The Addition of Intravenous Propofol and Ketorolac to a Sevoflurane Anesthetic Lessens Emergence Agitation in Children Having Bilateral Myringotomy with Tympanostomy Tube Insertion: A Prospective Observational Study

Abstract

The aim of this prospective observational study was to determine if children undergoing bilateral myringotomy and tympanostomy tube insertion with a sevoflurane anesthetic plus intravenous propofol and ketorolac experienced a lower incidence of emergence agitation than those receiving a sevoflurane anesthetic alone. Duration of procedure, length of stay in post-anaesthesia care and level of nursing effort required to care for patients were also assessed. In this study, 49 children younger than 13 years of age received a sevoflurane anesthetic. Fifty-one percent of these patients also received a single injection of propofol 1 mg/kg and ketorolac 0.5 mg/kg at the end of the procedure. Patients were assessed for emergence agitation using the Pediatric Anesthesia Emergence Delirium scale in the post-anaesthesia care unit. Four children receiving a sevoflurane anesthetic alone experienced emergence agitation, while no children receiving propofol and ketorolac experienced emergence agitation (p = 0.05). The length of stay until discharge from the hospital was 6.98 min longer for patients receiving propofol and ketorolac but did not reach statistical significance (p = 0.23). Nurses reported greater ease in caring for patients receiving the propofol and ketorolac injection (recovery questionnaire score 4.50 vs. 3.75, p = 0.002). In this study, adding a single injection of intravenous propofol and ketorolac to the end of a brief sevoflurane anesthetic for bilateral myringotomy with tube insertion was associated with a lower incidence of emergence agitation without significantly increasing the time to discharge from the hospital.

Office Insertion of Tympanostomy Tubes and the Role of Automated Insertion Devices

“…6 Tube insertion in children is nearly always performed in a surgical setting under general anesthesia, but interest in office insertion has grown because of convenience, possible cost savings, and concerns over potential anesthetic-related adverse events. These adverse events include emergence agitation (delirium) in up to two-thirds of children, 7 death ranging from 1 in 10,000 to 100,000 anesthetics delivered (but rarely in children without serious underlying medical problems), 8 and potential neurotoxicity. This last concern prompted the FDA to institute a label change on inhalational anesthetics, plus midazolam and propofol, warning that “exposure to these medicines for lengthy periods of time or over multiple surgeries or procedures may negatively affect brain development in children younger than 3 years.” 9…”

Efficacy and Safety of Intranasal Dexmedetomidine During Recovery From Sevoflurane Anesthesia in Children: A Systematic Review and Meta-analysis

“…Emergence agitation is a very common complication after surgery, especially for school-aged children with ages 3 to 5 years. 4 Although agitation during the recovery period is self-limiting, it increases the risk of children's self-harm, reduces parental anxiety and satisfaction, prolongs the hospital stay, and increases additional medical expenses. 32 Among them, sevoflurane anesthesia in children has a higher incidence of agitation during the recovery period, which can increase the incidence of agitation during the recovery period in children compared with propofol.…”

“…[1][2][3] Therefore, it is widely used in the induction and maintenance of pediatric anesthesia. 4 However, the incidence of agitation during recovery from sevoflurane anesthesia is generally higher. Relevant studies have shown that the incidence of agitation during recovery from sevoflurane inhalation anesthesia can be as high as 10% to 80%.…”

“…As a new type of inhalation anesthetic, sevoflurane has the advantages of being nonirritating, small blood/gas distribution coefficient, quick onset, quick recovery, low liver toxicity, and mild aroma 1–3 . Therefore, it is widely used in the induction and maintenance of pediatric anesthesia 4 . However, the incidence of agitation during recovery from sevoflurane anesthesia is generally higher.…”

Pediatric Anesthesiology Special Issue

“…Emergence agitation and delirium are common pediatric anesthesia complications. A prospective observational study found a single dose of propofol at the end of a sevoflurane-based myringotomy may decrease postoperative agitation [ 15 ].…”