Premedication with midazolam in low-risk surgery in children does not reduce the incidence of postoperative delirium. Cohort study
Abstract
Introduction: Pediatric postoperative delirium is a frequent complication for which preventive pharmacological measures have been suggested. The use of midazolam as a prophylactic strategy has not yet been thoroughly assessed. Notwithstanding the fact that it is used in pediatric presurgical separation anxiety, its role in delirium is yet to be established.
Objective: To quantify the incidence of pediatric postoperative delirium in patients undergoing low risk surgical interventions, exposed to oral midazolam-based premedication and to explore the protective and risk factors associated with the development of delirium.
Materials and methods: Prospective, analytical observational study with a cohort design. Children were conveniently selected in accordance with the daily list of surgical procedures in the operating rooms. The inclusion criteria were children between 2 and 10 years old, ASA I-II, undergoing low risk surgeries. Concurrent and longitudinal follow-up was then conducted upon admission to the post-anesthesia care unit (PACU) for the first hour.
Results: A total of 518 children were included. The overall incidence of delirium was 14.4 % (95 % CI: 11.4 %-17.5 %). In the subgroup exposed to midazolam, 178 children were analyzed, with an incidence of delirium of 16.2% (95% CI of 10,8 %-21,7). These patients exhibited a higher tendency to delirium with the use of sevoflurane or fentanyl, and/or when presenting with severe postoperative pain. Patients exposed to propofol and/or remifentanil showed lower incidences.
Conclusions: No reduction in the incidence of emergency pediatric delirium associated with the use of pre-surgical oral midazolam in low risk surgical procedures. Prospective controlled trials and additional research are required to study the effectiveness and safety of this intervention.
References
Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology. 2004;100(5):1138-45. doi: http://doi.org/10.1097/00000542-200405000-00015.
Dahmani S, Delivet H, Hilly J. Emergence delirium in children: an update. Curr Opin Anaesthesiol. 2014;27(3):309-15. doi: http://doi.org/10.1097/ACO.0000000000000076.
Kanaya A. Emergence agitation in children: risk factors, prevention, and treatment. J Anesth. 2016;30(2):261-7. doi: http://doi.org/10.1007/s00540-015-2098-5.
Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A, et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol. 2017;34(4):192-214. doi: http://doi.org/10.1097/EJA.0000000000000594.
González-Cárdenas VH, Munar-González FD, Pinzón-Villazón IL, Cabarique-Serrano SH, Burbano-Paredes CC, Cháves-Rojas N, et al. Study of paediatric postoperative delirium and acute pain in low surgical risk procedures. Colombian Journal of Anesthesiology. 2018;46(2):126-33. doi: http://doi.org/10.1097/cj9.0000000000000024.
Voepel-Lewis T, Malviya S, Tait AR. A prospective cohort study of emergence agitation in the pediatric post anesthesia care unit. Anesth Analg. 2003;96(6):1625-30. doi: http://doi.org/10.1213/01.ANE.0000062522.21048.61.
Byon HJ, Lee SJ, Kim JT, Kim HS. Comparison of the antiemetic effect of ramosetron and combined ramosetron and midazolam in children: a double-blind, randomized clinical trial. Eur J Anaesthesiol. 2012;29(4):192-6. doi: http://doi.org/0.1097/EJA.0b013e32834fc1fb.
Ko YP, Huang CJ, Hung YC, Su NY, Tsai PS, Chen CC, et al. Premedication with low-dose oral midazolam reduces the incidence and severity of emergence agitation in pediatric patients following sevoflurane anesthesia. Acta Anaesthesiol Sin. 2001;39(4):169-77.
Fang XZ, Gao J, Ge YL, Zhou LJ, Zhang Y. Network meta-analysis on the efficacy of dexmedetomidine, midazolam, ketamine, propofol, and fentanyl for the prevention of sevoflurane-related emergence agitation in children. Am J Ther. 2016;23(4):e1032-42. doi: http://doi.org/10.1097/MJT.0000000000000321.
Costi D, Cyna AM, Ahmed S, Stephens K, Strickland P, Ellwood J, et al. Effects of sevoflurane versus other general anaesthesia on emergence agitation in children. Cochrane Database Syst Rev. 2014:12;(9):CD007084. doi: http://doi.org/10.1002/14651858.CD007084.pub2.
Dahmani S, Stany I, Brasher C, Lejeune C, Bruneau B, Wood 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(2):216-23. doi: http://doi.org/10.1093/bja/aep376.
Martin JC, Liley DT, Harvey AS, Kuhlmann L, Sleigh JW, Davidson AJ. Alterations in the functional connectivity of frontal lobe networks preceding emergence delirium in children. Anesthesiology. 2014;121(4):740-52. doi: http://doi.org/10.1097/ALN.0000000000000376.
