Costi David, Ellwood James, Wallace Andrew, Ahmed Samira, Waring Lynne, Cyna Allan
Department of Paediatric Anaesthesia, Women's and Children's Hospital, Adelaide, SA, Australia; Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.
Paediatr Anaesth. 2015 May;25(5):517-23. doi: 10.1111/pan.12617. Epub 2015 Jan 13.
Emergence agitation (EA) is a common behavioral disturbance after sevoflurane anesthesia in children. Propofol 1 mg · kg(-1) bolus at the end of sevoflurane anesthesia has had mixed results in reducing the incidence of EA, whereas propofol infusion throughout anesthesia maintenance seems effective but is more complex to administer. If a simple, short transition to propofol anesthesia was found to be effective in reducing EA, this could enhance the recovery of children following sevoflurane anesthesia. We therefore aimed to determine whether transition to propofol over 3 min at the end of sevoflurane anesthesia reduces the incidence of EA in children.
In this prospective randomized controlled trial, 230 children aged 1-12 years, undergoing magnetic resonance imaging (MRI) scans under sevoflurane anesthesia were randomized to receive either propofol 3 mg · kg(-1) over 3 min (propofol group), or no propofol (control group), at the end of sevoflurane anesthesia. EA was assessed by a blinded assessor using the Pediatric Emergence Anesthesia Delirium (PAED) scale and the Watcha scale until 30 min after emergence. EA on the PAED scale was defined as a PAED score >12. EA on the Watcha scale was defined as a score ≥ 3. Times to emergence, postanesthesia care unit (PACU) discharge, and discharge home were also recorded.
Data were analyzed for 218 children. The incidence of EA was lower in the propofol group on both PAED (29% vs 7%; relative risk = 0.25; 95% confidence interval 0.12-0.52; P < 0.001) and Watcha (39% vs 15%; relative risk = 0.37; 95% confidence interval 0.22-0.62; P < 0.001) scales. Duration and severity of EA were also reduced in the propofol group. Preplanned subgroup analyses for midazolam premedication, preexisting cognitive or behavioral disturbance, and age group did not alter our findings. Emergence time and time in PACU were both increased by a mean of 8 min in the propofol group (P < 0.001) with no difference in time to discharge home.
Transition to propofol at the end of sevoflurane anesthesia reduces the incidence of EA and improves the quality of emergence. There is a small increase in recovery time, but no delay in discharge home.
苏醒期躁动（EA）是小儿七氟醚麻醉后常见的行为紊乱。在七氟醚麻醉结束时静脉注射1mg·kg⁻¹丙泊酚，对于降低EA发生率的效果不一，而在整个麻醉维持期输注丙泊酚似乎有效，但给药更复杂。如果发现简单、短暂地过渡到丙泊酚麻醉能有效降低EA发生率，这可能会促进小儿七氟醚麻醉后的恢复。因此，我们旨在确定在七氟醚麻醉结束时3分钟内过渡到丙泊酚麻醉是否能降低小儿EA的发生率。
在这项前瞻性随机对照试验中，230例年龄1至12岁、在七氟醚麻醉下接受磁共振成像（MRI）扫描的儿童被随机分为两组，在七氟醚麻醉结束时，一组在3分钟内接受3mg·kg⁻¹丙泊酚（丙泊酚组），另一组不接受丙泊酚（对照组）。由一名盲法评估者使用小儿苏醒期麻醉谵妄（PAED）量表和Watcha量表评估EA，直至苏醒后30分钟。PAED量表上的EA定义为PAED评分>12分。Watcha量表上的EA定义为评分≥3分。还记录了苏醒时间、麻醉后监护病房（PACU）出院时间和出院回家时间。
对218例儿童的数据进行了分析。丙泊酚组在PAED量表（29% vs 7%；相对危险度=0.25；95%置信区间0.12 - 0.52；P<0.001）和Watcha量表（39% vs 15%；相对危险度=0.37；95%置信区间0.22 - 0.62；P<0.001）上的EA发生率均较低。丙泊酚组EA的持续时间和严重程度也有所降低。针对咪达唑仑术前用药、既往存在的认知或行为障碍以及年龄组的预先计划亚组分析并未改变我们的研究结果。丙泊酚组的苏醒时间和在PACU的时间平均均增加了8分钟（P<0.001），而出院回家时间无差异。
七氟醚麻醉结束时过渡到丙泊酚麻醉可降低EA发生率并改善苏醒质量。恢复时间略有增加，但出院回家没有延迟。
