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Transition to propofol after sevoflurane anesthesia to prevent emergence agitation: a randomized controlled trial

David Costi¹, James Ellwood, Andrew Wallace

¹Department of Paediatric Anaesthesia, Women's and Children's Hospital, Adelaide, SA, Australia; Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.

Paediatric Anaesthesia

|January 15, 2015

Insights

Transitioning children to propofol after sevoflurane anesthesia significantly reduces emergence agitation (EA). This simple method improves recovery quality without delaying hospital discharge.

Area of Science:

Anesthesiology
Pediatric Anesthesia
Pharmacology

Background:

Emergence agitation (EA) is a common issue in children post-sevoflurane anesthesia.
Previous methods like propofol bolus have yielded inconsistent results, while continuous infusion is complex.
A simple, short transition to propofol could improve pediatric recovery.

Purpose of the Study:

To evaluate if a brief transition to propofol anesthesia reduces EA in children after sevoflurane anesthesia.

Main Methods:

A prospective randomized controlled trial involving 230 children (1-12 years) undergoing MRI under sevoflurane anesthesia.
Children received either a 3-minute propofol infusion (3 mg·kg-1) or no propofol at the end of sevoflurane anesthesia.
EA was assessed using the Pediatric Emergence Anesthesia Delirium (PAED) and Watcha scales by a blinded observer.

Main Results:

The propofol group showed significantly lower EA incidence on both PAED (7% vs. 29%) and Watcha (15% vs. 39%) scales.
Both the duration and severity of EA were reduced in the propofol group.
Emergence and PACU times increased by approximately 8 minutes, but discharge home time remained unaffected.

Conclusions:

Transitioning to propofol at the end of sevoflurane anesthesia effectively reduces EA incidence in children.
This method improves the quality of emergence from anesthesia.
While recovery time is slightly extended, it does not impact the overall discharge time from the hospital.

Read full analysis

Abstract

Background:

Emergence agitation (EA) is a common behavioral disturbance after sevoflurane anesthesia in children. Propofol 1 mg · kg(-1) bolus at the end of sevoflurane anesthesia has had mixed results in reducing the incidence of EA, whereas propofol infusion throughout anesthesia maintenance seems effective but is more complex to administer. If a simple, short transition to propofol anesthesia was found to be effective in reducing EA, this could enhance the recovery of children following sevoflurane anesthesia. We therefore aimed to determine whether transition to propofol over 3 min at the end of sevoflurane anesthesia reduces the incidence of EA in children.

Methods:

In this prospective randomized controlled trial, 230 children aged 1-12 years, undergoing magnetic resonance imaging (MRI) scans under sevoflurane anesthesia were randomized to receive either propofol 3 mg · kg(-1) over 3 min (propofol group), or no propofol (control group), at the end of sevoflurane anesthesia. EA was assessed by a blinded assessor using the Pediatric Emergence Anesthesia Delirium (PAED) scale and the Watcha scale until 30 min after emergence. EA on the PAED scale was defined as a PAED score >12. EA on the Watcha scale was defined as a score ≥ 3. Times to emergence, postanesthesia care unit (PACU) discharge, and discharge home were also recorded.

Results:

Data were analyzed for 218 children. The incidence of EA was lower in the propofol group on both PAED (29% vs 7%; relative risk = 0.25; 95% confidence interval 0.12-0.52; P < 0.001) and Watcha (39% vs 15%; relative risk = 0.37; 95% confidence interval 0.22-0.62; P < 0.001) scales. Duration and severity of EA were also reduced in the propofol group. Preplanned subgroup analyses for midazolam premedication, preexisting cognitive or behavioral disturbance, and age group did not alter our findings. Emergence time and time in PACU were both increased by a mean of 8 min in the propofol group (P < 0.001) with no difference in time to discharge home.

Conclusions:

Transition to propofol at the end of sevoflurane anesthesia reduces the incidence of EA and improves the quality of emergence. There is a small increase in recovery time, but no delay in discharge home.

Keywords:

agitation child delirium emergence propofol sevoflurane

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