Oral trans‐mucosal dexmedetomidine for controlling of emergence agitation in children undergoing tonsillectomy: a randomized controlled trial
Dexmedetomidina transmucosa oral para controle da agitação ao despertar em crianças submetidas a amigdalectomia: ensaio clínico randomizado
Hala S. Abdel-Ghaffar, Amani H. Abdel-Wahab, Mohammed M. Roushdy
Abstract
Objectives
Emergence agitation is a negative behavior commonly recorded after pediatric tonsillectomy. We investigated the efficacy of preoperative premedication with oral transmucosal buccal dexmedetomidine on the incidence and severity of emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia.
Methods
Ninety patients aged (3‐6y), ASA I‐II were enrolled into three groups (n = 30) to receive oral transmucosal dexmedetomidine 0.5 μg.kg‐1 (Group DEX I), 1 μg.kg‐1 (Group DEX II) or saline placebo (Group C). Our primary endpoint was the Watcha agitation score at emergence in PACU. Secondary outcomes were preoperative sedation score, intraoperative hemodynamics, postoperative Objective Pain Scale (OPS) and adverse effects.
Results
The patients’ demographics, preoperative sedation scores and extubation time showed no difference between groups. Significant differences between groups in incidence and frequency distribution of each grade of Watcha score were evident at 5 minutes (p = 0.007), 10 minutes (p = 0.034), 30 minutes (p = 0.022), 45 minutes (p = 0.034) and 60 minutes (p = 0.026), postoperatively with significant differences between DEX I and II groups. DEX groups showed lower OPS scores at 5 minutes (p = 0.011), 10 minutes (p = 0.037) and 30 minutes (p = 0.044) after arrival at PACU, with no difference between DEX I and II groups. Patients in DEX II group exhibited lower intraoperative mean heart rate at 15 minutes (p = 0.020), and lower mean arterial pressure at 30 minutes, (p = 0.040), 45 minutes (p = 0.002) and 60 minutes (p = 0.006) with no significant differences between groups in other time points.
Conclusion
This study demonstrates the clinical advantage and the simple technique of oral transmucosal DEX premedication for emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia compared with saline placebo.
Keywords
Resumo
Objetivos
A agitação ao despertar da anestesia é um comportamento negativo comumente registrado após amigdalectomia pediátrica. Avaliamos a eficácia da pré‐medicação com dexmedetomidina via transmucosa oral no pré‐operatório sobre a incidência e gravidade da agitação ao despertar em crianças pré‐escolares submetidas à amigdalectomia sob anestesia com sevoflurano.
Métodos
Noventa pacientes entre três e seis anos e estado físico ASA I‐II foram incluídos em três grupos (n = 30) para receber 0,5 μg.kg‐1 ou 1 μg.kg‐1 de dexmedetomidina via transmucosa oral (Grupo DEX I e Grupo DEX II, respectivamente) ou solução salina (Grupo C). O desfecho primário foi o escore de agitação ao despertar medido com a escala de Watcha na SRPA. Os desfechos secundários foram escore de sedação pré‐operatória, hemodinâmica intraoperatória, escore OPS (Objective Pain Scale) e efeitos adversos no pós‐operatório.
Resultados
A demografia dos pacientes, os escores de sedação pré‐operatória e o tempo de extubação não apresentaram diferença entre os grupos. Diferenças significativas entre os grupos na distribuição da incidência e frequência de cada grau do escore de Watcha foram evidentes aos 5 minutos (p = 0,007), 10 minutos (p = 0,034), 30 minutos (p = 0,022), 45 minutos (p = 0,034) e 60 minutos (p = 0,026) no pós‐operatório, com diferenças significativas entre os grupos DEX I e II. Os grupos DEX apresentaram escores OPS mais baixos aos 5 minutos (p = 0,011), 10 minutos (p = 0,037) e 30 minutos (p = 0,044) após a chegada à SRPA, sem diferença entre os grupos DEX I e II. Os pacientes do grupo DEX II apresentaram menor frequência cardíaca média aos 15 minutos de intraoperatório (p = 0,020) e menor pressão arterial média aos 30 minutos, (p = 0,040), 45 minutos (p = 0,002) e 60 minutos (p = 0,006), sem diferenças significativas entre os grupos em outros momentos.
Conclusão
Este estudo demonstra a vantagem clínica e a técnica simples da pré‐medicação com DEX por via transmucosa oral para agitação ao despertar em crianças pré‐escolares submetidas à amigdalectomia sob anestesia com sevoflurano, comparado à solução salina.
