Research on emergence agitation in children

Abstract

To the Editor,We commend Drs. J Chen et al. on their recently reported comparison of the effects of dexmedetomidine, ketamine, and placebo on emergence agitation after strabismus surgery in children. 1 This is a common problem in pediatric anesthesia that has been much studied but deserves continued research to identify strategies to decrease the incidence and to optimize treatment of this distressing side effect. While the subject area is important, we also identify several concerns regarding the study methodology. It is well established that strabismus surgery in children is complicated by a high incidence of emergence agitation (EA). 2 It has also been well established that propofol-based anesthetic techniques and/or techniques that include low doses of opioids or sedative hypnotics can significantly decrease the incidence of EA. 3 In their study, Chen et al. evaluated outcomes in children undergoing eye muscle surgery who received no propofol, sedatives, or parenteral analgesics during the study period. This technique ensures a high rate of EA in the placebo group and therefore increases the statistical effect of the intervention, but it doesn't serve the study population well. Also, the technique does little to inform the discussion on EA in children. In all likelihood, there would be a resulting benefit from any intervention providing sedation or analgesia to patients who undergo this procedure. 4 Children undergoing general anesthesia with inhaled anesthetics have an increased risk of postanesthetic agitation compared with adults. We know that this risk is increased in certain patient populations and with certain procedures. We also know that undertreated pain contributes to EA behaviours. 5 There are many published studies showing techniques that successfully decrease the incidence of EA in high-risk populations. We need to demand more from the next generation of protocols evaluating EA, and we ought to study patients who are receiving the best possible anesthetic for the procedure that is being performed. Only then can we investigate EA in order to identify risk factors for poor outcomes and evaluate treatments for patients who develop emergence agitation despite receiving the best possible evidence-based care.

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

“…Further research is required to confirm whether our findings would be replicated in a surgical setting. It would be important to have a trial design that includes adequate analgesia administered to all patients so that the possibility of pain acting as a confounding factor is minimized .…”