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Anesth Analg 2003;96:1320-1324
© 2003 International Anesthesia Research Society

PEDIATRIC ANESTHESIA

Tracheal Extubation of Deeply Anesthetized Pediatric Patients: A Comparison of Desflurane and Sevoflurane

Robert D. Valley, MD FAAP, Eugene B. Freid, MD FAAP, FCCM, Ann G. Bailey, MD FAAP, Vincent J. Kopp, MD FAAP, Linda S. Georges, MD FAAP, James Fletcher, MBBS, and Anne Keifer, MD

Department of Anesthesiology, Division of Pediatric Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina

Address correspondence to Robert D. Valley, MD, Department of Anesthesiology, University of North Carolina at Chapel Hill, CB# 7010 223 Burnett-Womack Building, Chapel Hill, NC 27599-7010. Address e-mail to rvalley{at}aims.unc.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
In this study, we examined the emergence characteristics of children tracheally extubated while deeply anesthetized with desflurane (Group D) or sevoflurane (Group S). Forty-eight children were randomly assigned to one of the two groups. At the end of the operation, all subjects were tracheally extubated while breathing 1.5 times the minimal effective concentration of assigned inhaled anesthetic. Recovery characteristics and complications were noted. Group D patients had higher arousal scores on arrival to the postanesthesia care unit than Group S patients. Later arousal scores were not significantly different. No serious complications occurred in either group. Coughing episodes and the overall incidence of complications after extubation were more frequent in Group D. Readiness for discharge and actual time to discharge were not significantly different between groups. Emergence agitation was common in both groups (33% overall, 46% for Group D, and 21% for Group S). Narcotic administration in the postanesthesia care unit occurred more frequently in Group D (10 of 24 patients) versus Group S (3 of 24 patients). Premedication with oral midazolam resulted in significantly longer emergence times regardless of the potent inhaled anesthetic administered.

IMPLICATIONS: Deep extubation of children can be performed safely with desflurane or sevoflurane. Airway problems occur more frequently with desflurane. Awakening occurs more quickly with desflurane. Midazolam premedication has a greater effect on emergence times than does the choice of inhaled anesthetic. Emergence agitation occurs frequently with either technique.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
In 1999, we published a study examining the emergence characteristics of children tracheally extubated while deeply anesthetized (deep extubation) with either sevoflurane or isoflurane (1). That study demonstrated that deep extubation in children could be performed safely with either anesthetic although a return to an arousable state occurred more quickly with sevoflurane and breath holding was more common with isoflurane. No difference in time to meeting discharge criteria from the postanesthesia care unit (PACU) was found.

Desflurane, although poorly tolerated for inhaled induction (2,3), has the lowest blood-gas and tissue-blood solubility coefficients of any potent inhaled anesthetic available for clinical use (4). Airway problems on emergence have not been a prominent feature of desflurane anesthesia in children (3,5–7). We hypothesized that desflurane anesthesia would provide a more rapid return to wakefulness after deep extubation than sevoflurane anesthesia. The emergence characteristics and the incidence of airway complications with each anesthetic were also of interest.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
After obtaining IRB approval and written informed consent, 48 ASA physical status I or II children were enrolled. The children ranged in age from 6 mo to 13 yr and were all scheduled for elective surgical procedures below the umbilicus. Children with a history of airway disease were excluded from the study. Preoperative sedation (oral midazolam, 0.5 mg/kg) was discouraged but the final decision for its use was left to the attending anesthesiologist. Children underwent either an IV induction with propofol or an inhaled induction with sevoflurane and nitrous oxide. All children were tracheally intubated with the use of muscle relaxants. Maintenance anesthesia was determined by random assignment to either the desflurane (D) or sevoflurane (S) group and consisted of the assigned potent inhaled anesthetic and nitrous oxide with oxygen. Monitoring of exhaled anesthetic was done using side stream sampling to an infrared analyzer (Datex Ultima; Datex-Engstrom, Inc., Tewksbury, MA). No systemic analgesics were administered preoperatively or in the operating room (OR). Oral airway use was at the discretion of the attending anesthesiologist. Each child was given an appropriate regional or local anesthetic block before awakening to provide effective postoperative analgesia. During the last 20 min of the operative procedure, any residual neuromuscular blockade, as determined by train-of-four monitoring, was reversed with neostigmine and the patient was allowed to breathe spontaneously. Nitrous oxide was discontinued and the inhaled anesthetic (D or S) adjusted to provide an age-appropriate end-tidal concentration of 1.5 of minimum effective alveolar anesthetic concentration (8–10). The patient was then turned on his or her side and the oropharynx gently suctioned. The endotracheal tube was removed and oxygen administered by facemask. Once the extubated airway was determined to be adequate, the child was transported to the PACU and observed until fully awake. Forty percent oxygen by facemask or "blow by" oxygen was given until judged not necessary by the PACU nursing staff. Pulse oximetry was provided continuously from induction, during transport, and through recovery.

