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      Recovery characteristics of total intravenous anesthesia with propofol versus sevoflurane anesthesia: a prospective randomized clinical trial

      1 , 2

      Journal of Pain Research

      Dove Medical Press

      emergence delirium, sevoflurane, propofol, TIVA, child, dental surgery

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          Abstract

          Background

          Pediatric dental procedures are performed under anesthesia because children may be uncooperative in the dental clinic due to their young age. Emergence delirium (ED), which involves a variety of behavioral disturbances that are frequently observed in children following emergence from general anesthesia, remains an unclear phenomenon. The aim of this randomized controlled trial is to compare the incidence of ED in children who underwent full mouth dental rehabilitation under either sevoflurane (SEVO) anesthesia or propofol-based total intravenous anesthesia (TIVA).

          Patients and methods

          One hundred and twenty children with American Society of Anesthesiologists status I–II, aged ≥3 and ≤6 years, undergoing dental rehabilitation were assigned to receive either TIVA or SEVO. ED and postoperative pain were evaluated by a blinded investigator using the Pediatric Anesthesia Emergence Delirium scale and the Face, Legs, Activity, Cry, Consolability scale every 5 min. The recovery time, satisfaction levels of parents or guardians, extubation time, duration of the operation, and type of dental procedure were also recorded.

          Results

          Data of 116 subjects were analyzed. The incidence of ED was higher after SEVO than after TIVA (65.5 vs 3.4%, P=0.00). Greater postoperative pain was observed in the SEVO group (median 3 vs 1, P=0.000). A statistically significant, moderate correlation (rs=0.46, P<0.0001) was found between the Face, Legs, Activity, Cry, Consolability and Pediatric Anesthesia Emergence Delirium scores. A higher parental satisfaction level was observed in the TIVA group.

          Conclusion

          A lower incidence of ED and a higher parental satisfaction level were observed after TIVA. Moreover, TIVA resulted in a more comfortable postoperative period due to reduced postoperative pain, and the extubation time and recovery time were not increased.

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          Most cited references 24

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          Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale.

          Emergence delirium has been investigated in several clinical trials. However, no reliable and valid rating scale exists to measure this phenomenon in children. Therefore, the authors developed and evaluated the Pediatric Anesthesia Emergence Delirium (PAED) scale to measure emergence delirium in children. A list of scale items that were statements describing the emergence behavior of children was compiled, and the items were evaluated for content validity and statistical significance. Items that satisfied these evaluations comprised the PAED scale. Each item was scored from 1 to 4 (with reverse scoring where applicable), and the scores were summed to obtain a total scale score. The degree of emergence delirium varied directly with the total score. Fifty children were enrolled to determine the reliability and validity of the PAED scale. Scale validity was evaluated using five hypotheses: The PAED scale scores correlated negatively with age and time to awakening and positively with clinical judgment scores and Post Hospital Behavior Questionnaire scores, and were greater after sevoflurane than after halothane. The sensitivity of the scale was also determined. Five of 27 items that satisfied the content validity and statistical analysis became the PAED scale: (1) The child makes eye contact with the caregiver, (2) the child's actions are purposeful, (3) the child is aware of his/her surroundings, (4) the child is restless, and (5) the child is inconsolable. The internal consistency of the PAED scale was 0.89, and the reliability was 0.84 (95% confidence interval, 0.76-0.90). Three hypotheses supported the validity of the scale: The scores correlated negatively with age (r = -0.31, P <0.04) and time to awakening (r = -0.5, P <0.001) and were greater after sevoflurane anesthesia than halothane (P <0.008). The sensitivity was 0.64. These results support the reliability and validity of the PAED scale.
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            A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit.

            Emergence agitation (EA) is a postanesthetic problem that interferes with a child's recovery and presents a challenge in terms of assessment and management. In this prospective cohort study, we sought to determine the incidence of EA, evaluate factors associated with and predictive of EA, and describe associated outcomes in healthy children. Children aged 3-7 yr who were undergoing general anesthesia for elective outpatient procedures were included. All perioperative care was documented, and postoperative behaviors in the postanesthesia care unit were recorded. Parents completed the Behavioral Style Questionnaire for 3- to 7-yr-olds. Five-hundred-twenty-one children were studied, of whom 96 (18%) had EA. Agitation lasted up to 45 min in some cases (range, 3-45 min; mean, 14 +/- 11 min), required pharmacologic intervention in 52% of children, and was associated with a prolonged postanesthesia care unit stay (117 +/- 66 min versus 101 +/- 61 min for nonagitated children; P = 0.02). Ten factors were found to be associated with EA, including age, previous surgery, adaptability, ophthalmology and otorhinolaryngology procedures, sevoflurane, isoflurane, sevoflurane/isoflurane, analgesics, and time to awakening. Of these, otorhinolaryngology procedures, time to awakening, and isoflurane were shown to be independent risk factors. Children may become agitated after general anesthesia. This study describes several factors that may increase the risk for agitation. These data are important in planning anesthesia care for young children.
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              Emergence delirium in children: many questions, few answers.

              The introduction of a new generation of inhaled anesthetics into pediatric clinical practice has been associated with a greater incidence of ED, a short-lived, but troublesome clinical phenomenon of uncertain etiology. A variety of anesthesia-, surgery-, patient-, and adjunct medication-related factors have been suggested to play a potential role in the development of such an event. Restless behavior upon emergence causes not only discomfort to the child, but also makes the caregivers and parents feel unhappy with the quality of recovery from anesthesia. Although the severity of agitation varies, it often requires additional nursing care, as well as treatment with analgesics or sedatives, which may delay discharge from hospital. To reduce the incidence of this adverse event, it is advisable to identify children at risk and take preventive measures, such as reducing preoperative anxiety, removing postoperative pain, and providing a quiet, stress-free environment for postanesthesia recovery. More clinical trials are needed to elucidate the cause as well as provide effective treatment.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2018
                06 July 2018
                : 11
                : 1289-1295
                Affiliations
                [1 ]Department of Oral and Maxillofacial Surgery, Division of Anesthesiology, Faculty of Dentistry, Adnan Menderes University, Aydin, Turkey, ozlemoget2002@ 123456yahoo.com
                [2 ]Department of Pediatric Dentistry, Faculty of Dentistry, Adnan Menderes University, Aydin, Turkey
                Author notes
                Correspondence: Ozlem Kocaturk, Department of Oral and Maxillofacial Surgery, Division of Anesthesiology, Faculty of Dentistry, Adnan Menderes University, Hasan Efendi St, Aydin 09100, Turkey, Tel +90 256 213 3939, Fax +90 256 215 1918, Email ozlemoget2002@ 123456yahoo.com
                Article
                jpr-11-1289
                10.2147/JPR.S164106
                6038881
                © 2018 Kocaturk and Keles. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Clinical Trial Report

                Anesthesiology & Pain management

                dental surgery, child, tiva, propofol, sevoflurane, emergence delirium

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