A presentation by David Costi at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.

1. Emergence Agitation
David Costi
Women’s and Children’s Hospital
Adelaide, Australia
No conflicts of interest

3. 2014 systematic review
158 RCTs 14,045 kids
69 compared other GA to sevo
100 studied adjuncts with sevo
Clinical heterogeneity of trials
EA incidence 37% (>6000 sevo controls)

4. Terminology / Definitions
Emergence agitation (EA)
Emergence delirium (ED)
Early post-operative negative behaviour (e-PONB)
>20 scales
PAED scale 2004 “validated”

5. PAED scale: score 0-20
Some report scores only
Arbitrary cut-off scores for EA: ≥10, >10, ≥12, >12, ≥16

6. Propofol* Desflurane
Fentanyl* Isoflurane
Dexmedetomidine* Oral Midazolam premedication
Clonidine* Parental presence at emergence
Halothane* Gradual sevo cessation
Ketamine Lower sevo concentration
IV Midazolam at end
Analgesia
Various sedatives
N2O washout
Effective Ineffective

7. The Big 3
Studies Participants RR 95% CI
Propofol (TIVA) 14 1098 0.35 0.25, 0.51
Fentanyl 15 1247 0.37 0.27, 0.50
Dexmedetomidine 12 851 0.37 0.29, 0.47

8. The Big 3
Studies Participants RR 95% CI
Propofol (TIVA) 14 1098 0.35 0.25, 0.51
Fentanyl 15 1247 0.37 0.27, 0.50
Dexmedetomidine 12 851 0.37 0.29, 0.47
Halothane 34 3534 0.51 0.41, 0.63

9. Propofol

10. Sevoflurane control
EA reduction<------------------------Anaesthesia---------------------->

11. Sevoflurane control
Propofol TIVA
EA reduction
Effective
<------------------------Anaesthesia---------------------->

12. Sevoflurane control
Propofol TIVA
EA reduction
Effective
Effective
Sevo for induction only
<------------------------Anaesthesia---------------------->

13. Sevoflurane control
Propofol for induction only
Propofol TIVA
EA reduction
Effective
Effective
Not effective
Sevo for induction only
<------------------------Anaesthesia---------------------->

14. Sevoflurane control
Propofol for induction only
Propofol TIVA
EA reduction
Effective
Effective
Not effective
Not effective
Sevo for induction only
<------------------------Anaesthesia---------------------->
Propofol 1 mg/kg bolus early


15. Sevoflurane control
Propofol for induction only
Propofol TIVA
EA reduction
Effective
Effective
Not effective
Not effective
Sometimes effective
Sevo for induction only
<------------------------Anaesthesia---------------------->
Propofol 1 mg/kg bolus early

Propofol 1mg/kg bolus at end


16. Sevoflurane control
Propofol for induction only
Propofol TIVA
EA reduction
Effective
Effective
Not effective
Not effective
Sometimes effective
?
Sevo for induction only
<------------------------Anaesthesia---------------------->
Propofol 1 mg/kg bolus early

Propofol 1mg/kg bolus at end

Propofol transition late

17. Propofol 1mg/kg bolus at end
MRI
Strabismus
Strabismus
Tonsillectomy
Tonsillectomy
Risk ratio 0.58 [0.38, 0.89]

18. Propofol 1mg/kg bolus at end
MRI
Strabismus
Strabismus
Tonsillectomy
Tonsillectomy
Emergence delayed 4 mins
Pediatr Anesth 2015; 25 :668-76

19. Intervention: Propofol 3 mg/kg over 3 minutes
Control: No propofol
230 MRI patients - avoid pain as a confounder
Sevoflurane via LMA
Ped Anesth 2015; 25(5):517-523

20. PAED > 12

21. Incidence of PAED score >12
Peak PAED scores
Incidence of Watcha score ≥3
EA outcomes

22. PAED >12 EA
PropofolSevoflurane
EA outcomes
29% 7% RR 0.25 (0.12-0.52)
p < 0.001

23. PAED >12 EA
39% 15%
PropofolSevoflurane
EA outcomes
Watcha ≥3 EA
29% 7% RR 0.25 (0.12-0.52)
p < 0.001
RR 0.37 (0.22-0.62)
p < 0.001

24. PAED >12 EA
39% 15%
PropofolSevoflurane
EA outcomes
Watcha ≥3 EA
29% 7% RR 0.25 (0.12-0.52)
p < 0.001
RR 0.37 (0.22-0.62)
p < 0.001
Peak PAED scores
median (IQR)
10 (6, 13) 6 (2, 10) p <0.001

25. 0
5
10
15
20
25
Sevoflurane
0
5
10
15
20
25
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Propofol
Number
of
Patients
PAED Score
Peak PAED score for each individual patient

26. Incidence of EA vs Time after emergence

27. Recovery: 8 minutes longer
Emergence +8 minutes (+4 mins for 1mg/kg)
Time in PACU +8 minutes
Discharge home – no difference
To avoid delays - make the switch earlier!