Breschan C, Platzer M, Jost R, Stettner H, Likar R. Midazolam does not reduce emergence delirio after sevoflurane anesthesia in children. Paediatr Anaesth. 2007;17(4):347-52. doi: http://doi.org/10.1111/j.1460-9592.2006.02101.x.
Vlajkovic GP, Sindjelic RP. Emergence delirio in children: many questions, few answers. Anesth Analg. 2007;104(1):84-91. doi: http://doi.org/10.1213/01.ane.0000250914.91881.a8.
García-Galicia A, Lara-Muñoz MdC, Arechiga-Santamaría A, Montiel-Jarquín AJ, López-Colombo A. Validez y consistencia de una nueva escala (facial del dolor) y de la versión en español de la escala de CHEOPS para evaluar el dolor posoperatorio en niños. Cir Cir. 2012;80:510-15.
Aldrete JA. The pos-anesthesia recovery score revisited. J Clin Anesth. 1995;7(1):89-91. doi: http://doi.org/10.1016/0952-8180(94)00001-k.
Kuratani N, Oi Y. Greater incidence of emergence agitation in children after sevoflurane anesthesia as compared with halothane: a meta-analysis of randomized controlled trials. Anesthesiology. 2008;109(2):225-32. doi: http://doi.org/10.1097/ALN.0b013e31817f5c18.
Gonsalvez G, Baskaran D, Upadhyaya V. Prevention of emergence delirio in children - a randomized study comparing two different timings of administration of midazolam. Anesth Essays Res. 2018;12(2):522-7. doi: http://doi.org/10.4103/aer.AER_52_18.
Lim BG, Lee IO, Ahn H, Lee DK, Won YJ, Kim HJ, et al. Comparison of the incidence of emergence agitation and emergence times between desflurane and sevoflurane anesthesia in children: A systematic review and meta-analysis. Medicine (Baltimore). 2016;95(38):e4927. doi: http://doi.org/10.1097/MD.0000000000004927.
Driscoll JN, Bender BM, Archilla CA, Klim CM, Hossain MJ, Mychaskiw G, et al. Comparing incidence of emergence delirium between sevoflurane and desflurane in children following routine otolaryngology procedures. Minerva Anestesiol. 2017;83(4):383-91. doi: http://doi.org/10.23736/S0375-9393.16.11362-8.
Wu X, Cao J, Shan C, Peng B, Zhang R, Cao J, et al. Efficacy and safety of propofol in preventing emergence agitation after sevoflurane anesthesia for children. Exp Ther Med. 2019;17(4):3136-40. doi: http://doi.org/10.3892/etm.2019.7289.
Chandler JR, Myers D, Mehta D, Whyte E, Groberman MK, Montgomery CJ, et al. Emergence delirio in children: a randomized trial to compare total intravenous anesthesia with propofol and remifentanil to inhalational sevoflurane anesthesia. Paediatr Anaesth. 2013;23(4):309-15. doi: http://doi.org/10.1111/pan.12090.
Guifarro S, Orellana-Folgar M, Sosa-Velásquez A, Espinoza-Murra D. Manifestaciones clínicas del delirio en la población pediátrica. Rev Facultad de Cíencias Médicas. Universidad Nacional Autónoma de Honduras. 2008;5(2):46-52.
Proal E, Álvarez-Segura M, de la Iglesia-Vayá M, Martí-Bonmatí L, Castellanos FX; Spanish Resting State Network. Functional cerebral activity in a state of rest: connectivity networks. Rev Neurol. 2011;52 Suppl 1(0 1):S3-10. doi: https://doi.org/10.33588/rn.52S01.2010792
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(1):34-8. doi: https://doi.org/10.1097/00000539-199901000-00007.
Fan KT, Lee TH, Yu KL, Tang CS, Lu DV, Chen PY, et al. Influences of tramadol on emergence characteristics from sevoflurane anesthesia in pediatric ambulatory surgery. Kaohsiung J Med Sci. 2000;16(5):255-60.
Bock M, Kunz P, Schreckenberger R, Graf BM, Martin E, Motsch J. Comparison of caudal and intravenous clonidine in the prevention of agitation after sevoflurane in children. Br J Anaesth. 2002;88(6):790-6. doi: https://doi.org/10.1093/bja/88.6.790.
Traube C, Silver G, Kearney J, Patel A, Atkinson TM, Yoon MJ, et al. Cornell assessment of pediatric delirium: a valid, rapid, observational tool for screening delirium in the PICU. Crit Care Med. 2014;42(3):656-63. doi: https://doi.org/10.1097/CCM.0b013e3182a66b76.
Downloads
Copyright (c) 2020 Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.)
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
| Article metrics | |
|---|---|
| Abstract views | |
| Galley vies | |
| PDF Views | |
| HTML views | |
| Other views | |
