Prevention of Emergence Agitation After Sevoflurane Anesthesia for Pediatric Cerebral Magnetic Resonance Imaging by Small Doses of Ketamine or Nalbuphine Administered Just Before Discontinuing Anesthesia

Abstract

Magnetic resonance imaging (MRI) requires long-lasting immobilization that frequently can only be provided by general anesthesia in pediatric patients. Sevoflurane provides adequate anesthesia but many patients experience emergence agitation. Small doses of ketamine and nalbuphine provide moderate sedation but their benefits have subsided at the time of emergence. We hypothesized that delaying their administration until the end of the procedure would prevent emergence agitation without prolonging patient wake-up and discharge times from the postanesthesia care unit. We performed a double-blind study involving 90 patients (aged 6 mo to 8 yr) randomly allocated to 1 of 3 groups receiving either saline (S-group), ketamine (0.25 mg/kg) (K-group), or nalbuphine (0.1 mg/kg) (N-group) at the end of an MRI procedure under sevoflurane anesthesia. We evaluated emergence conditions, sedation/agitation status and completion of discharge criteria at 30 min. The three groups were comparable in age, sex ratio, physical status, and associated medical disorders. Emergence conditions did not differ significantly. There were significantly more agitated children, at all times, in the S-group and more obtunded patients at early times (5 and 10 min) in both K- and N-groups. All patients met discharge criteria at 30 min but significantly more children were awake and quiet in the K-group and still more in the N-group. In conclusion, small doses of ketamine or nalbuphine administered at the end of an MRI procedure under sevoflurane anesthesia reduce emergence agitation without delaying discharge. Nalbuphine provided better results than ketamine.

The change of sevoflurane to desflurane after anesthesia induction induces rapid emergence without increased cardiovascular responses and emergence delirium in pediatric strabismus surgery patients

“…Volatile anesthetics such as sevoflurane and desflurane have been known to aggravate emergence delirium because of their rapid recovery. Dalens et al [17] suggested that small doses of ketamine or nalbuphine administered just before discontinuing anesthesia could prevent emergence delirium. Oral clonidine 4 μg/kg prior to induction has been shown to decrease emergence delirium compared with midazolam 0.5 mg/kg [18].…”

Comparative study of emergence agitation between isoflurane and propofol anesthesia in adults after closed reduction of distal radius fracture

“…Besides, there are reports showing that fentanyl, nalbuphine, midazolam, and lidocaine are effective in reducing emergence agitation (Galinkin et al, 2000;Cohen et al, 2001;Dalens et al, 2006;Kim et al, 2011;Seo et al, 2011). In our study, nalbuphine 10 mg was to be administered iv when a state of emergence agitation continued for more than 3 min, which if necessary, could be used again after 3 h. However, the state of emergence agitation in both groups only lasted about 1 min, so additional administration of medication was unnecessary.…”

Zastosowanie nalbufiny w anestezjologii pediatrycznej

“…This issue predominantly concerns pre-school children; its cause has not been fully elucidated, but post-sevoflurane excitation is estimated to occur in over 30% of children undergoing general anaesthesia with sevoflurane for non-surgical procedures [15,16]. The incidence of excitation following anaesthesia can be reduced by using propofol, ketamine or nalbuphine during the final stage of anaesthesia [15,17,18]. Nalbuphine in a dose of 0.1 mg kg -1 administered at the end of anaesthesia has been shown to decrease the incidence of excitation and anxiety after anaesthesia more effectively than ketamine without prolonging the awakening time [18].…”

“…The incidence of excitation following anaesthesia can be reduced by using propofol, ketamine or nalbuphine during the final stage of anaesthesia [15,17,18]. Nalbuphine in a dose of 0.1 mg kg -1 administered at the end of anaesthesia has been shown to decrease the incidence of excitation and anxiety after anaesthesia more effectively than ketamine without prolonging the awakening time [18].…”