Nitrous oxide administration during washout of sevoflurane improves postanesthetic agitation in children

Abstract

The use of sevoflurane in pediatric patients, which could enable a more rapid emergence and recovery, is complicated by a high incidence of postanesthetic agitation, probably due to residual sevoflurane during washout. The present study was designed to investigate whether administration of nitrous oxide (N2O) reduces sevoflurane concentration at awakening and suppresses postanesthetic agitation. The study enrolled 20 children classified as ASA physical status I. Anesthesia was induced with 5% sevoflurane and maintained with 2.5% end-tidal sevoflurane and N2O in oxygen. In the control group, sevoflurane and N2O were discontinued immediately after completion of surgery. In the N2O group, inspired N2O was replaced with oxygen after the bispectral index (BIS) had reached 80. The end-tidal concentrations of sevoflurane at awakening were significantly lower (P < 0.05) in the N2O group than in the control group. The BIS at awakening was higher (P < 0.01) in the N2O group than in the control group. The point scores of postanesthetic agitation were significantly lower (P < 0.01) in the N2O group than in the control group. Using N2O during washing out of sevoflurane may improve postanesthetic agitation at awakening in children.

Emergence agitation in children: an update

“…Controlling the speed of emergence by gradually decreasing the sevoflurane concentration only prolonged recovery without decreasing the incidence of emergence agitation. Recently, Shibata et al [31 ] speculated that the cause of sevoflurane agitation was related to the residual sevoflurane at awakening. By maintaining nitrous oxide after the discontinuation of sevoflurane, the concentration of the latter decreased while hypnosis was maintained, thereby the incidence of emergence agitation decreased in comparison to a second group in which nitrous oxide and sevoflurane were discontinued concomitantly.…”

Comparison of emergence agitation between sevoflurane/nitrous oxide administration and sevoflurane administration alone in children undergoing adenotonsillectomy with preemptive ketorolac

“…Sevoflurane is known to act on γ-aminobutyrateA (GABA A ) receptors, similar to benzodiazepine, but the mechanism and treatment of EA are still unclear [5,7,14]. Shibata et al [6] suggested that residual sevoflurane might be the contributing factor of EA and that decreasing the concentration of residual sevoflurane at the recovery of self-respiration by supplying N 2 O after the discontinuation of sevoflurane during emergence could reduce the incidence of emergency agitation. In this study, we concurrently discontinued all of the inhalation anesthetics at the end of the surgery and Et Sevo at the end of the surgery was lower in the sevoflurane with N 2 O group compared to sevoflurane alone group, but time to recovery of self-respiration and Et Sevo at recovery of self-respiration did not differ in the two groups.…”

“…However, it has been reported that emergence agitation (EA), occurring after general anesthesia in children, is more frequent after using sevoflurane [1-3]. Possible etiological factors of pediatric EA after using sevoflurane include rapid emergence, psychological and neurological immaturity of children [4,5], concentration of residual sevoflurane [6] and sevoflurane-induced increase in noradrenaline release from the central nervous system [7]. …”

“…Moreover, N 2 O has been reported to reduce EA by lowering the concentration of residual sevoflurane during emergence [6]. However, several animal studies have showed that the administration of N -methyl-D-aspartate (NMDA) receptor antagonists, including N 2 O, into a developing brain caused neurotoxicity [8,9].…”

Agitação no despertar da anestesia em crianças: aspectos atuais

“…3 Adding nitrous oxide to anesthesia with sevoflurane reduces the minimum alveolar concentration (MAC) of sevoflurane, meaning that lower concentrations of the anesthetic can be used, thereby reducing the incidence of postoperative agitation. 25 When compared with isoflurane, sevoflurane appears not just to increase the incidence of emergence agitation, but also to prolong the duration of that agitation, which is a problem that was detected in children maintained under anesthesia with sevoflurane, where the occurrence of the complication was 20%, compared with an incidence of 7% when isoflurane was employed. 26 One of the hypotheses offered to explain this increased incidence of emergence agitation when sevoflurane is used, is the low solubility of this agent in blood, when compared with halothane, promoting earlier emergence from anesthesia and emergence agitation.…”