Year : 2007 | Volume
| Issue : 2 | Page : 57-61
Fentanyl versus dexmedetomidine effect on agitation after sevoflurane anaesthesia
Essam M Manaa1, Ashraf A Abdelhaleem2, Elsayed A Mohamed3
1 Assistant Professor, Anesthesia Department, Assiut University Hospital, Assiut, Egypt; Consultant Anesthetist, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.
2 Lecturer of Anesthesia, Alexandria University Hospital, Alexandria University, Egypt; Acting Senior Registrar, Anesthesia Dept., King Abdulaziz University Hospital, Riyadh, Saudi Arabia.
3 Lecturer of Anesthesia, Liver Institute, Menoufiya University, Egypt; Acting Senior Registrar, Anesthesia Dept.,King Abdulaziz University Hospital, Riyadh, Saudi Arabia.
Essam M Manaa
Assistant Professor, Anaesthesia Department, Assiut University Hospital, Assiut, Egypt. Consultant Anaesthetist, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia, P.O. Box 7805 Riyadh 11472.
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||18-Jul-2009|
| Abstract|| |
Sixty ASA physical status I and II children aged 3 - 6 years were included in this study. After inhalation induction with sevoflurane, patients were randomly assigned to receive either Saline (group 1, n=20), fentanyl 1 mic /kg IV (group II, n=20) or dexmedetomidine 0.3mic/kg IV (group III, n=20)10 minutes before discontinuation of anesthetics.
There was no significant difference (p>0.05) between the three groups regarding age, weight, duration of anesthesia, duration of surgery, time to eye opening, modified Aldrete recovery scores and post operative complication.
The time of first postoperative analgesic dose was significantly shorter in group I compared with other two groups.
The incidence of agitation was significantly higher in group I compared with other two groups, the incidence of agitation was 40% in Group I, 15% in Group II and 20% in Group III. In conclusion, the dose of fentanyl 1 mic/kg iv or dexmedetomidine 0.3mic/kg iv that is administered 10 minutes before the termination of anesthesia reduces the postoperative agitation in children with no adverse effects.
Keywords: Emergence characteristics, inhalation anesthesia, Fentanyl, Dexmedetomidine, pediatric surgery.
|How to cite this article:|
Manaa EM, Abdelhaleem AA, Mohamed EA. Fentanyl versus dexmedetomidine effect on agitation after sevoflurane anaesthesia. Saudi J Anaesth 2007;1:57-61
|How to cite this URL:|
Manaa EM, Abdelhaleem AA, Mohamed EA. Fentanyl versus dexmedetomidine effect on agitation after sevoflurane anaesthesia. Saudi J Anaesth [serial online] 2007 [cited 2020 Jul 9];1:57-61. Available from: http://www.saudija.org/text.asp?2007/1/2/57/51862
| Introduction|| |
SEVOFLURANE IS WIDELY USED in pediatric anesthesia. It is polyfluorinated methyl, isopropyl ether anesthetic which has lower blood and tissues solubilities  . It has a rapid induction and rapid recovery profile, is pleasant, non-pungent, non irritant to airways. However quick recovery after sevoflurane has been associated with an increased amount of agitation on emergence from anesthesia in children when compared with a more soluble anesthetic (Halothane) ,3],,,,, , even in the absence of any surgical intervention  Opioids are often used to great effect to manage moderate to severe pain, such usage may also incidentally help alleviate agitation that results from pain. 
Dexmedetomidine is an a-2 adrenergic agonist with a larger ratio of a2/a1 activity (1600:1) when compared to clonidine (200 :1).The hemodynamic effects of dexmedetomidine are similar to that of clonidine and the effects can vary depending on the dose, rate and route of administration.  ,
Dexmedetomidine has been used as an adjuvant in general anesthesia and for post operative sedation and analgesia.  ,
This study was designed to compare the effectiveness of intravenous dexmedetomidine versus fentanyl to attenuate post operative agitation after sevoflurane anesthesia in pediatric patients.
| Patients and Methods|| |
Sixty patients ASA physical status I &II aged 3-6 years were included in this prospective study after local hospital ethical committee approval and written informed consent from the parents. The children scheduled for elective lower abdominal surgical procedures (inguinal hernia repair and hypospadias) under general anesthesia.