A research nurse, blinded to the assigned group, observed the induction, extubation, transport, and recovery. The use of airway adjuncts, the need for airway support, and the occurrence of airway events (excessive secretions, breath holding, coughing, and laryngospasm) were noted during each time period. The number, severity, and duration of any desaturation episodes as determined by a pulse oximetry reading of <95% were recorded. Arousal scores were monitored until the patient was either discharged from the PACU or fully awake. If unarousable, a score of "0" was assigned. A score of "1" was given to children arousable only with vigorous stimulation, a score of "2" if they were easily arousable, and a score of "3" if they were awake. Time from extubation to spontaneous eye opening, time to meeting standard discharge criteria, and the actual time to discharge from Phase 1 PACU were noted. Any analgesic requirements and postoperative vomiting were noted. The incidence and duration of emergence agitation were also recorded. Emergence agitation was defined as disoriented behavior characterized by inconsolable agitation, similar to the definition used by Davis et al. (5).

An a priori power analysis was performed based on an estimated 50% difference in the time to alertness (11). Assuming a power of 0.8, a difference of the means of 5 min and a standard deviation of 6 min, it was estimated that a sample size of 24 subjects per study group would be necessary to demonstrate a difference at the 0.05 level.

Unless otherwise noted, all data were reported as the mean ± 1 SD. Parametric data were analyzed by using an unpaired Student’s t-test. Ordinal data were analyzed using the Mann-Whitney ranked sum test. Nominal data were analyzed using either {chi}2 or Fisher’s exact test. A P value < 0.05 was considered significant.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
Demographic data for the two study groups are presented in Table 1. There were no significant differences between groups for age, weight, sex, type of surgery, duration of anesthesia, or type of regional or local block performed.


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  		Table 1. Demographics: Desflurane Versus Sevoflurane
 
All patients were successfully extubated in the OR. No patient required reintubation. Recovery times are shown in Table 2. Early arousal scores were significantly higher in the D group. Time to eye opening, time to meeting standard discharge criteria, and actual time to discharge are also listed in Table 2. There were no differences between groups for any of these variables.


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  		Table 2. Recovery Variables in Postanesthesia Care Unit: Desflurane Versus Sevoflurane
 
Problems with the airway and the use of oral airways at extubation in the OR, during transport, and in the PACU are noted in Table 3. Breath holding, excessive secretions, and desaturation episodes occurred more frequently in Group D, although these did not reach statistical significance. The total number of coughing episodes was significantly greater in the D group, occurring 36 times in 19 patients versus 18 times in 12 patients in the S group (P = 0.003). The overall incidence of airway problems (sum of the number of patients that experienced coughing, breath holding, excessive secretions, laryngospasm, or desaturation episodes on at least 1 occasion) was significantly greater in the D group (33 of a possible 120 patient-complications versus 17 of a possible 120 patient-complications, P = 0.017). All of the postextubation airway events were managed by the PACU nursing staff and did not significantly alter the care provided.


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  		Table 3. Airway Support Use, Airway Problems, and Desaturation Episodes After Extubation: Desflurane Versus Sevoflurane
 
In the PACU, there were 10 episodes of vomiting in 6 patients in the D group and 2 episodes in 2 patients in the S group (P = 0.408). Emergence agitation occurred in 45% (11 of 24) of patients in the D group and 20% (5 of 24) of patients in the S group (P = 0.126). Of note, significantly more patients from Group D received narcotics during the first 30 min in the PACU (8 of 24 for Group D versus 1 of 24 for Group S, P = 0.023). Six of eight of the Group D patients receiving narcotics had emergence agitation. The remaining two patients received narcotics for treatment of pain.

