Intraoperative clonidine to prevent postoperative emergence delirium following sevoflurane anesthesia in pediatric patients: a randomized clinical trial
Fernando A. Sousa-Júnior, Alex S.R. Souza, Luciana C. Lima, Ítalo G.M. Santos, Leonardo A.P. Menezes, Pedro A.P.L. Ratis, Tania C.M. Couceiro
Introduction and objective
Emergence Delirium (ED), particularly in children, is characterized by mental confusion, irritability, disorientation, and inconsolable crying. ED prolongs the time required in the Post-Anesthesia Care Unit (PACU) and increases concern and anxiety in parents. The present study aimed to determine the effectiveness and safety of low-dose clonidine in preventing ED in children receiving sevoflurane anesthesia for tonsillectomy/adenotonsillectomy.
A randomized, double-blind clinical trial was conducted between November 2013 and January 2014. Sixty-two children aged 2–12 years, scheduled to undergo tonsillectomy/adenotonsillectomy and classified as American Society of Anesthesiologists (ASA) physical status I/II were included, with 29 being randomized to receive 1 μg.kg-1 clonidine intravenously, and 33 allocated to a control group that received no clonidine. Anesthesia was induced and maintained with sevoflurane. Children with altered state of consciousness, neurological deficit, history of allergy to dipyrone, or receiving other drugs such as preanesthetic agents were excluded from the study. The primary outcome was the presence of ED in the initial 20 minutes in the PACU according to the Pediatric Anesthesia Emergence Delirium (PAED) scale. The Chi-Square test and Fisher’s two-tailed exact test were used for statistical analysis, as applicable. Significance level was set at 5%, and Risk Ratios (RR) and their 95% Confidence Intervals (95% CI) were calculated.
The frequency of ED was significantly decreased in the group of children who received clonidine (17.2% vs. 57.6%; RR = 0.30; 95% CI 0.13–0.70; p = 0.001). There was no difference between groups with respect to the frequency of postoperative self-harm (falls and bruises), dislodged catheters, and for most of the other adverse events evaluated.
The use of 1 μg.kg-1 intravenous clonidine during anesthesia induction can effectively reduce the incidence of ED in children undergoing elective tonsillectomy/adenotonsillectomy under general inhalation anesthesia with sevoflurane.
1 K. Hudek Emergence delirium: a nursing perspective AORN J., 89 (2009), pp. 509-516
2 GP Vlajkovic, RP Sindjelic Emergence delirium in children: many questions, few answers Anesth Analg., 104 (2007), pp. 84-91
3 S.L. Lapin, S.M. Auden, L.J. Goldsmith, et al. Effects of sevoflurane anaesthesia on recovery in children: a comparison with halothane Paediatr Anaesth., 9 (1999), pp. 299-304
4 L.G. Welborn, R.S. Hannallah, J.M. Norden, U.E. Ruttimann, C.M. Callan Comparison of emergence and recovery characteristics of sevoflurane, desflurane, and halothane in pediatric ambulatory patients Anesth Analg., 83 (1996), pp. 917-920
5 MT Aouad, VG Nasr Emergence agitation in children: an update Curr Opin Anaesthesiol., 18 (2005), pp. 614-619
6 N. Silkich, J. Lerman Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale Anesthesiol., 100 (2004), pp. 1138-1145
7 GM Scott, JI Gold Emergence delirium: a re-emerging interest Semin Anesth Perioperat Med Pain., 25 (2006), pp. 100-104
8 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
9 F. Veyckemans Excitation phenomena during sevoflurane anaesthesia in children Curr Opin Anaesthesiol., 14 (2001), pp. 339-343
10 M.T. Aouad, V.G. Yazbeck-Karam, V.G. Nasr, M.F. El-Khatib, G.E. Kanazi, J.H. Bleik A single dose of propofol at the end of surgery for the prevention of emergence agitation in children undergoing strabismus surgery during sevoflurane anesthesia Anesthesiol., 107 (2007), pp. 733-738
11 Y.F. Bryan, L.K. Hoke, T.A. Taghon, et al. A randomized trial comparing sevoflurane and propofol in children undergoing MRI scans Paediatr Anaesth., 19 (2009), pp. 672-681
12 P.J. Kulka, M. Bressem, M. Tryba Clonidine prevents sevoflurane-induced agitation in children Anesth Analg., 93 (2001), pp. 335-338
13 L.1 Fazi, E.C. Jantzen, J.B. Rose, C.D. Kurth, M.F. Watcha A comparison of oral clonidine and oral midazolam as preanesthetic medications in the pediatric tonsillectomy patient Anesth Analg., 92 (2001), pp. 56-61
14 S. Malviya, T Voepel-Lewis, R.J. Ramamurthi, C. Burke, A.R. Tait Clonidine for the prevention of emergence agitation in young children: efficacy and recovery profile Paediatr Anaesth., 16 (2006), pp. 554-559
15 M. Ydemann, B.N. Nielsen, S. Henneberg, J.C. Jakobsen, J. Wetterslev, T. Lauritsen, et al. Intraoperative clonidine for prevention of postoperative agitation in children anaesthetised with sevoflurane (PREVENT AGITATION): a randomised, placebo-controlled, double-blind trial Lancet Child Adolesc Health., 2 (2018), pp. 15-24
16 A. Pickard, P. Davies, K. Birnie, R. Beringer Systematic review and meta-analysis of the effect of intraoperative a2-adrenergic agonists on postoperative behaviour in children Br J Anaesth., 112 (2014), pp. 982-990
17 M. Daabiss American Society of Anaesthesiologists physical status classification Indian J Anaesth., 55 (2011), pp. 111-115
18 N. Tazeroualti, F. De Groote, S. De Hert, et al. Oral clonidine vs. midazolam in the prevention of sevoflurane-induced agitation in children: a prospective, randomized, controlled trial Br J Anaesth., 98 (2007), pp. 667-671
19 M. Bock, P. Kunz, R. Schreckenberger, B.M. Graf, E. Martin, J. Motsch Comparison of caudal and intravenous clonidine in the prevention of agitation after sevoflurane in children Br J Anaesth., 88 (2002), pp. 790-796
20 U. Lankinen, R. Avela, P. Tarkkila The prevention of emergence agitation with tropisetron or clonidine after sevoflurane anesthesia in small children undergoing adenoidectomy Anesth Analg., 102 (2006), pp. 1383-1386
21 A De Jonge, PBMWM Timmermans, PA van Zweiten Participation of cardiac presynaptic α2-adrenoceptors in the bradycardic effects of clonidine and analogues Naunyn Schmiedebergs Arch Pharmacol., 317 (1981), pp. 8-12
22 H.T. Bergendahl, P.A. Lonnqvist, S. Eksborg, et al. Clonidine vs midazolam as premedication in children undergoing adenotonsillectomy: a prospective, randomized, controlled clinical trial Acta Anaesthesiol Scand., 48 (2004), pp. 1292-1300
23 S. Dahmani, J. Mantz, F. Veyckemans Case scenario: severe emergence agitation after myringotomy in a 3-yr-old child Anesthesiol., 117 (2012), pp. 399-406