Exclusion criteria included chronic or acute intake of any sedative or analgesic drugs, patient with a defined psychological& emotional disorder or cognitive delay, with acute respiratory illness, asthmatics and any neurological condition that would limit the patient's ability to communicate with or understand nursing personnel and failure of the caudal block.
Patients were randomly categorized into 3 groups.
Group 1: received saline 10ml I.V. 10 minutes before the end of anesthesia.
Group 2: received fentanyl 1 mic/kg diluted in 10 ml I.V 10 minutes before the end of anesthesia
Group 3: received dexmedetomedine 0.3mic/kg diluted in 10 ml I.V 10 minutes before the end of anesthesia.
All patients underwent thorough preoperative evaluation, which included history, physical examination and relevant laboratory investigations. None of the patients was given any solid food overnight, but each was encouraged to take clear fluids until 2 hours before induction of anesthesia. None of the patients received preanesthetic medication.
Inhalation induction via transparent face mask after saturating the breathing system (Jackson-Rees modification of Ayer's T-piece) with a mixture of sevoflurane 8% with N2O 60% in O2. After loss of consciousness, intravenous line was inserted and when adequate depth of anesthesia was reached, a laryngeal mask airway (LMA) of appropriate size for the age and weight of the child was placed and patient was allowed to breath spontaneously. The anesthetic was delivered in a concentration that maintained a stable heart rate, blood pressure and respiratory rate (base line ± 20%). Sevoflurane was reduced to 2% with 60% N 2 0 in O2. Standard monitoring included ECG, Non-invasive blood pressure, respiratory rate, temperature, pulse oximetry, capnography and both inspiratory and end expiratory concentration of CO2, N2O and Sevoflurane were measured continuously during anesthesia using multigas analyzer (Datex-Ohmeda, Cardiocap 5).
Ventilation was assisted if the end-tidal carbon dioxide increased to > 55 mmHg. Caudal block with 0.5 -1.0 ml/kg 0.25% bupivacaine was performed in all patients. Failure of caudal block was defined as increase in heart rate and or mean arterial blood pressure (MAP) > 10% than pre-incisional value at the start of surgery.
At the end of procedure anesthetic gases were discontinued and maintained on O2 100% > 5 L/min.
LMA was removed when patient showed adequate recovery from anaesthesia, patient transferred to the recovery room for monitoring of vital signs till discharged to the ward.
The following parameters were recorded : duration of anaesthesia (time from the start of induction till discontinuation of anesthetics in min., duration of surgery from skin incision to final skin sutures in min., time of emergence (time from the termination end of anesthesia (to) till eye opening on command) in min. and behaviour during emergence according to a Four-Points Scale i.e. 1=calm, 2=Not calm but easily calmed, 3=moderately agitated or restless, 4=excited or disoriented. 
In post anesthesia care unit (PACU) parents were allowed to be at the child's bed side immediately upon admission one trained nurse, blinded to patient group assignment stayed with the patient until discharged to the ward and recording every 10 min the worst rating for each score observed during the previous 10 min. Criteria for transfer to the ward included a patient with no pain, calm and with a Modified Aldrete Score > 10. The time to meet these criteria was also recorded. All syringes with study drugs or placebo were prepared by the same investigator. Administration of anesthesia study drugs and intraoperative data collection were done by 2 investigators blinded to the study drugs.
Data were expressed as mean ± standard deviation and were analyzed using student t test and analysis of variance ANOVA single factor. P<0.05 was considered significant.
| Results|| |
The three groups were comparable as regards age, weight duration of anesthesia and duration of surgery [Table 3].
Emergence time and number of patients who achieved modified aldrete score > 8 were similar between all 3 groups [Table 4].
The time of first postoperative analgesic dose was significantly shorter in group1 compared with group II & III with p=0.0061 and <0.001with no significant difference between group II and III p < 0.5 significant [Table 5].
The number of patients who suffered from pain or discomfort according to objective pain discomfort score was higher in group I (10 patients after 60 minutes) compared with the other two groups (4 and 3 patients after 60 minutes in group I and II respectively) starting from 20 minutes after LMA removal with no significant difference between group II & III [Figure 1].
As regard behaviour during emergence, the incidence of agitation was significantly higher (p <0.001) in group I (40%) compared with other two groups (15% and 20% in group I and II respectively) with no significant difference between group II& III [Figure 2].