Because a number of patients in each group received premedication with midazolam, a separate analysis of the data was done to look at the effects of premedication on the above results. When comparing the D group with the S group after eliminating all patients who received midazolam, arousal scores on arrival to the PACU were still significantly higher in the D group (P = 0.048). No other significant differences were found. The data were subsequently analyzed after combining the D and S groups and then comparing patients who received midazolam premedication (n = 10) with those who did not (n = 38). These two groups were similar for age (2.9 ± 1.7 versus 3.4 ± 3.4 yr), weight (18.5 ± 13.4 versus 16.7 ± 12.1 kg), and duration of anesthesia (124 ± 58 versus 112 ± 60 min). The arousal data are shown in Table 4. Arousal scores were lower and time to awakening longer in the premedicated patients. The incidence of emergence agitation did not differ with midazolam premedication (30% with premedication, 34% without premedication). The incidence of airway problems and desaturation episodes also did not differ between these two groups.


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  		Table 4. Recovery Variables in Postanesthesia Care Unit: Premedicated Versus Unpremedicated
 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
In this study, we compared the recovery characteristics of children tracheally extubated while deeply anesthetized with either desflurane or sevoflurane. Children extubated while breathing desflurane had higher arousal scores on arrival to the PACU than children extubated while breathing sevoflurane. Based on the different blood/gas and blood/brain partition coefficients for sevoflurane (0.65 and 1.7, respectively) versus desflurane (0.45 and 1.3, respectively) and previous studies, a more rapid emergence would be expected (4,11–13). Cohen et al. (12) were able to demonstrate more rapid emergence times and time to discharge readiness in children receiving maintenance anesthesia with desflurane versus sevoflurane. In our study, differences in time to eye opening, 5-minute arousal scores, and time to an arousal score of 2 did not reach statistical significance, although they trended in the same direction. Times to discharge readiness and to actual discharge were similar for both groups. We had anticipated that evidence for a more rapid emergence with desflurane would have been evident further into the recovery period. Later measures of arousal were probably confounded by the fact that significantly more patients in the D group (8 of 24) versus the S group (1 of 24) were given fentanyl during the first half hour in the PACU, most of these for management of emergence agitation.

The number of coughing episodes was significantly larger in the D group. Although not statistically significant, desaturation episodes, breath holding, excessive secretions, and laryngospasm occurred more often after extubation in the D group. The number of complications experienced at least once by study patients was significantly more in Group D compared with Group S (33 versus 17). A high incidence of airway difficulties during induction with desflurane has been well documented (2,3). Similar findings have not been reported during emergence and recovery (5–9,12). This is an interesting finding and may have been evident in our study population because it consisted of predominantly unpremedicated children who had not received preoperative or intraoperative narcotics. In addition, because our patients were extubated while deeply anesthetized, it may have allowed for some airway complications to occur (i.e., after tracheal extubation) that would not have been apparent in patients that were left intubated until reaching a more awake state. Smith et al. (7) did not see a difference in the incidence of coughing in their study of adult patients extubated while deeply anesthetized with isoflurane versus desflurane. In this study, however, all patients received intraoperative narcotics and the "pungency" characteristics of these two drugs are more similar than those of desflurane compared with sevoflurane.

Postoperative agitation or emergence agitation is a common problem after anesthesia with either sevoflurane or desflurane (5,14). The overall incidence in our study population (33%) was similar to that in our previous study (32%) comparing emergence characteristics after isoflurane versus sevoflurane anesthesia (1). The incidence of emergence agitation with sevoflurane was also consistent with our previous study (25% in our previous study versus 21% in this study). Although emergence agitation occurred more frequently in our Group D patients (46%), this did not reach statistical significance. It is noteworthy that, although we did not grade the severity of emergence agitation, significantly more patients in Group D received narcotics in the PACU.

Although our study was not designed to look specifically at the effects of oral midazolam premedication on emergence characteristics, we were able to demonstrate a significant effect. Children premedicated with oral midazolam when compared with those with no premedication took longer to reach arousal scores of 1 (25.0 versus 10.0 minutes, respectively). They also had a longer time postextubation to arousal score >2 (29.2 versus 17.1 minutes, respectively) and a longer time to spontaneous eye opening (34.1 versus 16.9 minutes). Viitanen et al. (15) found a similar effect of oral midazolam on awakening in children after sevoflurane anesthesia for adenoidectomy. That study found no effect of oral midazolam on the incidence of emergence agitation, airway complications, or desaturation episodes. Our findings were similar. Whereas premedication did affect time to discharge readiness in the study by Viitanen et al., it did not in our study. This may be explained by the shorter duration of the surgery in the study by Viitanen et al. (mean surgical time approximately 14.5 minutes) versus the longer surgical times in our study (mean surgical time 115.6 minutes). The effect of oral midazolam on arousal time but lack of effect on discharge readiness could be the result of enough residual sedation from oral midazolam at about two hours postadministration to prolong arousal from deep inhaled anesthesia but not enough to significantly alter the arousal state three hours postadministration when the effects of any residual inhaled anesthesia should be nearly gone.