28. Fentanyl

29. Fentanyl

30. Subgroup analysis - nasal fentanyl effective
- IV fentanyl not effective
Our larger meta-analysis found both routes effective
Confirmed this month – Pediatr Anesth 2017; 27: 885-892.

31. Fentanyl
Nasal route useful when no IV access:
Grommets - 2 mcg/kg intra-nasal
(Galinkin 2000, Finkel 2001, Hippard 2012)
- 1 mcg/kg intra-nasal ineffective
(Rampersad 2010)
Rescue for established EA with no IV access

32. Fentanyl
Effective even in the absence of pain:
1 mcg/kg IV 10 mins from end – MRI
no difference in side effects
(Cravero 2003)

33. Fentanyl 1 mcg/kg v Propofol 1mg/kg v Placebo (at end)
Inguinal hernia repair with caudal block
Equally effective for EA
More PONV with fentanyl (no intra-op anti-emetics)

34. Fentanyl v Clonidine
2014 24:614-619
Fentanyl 2 mcg/kg v Clonidine 2 mcg/kg v Placebo (at start)
Sub-umbilical surgery with “effective blocks”
Only fentanyl reduced EA/ED
More PONV with fentanyl (no anti-emetics)

35. α2 agonists
clonidine
dexmedetomidine

36. Clonidine
Can be effective via several routes: Oral, IV, Caudal
Doses studied in RCTs:
IV 1, 1.5, 2, 3 mcg/kg (most commonly 2 mcg/kg)
Caudal 0.75, 1, 3 mcg/kg
Oral premed 4 mcg/kg (vs midazolam)
But………….

37. Clonidine
Efficacy limited to RCTs with regional blocks (not ENT)
Dose dependent side effects – emergence time / sedation
Incidents with higher doses -> ANZCA alert…….

39. Clonidine

40. Clonidine
Penile block
Caudal block
Regional/central
Penile block
Caudal/penile block
Sub-Tenon block
Caudal

41. Clonidine
Adenoidectomy study used 1.5 mcg/kg IV – ineffective
2 mcg/kg in pilot study delayed discharge
Adenoidectomy
Ear / pulse dye laser

42. Dexmedetomidine
Effective by a range of routes and doses:
IV bolus 0.15, 0.3, 0.5, 1 mcg/kg (early / late)
IV infusion 0.2 mcg/kg/hr
IV load 2mcg/kg then infusion 0.7 mcg/kg/hr
IV load 1mcg/kg then infusion 0.1-1 mcg/kg/hr
Caudal 1mcg/kg
Nasal premed 1, 2 mcg/kg
Oral premed 2.5mcg/kg

43. Dexmedetomidine

44. Dexmedetomidine
4 other systematic reviews in 2014
IV route only

46. Other benefits IV Dexmed
EA with or without regional blocks
EA with adenotonsillectomy
rescue analgesia
PONV
Minimal increase in emergence
Best dosing of IV dexmed??

47. Intra-nasal dexmedetomidine
premedication

48. 2015 25: 468–476
Outcome Dex vs Midaz (13 studies)
EA Dex better (10% v 40%) 4 studies
Separation from parents Dex better
Sedation at induction <->
Post-op analgesia Dex better
Side effects <->

49. May 2015
1 mc/kg v 2mcg/kg v placebo 45 mins pre-op
Dose dependent  EA
Dose dependent  MACLMA
Emergence – 6 and 8 mins longer
PACU time – no difference

50. Current practices
Pediatr Anesth 2016; 26 :207-12
106 responses (51%)
45% routinely give something to prevent EA

51. Prevention Treatment
1. Propofol 68% 1. Propofol 42%
2. Fentanyl 46% 2. Midazolam 31%
3. Midazolam 42% 3. Fentanyl 10%
4. Morphine 31% 4. Morphine 7%
5. Dexmedetomidine 15% 5. Dexmedetomidine 5%
Pediatr Anesth 2016; 26 :207-12

52. German anaesthesia society survery
1200 responses from 10,000 emails

53. Prevention of EA

54. Treatment of EA
Propofol, Opioids, Clonidine – approx 30% each
Ketamine 3%
Dexmedetomidine 1 %
(84% used midazolam premeds)

56. Sevo ind/maint via face mask
IV access – sufentanil, paracetamol
Severe EA –> more sufentanil

57. Lost opportunity in a child with IV access
Almost every pre-schooler deserves to
emerge on propofol!

58. My approach for a calm emergence:
Multimodal EA prophylaxis
(Analogous to PONV prophylaxis / pain management)
Stratify risk (consider no. of risk factors)
pre-school age
anxiety
temperament
previous EA
procedure (ENT, strabismus, dental)
Decide type and number of prophylactic interventions
always context specific

60. Propofol
TIVA, maintenance, transition, or bolus at end
Adequate analgesia at emergence
including Fentanyl (nasal fentanyl if no cannula)
If using N2O, then N2O washout
+/- α2 agonist (premed or IV)
Approach for Calm Emergence

61.  Age
 Pediatric Anesthesia Behaviour score
 Anaesthesia time
 Surgery type