Can we decrease incidence of postoperative delirium in children by changing premedication?
Authors:
A. Kurzová 1; J. Málek 1; L. Hess 2
Authors‘ workplace:
KAR 3. LF UK a FNKV, Praha
1; IKEM, Praha, Česká republika
2
Published in:
Anest. intenziv. Med., 26, 2015, č. 6, s. 328-332
Category:
Anaesthesiology - Original Paper
Overview
Objective:
Causes of postoperative delirium in children are probably multifactorial. The aim of our study was to assess if using tramadol instead of midazolam in premedication would decrease incidence of postoperative delirium without worsening conditions for induction to anaesthesia.
Design:
Randomised, double blinded trial.
Setting:
University hospital.
Methods:
After ethics committee approval and parents’ consent, 63 children scheduled for adenoidectomy or tympanostomy were included in the study. Oral premedication of atropine drops 0.02 mg/kg + ibuprofen syrup5 mg/kg and either midazolam 0.4–0.5 mg/kg (group Midazolam), or tramadol 1.0–1.5 mg/kg (group Tramadol) was given 30 minutes before induction. Induction and maintenance of anaesthesia were standardised. The level of anxiety on arrival to operation theatre (OT) (1–5), quality of induction to anaesthesia, postoperative delirium in OT and on ward (during postanaesthetic ward round), incidence of PONV and the interval to the first analgesic request were recorded. Statistical analysis was performed by Mann-Whitney and Pearson xi-square tests with Yates correction, P value < 0.05 was considered significant.
Results:
There were 35 patients in the Midazolam and 28 patients in the Tramadol groups. There were no differences in demography, anxiety on arrival to OT, induction to anaesthesia, need of perioperative analgesics and incidence of PONV. The main difference was in the incidence of postoperative delirium both in OT (24 vs. 8 patients, p = 0.0016) and on the ward (26 vs. 3 patients, p = 0.0000).
Conclusion:
Premedication of children with tramadol instead of midazolam results in significantly reduced incidence of postoperative delirium with unchanged conditions for induction to anaesthesia. Tramadol does not increase the incidence of PONV.
Keywords:
premedication – paediatric anaesthesia – general anaesthesia – postoperative complication – delirium – midazolam – tramadol
Sources
1. Dahmani, S., Delivet, H., Hilly, J. Emergence delirium in children: an update. Curr. Opin. Anaesthesiol., 2014, 27, p. 309–315.
2. Breschan, C., Platzer, M., Jost, R., Stettner, H., Likar, R. Midazolam does not reduce emergence delirium after sevoflurane anesthesia in children. Paediatr Anaesth., 2007, 17, p. 347–352.
3. Dong, Y. X., Meng, L. X., Wang, Y., Zhang, J. J., Zhao, G. Y., Ma, C. H. The effect of remifentanil on the incidence of agitation on emergence from sevoflurane anaesthesia in children undergoing adenotonsillectomy. Anaesth. Intensive Care, 2010, 38, p. 718–722.
4. Kim, J. Y., Chang, Y. J., Lee, J. Y., Park, H. Y., Kwak, H. J. Post-induction alfentanil reduces sevoflurane-associated emergence agitation in children undergoing an adenotonsillectomy. Acta Anaesthesiol. Scand., 2009, 53, p. 678–681.
5. Na, H. S., Song, I. A., Hwang, J. W., Do, S. H., Oh, A. Y. Emergence agitation in children undergoing adenotonsillectomy: a comparison of sevoflurane vs. sevoflurane-remifentanil administration. Acta Anaesthesiol. Scand., 2013, 57, p. 100–105.
6. Jenkins, B. N., Fortier, M. A, Kaplan, S. H., Mayes, L. C., Kain, Z. N. Development of a short version of the modified Yale Preoperative Anxiety Scale. Anesth. Analg., 2014, 119, p. 643–650.
7. Costi, D., Cyna, A. M., Ahmed, S. et al. Effects of sevoflurane versus other general anaesthesia on emergence agitation in children. Cochrane Database Syst. Rev., 2014, 9, CD007084.
8. Cravero, J., Surgenor, S., Whalen, K. Emergence agitation in paediatric patients after sevoflurane anaesthesia and no surgery: a comparison with halothane. Paediatr. Anaesth., 2000, 10, p. 419–424.
9. Kain, Z. N., Caldwell-Andrews, A. A., Maranets, I. et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth. Analg., 2004, 99, p. 1648–1654
10. Kain, Z. N., Mayes, L. C., Caldwell-Andrews, A. A., Karas, D. E., McClain, B. C. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics, 2006, 118, p. 651–658.
11. Cox, R. G., Nemish, U., Ewen, A., Crowe, M. J. Evidence-based clinical update: does premedication with oral midazolam lead to improved behavioural outcomes in children? Can. J. Anaesth., 2006, 53, p. 1213–1219.
12. Dahmani, S., Stany, I., Brasher, C. et al. Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies. Br. J. Anaesth., 2010, 104, p. 216–223.
13. Dahmani, S., Brasher, C., Stany, I. et al. Premedication with clonidine is superior to benzodiazepines. A meta analysis of published studies. Acta Anaesthesiol. Scand., 2010, 54, p. 397–402.
14. Bortone, L., Bertolizio, G., Engelhardt, T., Frawley, G., Somaini, M., Ingelmo, P. M. The effect of fentanyl and clonidine on early postoperative negative behavior in children: a double-blind placebo controlled trial. Paediatr. Anaesth., 2014, 24, p. 614–619.
15. Abu-Shahwan, I., Chowdary, K. Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia. Paediatr. Anaesth., 2007, 17, p. 846–850.
16. Bilgen, S., Koner, O., Karacay, S., Sancar, N. K., Kaspar, E. C., Sozubir, S. Effect of ketamine versus alfentanil following midazolam in preventing emergence agitation in children after sevoflurane anaesthesia: a prospective randomized clinical trial. J. Int. Med. Res., 2014, 42, p. 1262–1271.
17. Kanaya, A., Kuratani, N., Satoh, D., Kurosawa, S. Lower incidence of emergence agitation in children after propofol anesthesia compared with sevoflurane: a meta-analysis of randomized controlled trials. J. Anesth., 2014, 28, p. 4–11.
18. Aouad, M. T., Yazbeck-Karam, V. G., Nasr, V. G., El-Khatib, M. F., Kanazi, G. E., Bleik, J. H. A single dose of propofol at the end of surgery for the prevention of emergence agitation in children undergoing strabismus surgery during sevoflurane anesthesia. Anesthesiology, 2007, 107, p. 733–738.
19. Lee, C. R., McTavish, D., Sorkin, E. M. Tramadol. A preliminary review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in acute and chronic pain states. Drugs, 1993, 46, p. 313–340.
20. Lewis, K. S., Han, N. H. Tramadol: a new centrally acting analgesic. Am. J. Health Syst. Pharm., 1997, 54, p. 643–652.
21. Bhatnagar, S., Das, U. M., Bhatnagar, G. Comparison of oral midazolam with oral tramadol, triclofos and zolpidem in the sedation of pediatric dental patients: an in vivo study. J. Indian. Soc. Pedod. Prev. Dent., 2012, 30, p. 109–114.
22. Bolton, C. M., Myles, P. S., Nolan, T., Sterne, J. A. Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis. Br. J. Anaesth., 2006, 97, p. 593–604.
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