Emergence agitation prevention in paediatric ambulatory surgery: A comparison between intranasal Dexmedetomidine and Clonidine

Abstract

Objective:Emergence agitation (EA), a short-lived, self-limiting phenomenon, arises frequently after the use of inhalational agents and hampers the implementation of pediatric ambulatory surgery in spite of using so many drugs with variable efficacy.Methods:In this prospective, double-blinded, parallel group study (2008–2009), 80 children of both sex aged 3–7 years, with American Society of Anesthesiologists (ASA) physical status grade I-II, undergoing sevoflurane-based general anesthesia for elective day care surgery were randomly assigned into groups C or D. Group C received 4 μg/kg intranasal clonidine, whereas group D received 1 μg/kg intranasal dexmedetomidine, 45 min before induction of anesthesia. In postanesthesia care unit (PACU), the incidence of EA was assessed with Aonos four-point scale and the severity of EA was assessed with pediatric anesthesia emergence delirium scale upon admission (T0), after 5 min (T5), 15 min (T15), and 25 min (T25). Extubation time, emergence time, duration of PACU stay, dose and incidence of fentanyl use for pain control were noted.Findings:Based on comparable demographic profiles, the incidence and severity of EA were significantly lower in group D as compared to group C at T0, T5, T15, and T25. But time of regular breathing, awakening, extubation, and emergence were significantly delayed in group D than C. The number and dose of fentanyl used in group C were significantly higher than group D. PACU and hospital stay were quite comparable between groups.Conclusion:Intranasal dexmedetomidine 1 μg/kg was more effective than clonidine 4 μg/kg in decreasing the incidence and severity of EA, when administered 45 min before the induction of anesthesia with sevoflurane for pediatric day care surgery. Dexmedetomidine also significantly reduced fentanyl consumption in PACU.

The Effect of Dexmedetomidine on Emergence Agitation or Delirium in Children After Anesthesia—A Systematic Review and Meta-Analysis of Clinical Studies

“…Eventually, 63 trials (19-81) including 7,714 patients were identified through our search strategy (Figure 1). All included trials were divided into nine groups based on control drugs: placebo , midazolam (19,(59)(60)(61)(62)(63)(64)(65)(66)(67)(68)(69)(70)(71), opioids (29,45,(72)(73)(74), propofol (or pentobarbital) (22,25,42,75,76), ketamine (26,60,(77)(78)(79), clonidine (80), chloral hydrate (81), melatonin (59), and ketofol (ketamine and propofol) (23). We assigned propofol and pentobarbital into the same group because both of them produced general anesthetic efficacy through directly activating the γ-aminobutyric acid A receptor of the central nervous system (82).…”

Effects of dexmedetomidine versus midazolam for premedication in paediatric anaesthesia with sevoflurane: A meta-analysis

“…Because of the particularity and arduous work of paediatric anaesthesia, it is necessary to administer premedication using drugs such as dexmedetomidine (DEX) or midazolam (MDZ) for sedation, analgesia, relief of the stress response, and elimination of nervousness, anxiety, and fear. DEX, a highly selective α 2 -receptor agonist with a ratio of affinity between α 2 and α 1 receptors 7.36 times higher that of clonidine, 5 is the most prevalent premedication used in paediatric anaesthesia because of its sedative, analgesic, amnesic, anxiolytic, and sympatholytic properties without respiratory depression. 6 Various studies have demonstrated that DEX more effectively decreases anxiety and sedation, reduces EA, and provides postoperative analgesia than does MDZ in children; 7 – 10 however, the definitive effects of DEX versus MDZ in paediatric anaesthesia with sevoflurane remain unclear.…”

Dexmedetomidine Effect on Emergence Agitation and Delirium in Children Undergoing Laparoscopic Hernia Repair: a Preliminary Study

“…Some previous studies suggested that Dex is safe in children. 3 – 5 , 10 , 19 – 22 Some showed that agitation and pain scores were significantly reduced by Dex, although the waking and extubation times were both significantly longer in children administered a single dose of Dex (0.5 µg/kg) 5 min after tonsillectomy 23 or in children given Dex 0.5 µg/kg/h intravenously after anesthesia induction. 24 Another randomized, controlled trial showed that a continuous infusion of Dex (0.2 µg/kg/h) after anesthesia induction could significantly reduce the frequency of ED by 10%–26%.…”

“…Some previous studies suggested that dexmedetomidine (Dex) is safe in children. 3 – 5 With its hypnotic, analgesic, sedative, and anxiolytic effects, 6 it has been shown to improve intraoperative hemodynamic stability, minimize responses to stimuli, and reduce the need for other anesthetic agents. 7 Previous studies, however, have reported conflicting results on the effects of Dex on EA and ED.…”