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The Effect of Small Dose Fentanyl on the Emergence Characteristics of Pediatric Patients After Sevoflurane Anesthesia Without SurgeryCravero J, Beach M, Thyr B, Whalen K. Anesthesia & Analgesia 2003;97:364-367.
Reviewed by: Cheryl K. Gooden, MD, FAAP
The goal of the study was to determine whether a small dose of IV fentanyl would improve the emergence agitation (EA) of a group of patients receiving sevoflurane anesthesia and no surgery. The investigators of this study evaluated the percentage of patients with emergence agitation, the duration of agitation, and the time required to meet hospital discharge criteria. This randomized, double-blinded study consisted of 32 patients, aged 18 mo - 10 yrs. American Society of Anesthesiologists physical status I or II, and scheduled for magnetic resonance imaging (MRI) scans with general anesthesia. Exclusion criteria for this study were patients with a defined psychological / emotional disorder, cognitive delay, or any neurological condition that would limit one's ability to communicate or comprehend. Patients were randomized to receive either placebo (saline) or fentanyl during the MRI.
The decision to premedicate the patient was at the sole discretion of the anesthesiologist. Any patient who received midazolam was considered ineligible for the study.
An inhalation induction consisting of sevoflurane in oxygen and nitrous oxide was the technique of choice. After induction, an intravenous catheter was inserted, and then followed by placement of a laryngeal mask airway (LMA). Anesthesia maintenance consisted of sevoflurane with oxygen and nitrous oxide was discontinued. Those patients randomized to receive fentanyl, were given 1 mcg/kg IV 10 min before the end of the anesthetic. The other patients randomized to receive saline, were given an equal volume of saline IV 10 min before the end of the anesthetic.
At the completion of the scan, sevoflurane was discontinued. The LMA was removed while the patient was still nonresponsive to stimulation. Following removal of the LMA, the patient was transferred to the PACU, and subsequently to the secondary recovery unit (SRU). A blinded observer was present at the end of the anesthetic and upon admission to the PACU. The observer recorded the level of agitation, starting with discontinuation of anesthesia, using an EA scale. The scale assessed agitation from one to five as follows: 1) the obtunded patient with no response to stimulation, 2) asleep but responsive to movement or stimulation, 3) awake and appropriately responsive, 4) crying and difficult to console and 5) wild thrashing behavior. EA was defined as a score, greater than or equal to four for greater than or equal to five min, despite efforts to calm the patient. A record of agitation levels was kept until the patient was awake, alert, calm, and responsive to his/her parent or guardian. The nurses in the PACU and SRU determined respectively, when the child met discharge criteria from each unit.
Following final analysis of the data, this study showed a decreased incidence of agitation (12% vs 56%) in patients who received fentanyl compared with placebo. The difference in the time to meet discharge criteria was not significant.
Comments: This study is the first to examine the incidence of EA, outside the realm of surgical procedures. Over the course of the past year, I have reviewed several studies that described the incidence and characteristics of EA in pediatric patients receiving sevoflurane anesthesia, and undergoing a surgical procedure. Despite the small number of patients, the significance of this study, is that the effect of fentanyl on emergence behavior being strictly related to its pain control could be eliminated. The behavior observed with EA can be quite distressing to the child, the parent/guardian, and all involved in his/her care. The results generated are truly worthy of consideration in one's clinical practice
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