In summary, we found that deep extubation of children could be safely performed from 1.5 minimum effective alveolar anesthetic concentration of sevoflurane or desflurane. Children extubated while breathing desflurane reached an arousable state more quickly than those extubated from sevoflurane, although this difference was significant only in the first few minutes upon arrival in the PACU. Problems related to the airway were more common with desflurane and emergence agitation required treatment more frequently. Premedication with oral midazolam had an effect on emergence times that was more profound than the choice of anesthetic. When choosing an anesthetic regimen for deep extubation of children, one must take all of these factors into consideration.


   Acknowledgments
 
We thank our research nurses Tamra Jaynes, RN, Ann Jenkins, RN, and Angela Monnig, RN, for their invaluable help with data collection, and Sabrina Sue, MD, for assistance with the statistical analysis.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Valley RD, Ramza JT, Calhoun P, et al. Tracheal extubation of deeply anesthetized pediatric patients: a comparison of isoflurane and sevoflurane. Anesth Analg 1999; 88: 742–5.[Abstract/Free Full Text]
  2. Zwass MS, Fisher DM, Welborn LG, et al. Induction and maintenance characteristics of anesthesia with desflurane and nitrous oxide in infants and children. Anesthesiology 1992; 76: 373–8.[ISI][Medline]
  3. Taylor RH, Lerman J. Induction, maintenance and recovery characteristics of desflurane in infants and children. Can J Anaesth 1992; 39: 6–13.[Abstract/Free Full Text]
  4. Eger EIII. New inhaled agents. Anesthesiology 1994; 80: 906–22.[ISI][Medline]
  5. Davis PJ, Cohen IT, McGowan FX, Latta K. Recovery characteristics of desflurane versus halothane for maintenance of anesthesia in pediatric ambulatory patients. Anesthesiology 1994; 80: 298–302.[ISI][Medline]
  6. Ghouri AF, Bodner M, White PF. Recovery profile after desflurane-nitrous oxide versus isoflurane-nitrous oxide in outpatients. Anesthesiology 1991; 74: 419–24.[ISI][Medline]
  7. Smith I, Taylor E, White PF. Comparison of tracheal extubation of patients deeply anesthetized with desflurane or isoflurane. Anesth Analg 1994; 79: 642–5.[Abstract/Free Full Text]
  8. Lerman J, Sikich N, Kleinman S, Yentis S. The pharmacology of sevoflurane in infants and children. Anesthesiology 1994; 80: 814–24.[ISI][Medline]
  9. Taylor RH, Lerman J. Minimum alveolar concentration of desflurane and hemodynamic responses in neonates, infants and children. Anesthesiology 1991; 75: 975–9.[ISI][Medline]
  10. Katoh T, Ikeda K. Minimum alveolar concentration of sevoflurane in children. Br J Anaesth 1992; 68: 139–41.[Abstract/Free Full Text]
  11. Eger EIII, Johnson BH. Rates of awakening from anesthesia with I-653, halothane, isoflurane and sevoflurane. Anesth Analg 1987; 66: 977–82.[Abstract/Free Full Text]
  12. Cohen IT, Finkel JC, Hannallah RS, et al. The effect of fentanyl on the emergence characteristics after desflurane or sevoflurane anesthesia in children. Anesth Analg 2002; 94: 1178–81.[Abstract/Free Full Text]
  13. Nathanson MH, Fredman B, Smith I, White PF. Sevoflurane versus desflurane for outpatient anesthesia: a comparison of maintenance and recovery profiles. Anesth Analg 1995; 81: 1186–90.[Abstract]
  14. Welborn LG, Hannallah RS, Norden JM, et al. Comparison of the emergence and recovery characteristics of sevoflurane, desflurane and halothane in pediatric ambulatory patients. Anesth Analg 1996; 83: 917–20.[Abstract]
  15. Viitanen H, Annila P, Viitanen M, Tarkkila P. Premedication with midazolam delays recovery after ambulatory sevoflurane anesthesia in children. Anesth Analg 1999; 89: 75–9.[Abstract/Free Full Text]
Accepted for publication January 14, 2003.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press