None of the children had significant itching, vomiting, shivering or bradycardia.
| Discussion|| |
The incidence of emergence agitation after sevoflurane anesthesia in children has been a topic described in many studies. The cause of agitation after sevoflurane anesthesia is uncertain, the incidence of this excitatory behaviour seems to be reduced by the perioperative use of sedative and analgesic drugs. ,,,,,,,
Compared with placebo oral midazolam 0.5 mg /kg administered before surgery reduced the incidence of agitation after sevoflurane anesthesia from 67% to 39% after myringotomy surgery but not after adenoidectomy (47% versus 60% with placebo (3-8).
The result of our study showed that, in children administration of either dexmedetomidine 0.3mic/kg IV or fentanyl 1 mic /kg IV before the end of surgery reduced the incidence of emergence agitation after sevoflurane anesthesia.
Davis et al. observed that incidence of excitement and agitation was less in patients receiving halothane or sevoflurane when ketorolac was given IV after induction of anesthesia (14% versus 38% (P< 0.005). 
Johannesson et al. found that acetaminophen given after induction of anesthesia decreased agitation after sevoflurane anesthesia. 
It is notable that the first study to describe postoperative agitation found that patients who received an opioid-based anesthesia has less frequent incidence of postoperative disturbance behaviour when compared with those who received cyclopropane anesthesia (0.4% versus 8%). 
Our results are in agreement with Cravero et al who found that addition of fentanyl I mic /kg iv to inhaled sevoflurane anesthesia decreased incidence of postoperative agitation in children scheduled for magnetic resonance imaging scans without any surgical intervention.  We found that agitation reached the highest percentage in group I (40%) while it was less when we used fentanyl (15%) and dexmedetomidine (20%). Galinkin et al observed that the use of intranasal fentanyl 2 mic /kg administered after induction of anesthesia reduced the incidence of agitation after sevoflurane anesthesia from 23% to 2% without increasing the discharge times. 
In our study, there was no significant difference in the time required to reach discharge criteria when fentanyl or dexmedetomidine were given.
On the other hand, Aono et al stated that agitation after sevoflurane anesthesia in children is present even if adequate analgesia given intraoperatively or even if regional block was used. 
Clonidine has also been shown to decrease agitation on emergence from anesthesia. Kulka et al documented a significant decrease in agitation (10% versus 72%) in a clonidine-treated group undergoing circumcision. 
Dexmedetomidine has similar action to clonidine and in our study, when administered IV before discontinuation of anesthetic. It resulted in a reduction of postoperative agitation after sevoflurane anesthesia from 40% in the control group to 20 % in dexmedetomidine group.
The time for first operative analgesic dose was significantly shorter in group I (placebo) compared with other two groups .This may be due to pain or discomfort after sevoflurane anesthesia which is explained by rapid recovery.
Ibacache et al observed that dexmedetomidine decreased the incidence of agitation after sevoflurane anesthesia  We noticed that dexmedetomidine in a dose of 0.3mg /kg iv appear to be safe for intraoperative use in children also we found that it has no significant hemodynamic effects compared with either fentanyl or placebo groups. The incidence of postoperative complication other than agitation was comparable between the three groups.
In conclusion, we found that the incidence of postoperative agitation in patients receiving sevoflurane was significantly decreased by either fentanyl or dexmedetomidine IV 10 minutes before the end of anesthesia.