Palavras-chave
References
1 A. Smessaert, C.A. Schehr, J.F. Artusio Jr. Observations in the immediate postanesthesia period. II. Mode of recovery Br J Anaesth., 32 (1960), pp. 181-185
2 J.E. Eckenhoff, D.H. Kneale, R.D. Dripps The incidence and etiology of postanesthetic excitement. A clinical survey Anesthesiology., 22 (1961), pp. 667-673
3 T. Voepel-Lewis, S. Malviya, A.R. Tait A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit Anesth Analg., 96 (2003), pp. 1625-1630
4 K.P. Mason Pediatric emergence delirium: a comprehensive review and interpretation of the literature Br J Anaesth., 118 (2017), pp. 335-343
5 A.D. Moore, D.L. Anghelescu Emergence delirium in pediatric anesthesia Paediatr Drugs., 19 (2017), pp. 11-20
6 M.A. Amorim, C.S. Govêia, E. Magalhães, et al. Effect of dexmedetomidine in children undergoing general anesthesia with sevoflurane: a meta‐analysis Braz J Anesthesiol., 67 (2017), pp. 193-198
7 E.K. Choi, S. Lee, W.J. Kim, et al. Effects of remifentanil maintenance during recovery on emergence delirium in children with sevoflurane anesthesia Paediatr Anaesth., 28 (2018), pp. 739-744
8 J.Y. Chen, J.E. Jia, T.J. Liu, et al. Comparison of the effects of dexmedetomidine, ketamine and placebo on emergence agitation after strabismus surgery in children Can J Anaesth., 60 (2013), pp. 385-392
9 M. Ydemann, B.N. Nielsen, S. Henneberg, et al. Intraoperative clonidine for prevention of postoperative agitation in children anaesthetized with sevoflurane a randomized, placebo‐controlled, double‐blind trial Lancet Child Adolesc Health., 2 (2018), pp. 15-24
10 M.T. Aouad, V.G. Yazbeck-Karam, V.G. Nasr, et al. A single dose of propofol at the end of surgery for the prevention of emergence agitation in children undergoing strabismus surgery during sevoflurane anesthesia Anesthesiology., 107 (2007), pp. 733-738
11 C. Chrysostomou, C.G. Schmitt Dexmedetomidine: sedation, analgesia and beyond Expert Opin Drug Metab Toxicol., 4 (2008), pp. 619-627
12 S. Keles, O. Kocaturk Comparison of oral dexmedetomidine and midazolam for premedication and emergence delirium in children after dental procedures under general anesthesia: a retrospective study Drug Des Devel Ther., 12 (2018), pp. 647-653
13 L.Q. Li, C. Wang, H.Y. Xu, et al. Effects of different doses of intranasal dexmedetomidine on preoperative sedation and postoperative agitation in pediatric with total intravenous anesthesia undergoing adenoidectomy with or without tonsillectomy Medicine (Baltimore)., 97 (2018), p. e12140
14 F. Chen, C. Wang, Y. Lu, et al. Efficacy of different doses of dexmedetomidine as a rapid bolus for children: a double‐blind, prospective, randomized study BMC Anesthesiol., 18 (2018), p. 103
15 J.A. Kim, H.J. Ahn, M. Yang, et al. intraoperative use of dexmedetomidine for the prevention of emergence agitation and postoperative delirium in thoracic surgery: a randomized‐controlled trial Can J Anaesth., 66 (2019), pp. 371-379
16 Z.S. Cimen, A. Hanci, G.U. Sivrikaya, et al. Comparison of buccal and nasal dexmedetomidine premedication for pediatric patients Ped Anesth., 23 (2013), pp. 134-138
17 N.C. Wilton, J. Leigh, D.R. Rosen, et al. Pre‐anesthetic sedation of preschool children using intranasal midazolam Anesthesiology., 69 (1988), pp. 972-975
18 S.A. Bajwa, D. Costi, A.M. Cyna A comparison of emergence delirium scales following general anesthesia in children Pediatr Anesth., 20 (2010), pp. 704-711
19 S. Suraseranivongse, U. Santawat, K. Kraiprasit, et al. Cross‐validation of a composite pain scale for preschool children within 24 hours of surgery Br J Anaesth., 87 (2001), pp. 400-405
20 J.A. Aldrete The post‐anesthesia recovery score revisited J Clin Anesth., 7 (1995), pp. 89-91
21 A.G. Tsiotou, A. Malisiova, E. Kouptsova, et al. Dexmedetomidine for the reduction of emergence delirium in children undergoing tonsillectomy with propofol anesthesia: A double‐blind, randomized study Pediatr Anesth., 28 (2018), pp. 632-638
22 M.A. Ali, A.A. Abdellatif Prevention of sevoflurane related emergence agitation in children undergoing adenotonsillectomy: a comparison of dexmedetomidine and propofol Saudi J Anaesth., 7 (2013), pp. 296-300
23 A.M.A. El-Hamid, H.M. Yassin Effect of intranasal dexmedetomidine on emergence agitation after sevoflurane anesthesia in children undergoing tonsillectomy and/or adenoidectomy Saudi J Anaesth., 11 (2017), pp. 137-143
24 Y. Sakurai, T. Obata, A. Odaka, et al. Buccal administration of dexmedetomidine as a preanesthetic in children J Anesth., 24 (2010), pp. 49-53
25 M. Somaini, T. Engelhardt, R. Fumagalli, et al. Emergence delirium or pain after anaesthesia--how to distinguish between the two in young children: a retrospective analysis of observational studies Br J Anaesth., 116 (2016), pp. 377-383
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