a dose of 2.5 µg/kg in children receiving desflurane or sevoflurane results in a low incidence of emergence agitation. Desflurane allows for a more rapid emergence and recovery than sevoflurane.
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Introduction |
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Methods |
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Patients were not premedicated. Anesthesia was induced with an inhaled technique consisting of nitrous oxide/oxygen (70%:30%) and sevoflurane. An IV catheter was placed, mivacurium 0.25 mg/kg was given to facilitate endotracheal intubation, and the previously calculated mean effective dose of fentanyl (2.5 µg/kg) was given. Ondansetron 0.1 mg/kg was given to reduce the incidence of postoperative nausea and vomiting. For anesthesia maintenance, patients were randomly assigned to receive either desflurane 4%–6% or sevoflurane 1.5%–2.0% with N2O 2 L/min and O2 1 L/min via the endotracheal tube. Ventilation was controlled to maintain an end-tidal CO2 of 35 ± 4 mm Hg. Vital signs were monitored and recorded throughout the study. Standard monitoring included electrocardiogram, blood pressure cuff, pulse oximeter, temperature, and end-tidal gas measurements.
At the completion of surgery, defined as the time when the mouth gag was removed, desflurane or sevoflurane and nitrous oxide were discontinued simultaneously. Controlled ventilation was continued at the same settings and a total gas flow of 3 L/min of oxygen, without any attempt to stimulate the patient. With the return of the cough reflex, patients were allowed to breathe spontaneously. When patients demonstrated recovery of neuromuscular function and complete emergence from anesthesia by displaying a regular respiratory pattern, facial grimacing, and purposeful movement, they were tracheally extubated and transferred to the PACU. An observer who was blinded to the anesthetic used, recorded time to first cough, facial grimacing, purposeful movement, eye opening, and extubation. Agitation was scored on a 3-point scale (1 = calm, 2 = agitated but consolable, 3 = severely agitated, inconsolable). Pain was assessed by using the objective pain scale (10) and recovery was determined by using the Steward recovery score (11) by the same observer. Times until the child was ready for discharge from the PACU (Steward recovery score = 6) to the short stay (Phase 2) recovery unit (SSRU), and from the SSRU to home were recorded. Each patient was contacted 24 h after surgery to follow up on the incidence of agitation, pain, and vomiting at home.
A power analysis determined the total number of observations needed to be 88 by comparing both the range of emergence times and the mean incidence of emergence agitation controlling for the probability of Type I and Type II errors. Emergence agitation was the primary endpoint using an incidence of previously published results. The sample size was increased by 5% to allow for the use of nonparametric tests and another 5% for attrition protection.
Statistical analysis of the results was preformed by using the SAS software (12) (SAS, Cary, NC), and the significance tests used were the Student’s t-test and Kruskal-Wallis test when comparing the demographic data and the measured time intervals. Nonparametric data including sex, agitation scores, pain scores, and the incidence of vomiting were compared by using 
2 analysis and Fisher’s exact test. All tests were considered significant if P < 0.05.
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Results |
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6), and vomiting were similar between the two groups (Table 3).
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Discussion |
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In our previous study, the dose of fentanyl effective in reducing emergence agitation in desflurane-anesthetized children was determined by implementing the classic up-down method (9). Using the same age group, surgical procedure, extubation criteria, and emergence behavior scales, we observed similar emergence times and incidence of emergence agitation in this study. When comparing the incidence of severe agitation between the 2 treatment groups, no significance difference (P = 0.624) was found. Approximately 20% of all patients were assessed to have severe emergence agitation.
There was a statistically significant delay in meeting emergence criteria, extubation, and PACU discharge in the Sevoflurane group as compared with the Desflurane group. We found that emergence was faster with desflurane than sevoflurane by approximately three to five minutes. Similar results and times have been reported in adults (17). This amount of time in a busy, rapid turnover surgical setting can be particularly important in high acuity/high cost areas as the operating room and PACU. In an operation that is typically <30 minutes, a 10% prolongation of emergence can be important.
The lack of any difference between the treatment groups in the time to be discharged to home is not surprising. With average time to discharge being approximately two hours and multiple factors (such as nursing care, patient willingness to drink, walk, and get dressed, and parental readiness to depart) impinging on discharge, a difference of three to five minutes can become obscured.
The frequent incidence of severe postoperative pain is unexpected in these children pretreated with a relatively large dose of fentanyl. The pain score results are reported as the highest score achieved during recovery. Pain experienced after adenoidectomy is typically described as moderate and not requiring repeated doses of potent analgesics. In past studies with desflurane and sevoflurane, the increased need for analgesics has been reported. Although this can be attributed to the severe emergence agitation causing a high score on an observational pain scale, in this study, the percent of patients exhibiting severe agitation is decidedly less than those experiencing severe pain. Also, the high pain scores were often recorded later in the recovery course and self reported by patients.
It should be noted that no premedication was used in this study; midazolam and other sedatives significantly prolong emergence when used to facilitate induction or reduce the incidence of emergence agitation (18,19). Prophylactic treatment with the antiemetic ondansetron was included in the study design secondary to the frequent incidence of vomiting in our previous study (9). The incidence of vomiting was small in both treatment groups.
We conclude that when using the highly insoluble anesthetic gases, a balance needs to be achieved between maintaining rapid emergence and minimizing the incidence of agitation. In children undergoing adenoidectomy with desflurane or sevoflurane, 2.5 µg/ kg fentanyl reduces the incidence of emergence agitation compared with previously reported results (3–6) whereas delaying emergence and recovery in those patients who received sevoflurane compared with those who received desflurane. Although in this study there were no incidences of upper airway obstruction or apnea, well supervised postanesthesia care and avoidance of additional sedatives when using this dose of fentanyl are recommended. In addition, the need for antiemetics with this technique should be anticipated.
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