We recommend further studies on the effects of different doses of dexmedetomidine and fentanyl on emergence agitation after sevoflurane anesthesia.[Table 1], [Table 2]
| References|| |
|1.||Behne M, Wilke HJ, Horder S. Clinical pharmacokinetics of sevoflurane.Clin Pharmacokinet 1993;36:13-26. |
|2.||Davis PJ, Greenberg JA, Gendelman M, Fertal K. Recovery characteristics of sevoflurane and halothane in preschool-aged children undergoing bilateral myringotomy and pressure equalization tube insertion. Anesth Analg 1999;88:34-8. [PUBMED] [FULLTEXT]|
|3.||Lapin SL, Auden SM, Goldsmith LJ, Reynolds AM. Effects of sevoflurane anaesthesia on recovery in children : a comparison with halothane. Paediatr Anaesth 1999;9:299-304. [PUBMED] [FULLTEXT]|
|4.||Welborn LG, Hannallah RS, Norden JM, et al. Comparison of emergence and recovery characteristics of sevoflurane, desflurane and halothane in pediatric ambulatory patients. Anesth Analg 1996;83:917-20. [PUBMED] [FULLTEXT]|
|5.||Beskow A, westrin P. Sevoflurane causes more postoperative agitation in children than does halothane. Acta Anaesthesiol Scand 1999;43:536-41. [PUBMED] [FULLTEXT]|
|6.||Cravero JP, Beach M, Dodge CP, Whalen K. Emergence characteristics of sevoflurane compaired to halothane in pediatric patients undergoing bilateral pressure equalization tube insertion J Clin Anesth 2000;12:897-901. |
|7.||Sury MR, Black A , Himinton L, et al . A comparison of the recovery characteristics of sevoflurane and halothane in children . Anaesthesia 1996;51:543 -6. |
|8.||Sarner JB, Levine M, Davis PJ, et al . Clinical characteristics of sevoflurane in children: a comparison with halothane. Anaesthesiology 1995;82:28-46. |
|9.||Cravero J, Surgenor S, Whalen K. Emergence agitation in pediatric patients after sevoflurane anaesthesia and no surgery : a comparison with halothane. Paediatr Anaesth 2000;10:419-24. [PUBMED] [FULLTEXT]|
|10.||Hassan E, Fontaine DK, Nearman HS. Therapeutic considerations in the management of agitated or delirious critically ill patients .Pharmacotherapy 1998;18 (1) :113-129. |
|11.||Dyck JB, Maze M, Haack C, et al . The pharmacokinetics and hemodynamic effects of intravenous and intramuscular dexmedetomidine hydrochloride in adult human volunteers. Anaesthesiology 1993;78:813-20. |
|12.||Arain SR, Ebert TJ. The efficacy, side effects and recovery characteristics of dexmedetomidine versus propofol when used for Intraoperative sedation. . Anesth Analg 2002;95:461-6. |
|13.||Tobias JD, Berkenbosch JW. Initial experience with dexmedetomidine in paediatric -aged patients. Paediatr Anaesth 2002;12:171-5. [PUBMED] [FULLTEXT]|
|14.||Aho MS, Erkola OA, Scheinin H , et al. Effects of intravenously administered dexmedetomidine on pain after laparoscopic tubal ligation . Anesth Analg 1991;73:112-18. [PUBMED] [FULLTEXT]|
|15.||Aono J, Ueda W, Mamiya K, et al. Greater incidence of delirium during recovery from sevoflurane anaesthesia in preschool boyes. Anesthesiology 1997;87:1298-300. [PUBMED] [FULLTEXT]|
|16.||Aldrete JA, Kroulik D. A post-anesthetic recovery score. Anesth Analg 1970;49:924-934. [PUBMED] [FULLTEXT]|
|17.||Lerman J, Davis PJ, Welborn LG, Orr RJ, et al. Induction , recovery and safety characteristics of sevoflurane in children under going ambulatory surgery. Anesthesiology 1996;84:1332-40. [PUBMED] [FULLTEXT]|
|18.||Viitanen H, Annila P, Viitanen M,Tarkkila P. Premedication with midazolam delayes recovery after ambulatory sevoflurane anesthesia in children. Anesth Analg 1999;89:75 -9. |
|19.||Johannesson GP, Floren M, Lindahl SG. Sevoflurane for ENT - surgery in children : a comparison with halothane. Acta Anesthesiol Scand 1995;39:546-50. |
|20.||Eckenhoff JE, Kneale DH, Drpps RD. The incidence and etiology of postanesthetic excitement : a clinical survey. Anesthesiology 1961;22:667-73. |
|21.||Cravero JP, Beach M, Thyr B, et al .The effect of small dose Fentanyl on the emergence characteristics of pediatric patients after sevoflurane anesthesia without surgery . Anesth Analg 2003;97:364 -7. [PUBMED] [FULLTEXT]|
|22.||Galinkin JL, Fazi LM, Cuy RM, et al. Use of intranasal Fentanyl in children undergoing bilateral myringotomy and tube placement during halothane and sevoflurane anesthesia. Anesthesiology 2000;93:1378-83. [PUBMED] [FULLTEXT]|
|23.||Kulka PJ, Bressem M, Tryba M. Clonidine prevents Sevoflurane - - induced agitation in children. Anesth Analg 2001;93:335 -8. [PUBMED] [FULLTEXT]|
|24.||Ibacache ME, Munoz HR, Brandes V, et al. Single-dose dexmedetomidine reduces agitation after sevoflurane anesthesia in children . Anesth Analg 2004;98:60 -3. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]