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Literature Review

A Prospective Cohort Study of Emergence Agitation in the Pediatric Postanesthesia Care Unit

Voepel-Lewis T, Malviya S, Tait A. Anesthesia & Analgesia 2003;96:1625-30.

Review: The goal of the study was to determine the incidence of emergence agitation (EA), evaluate factors associated with as well as predictive of EA, and examine outcomes in relation to EA in children. The investigators of this study defined EA as "agitation with nonpurposeful movement, restlessness, or thrashing; incoherence; inconsolability; and unresponsiveness." The prospective study consisted of 521 children over a 1-year period, using a nonprobability, consecutive-sampling technique. Inclusion criteria for this study were patients aged 3-7 years, American Society of Anesthesiologists physical status I or II, outpatient surgical procedure, and cognitively intact.

Patients were not randomized to receive a particular medication during the surgical procedure. The decision to premedicate the child, and in addition the choice of anesthetic induction agents and maintenance medication was at the sole discretion of the anesthesiologist.

At the induction of anesthesia the attending anesthesiologist assessed the patient's behavior upon separation from the parent. Also, included in the study data were anesthetics and perioperative medication, the duration of a trained observer documented emergence behaviors. PACU nurses recorded the occurrence of EA, and adverse events.

The results of the study demonstrated ten variables that were associated with an increased incidence of AE. The variables included young age, no previous surgery, poor adaptability, ophthalmology procedures, otorhinolaryngology procedures, sevoflurane, isolflurane, sevoflurane/isoflurane, analgesics, and short time to awakening. Of these ten factors, three were identified as predictive of EA. The factors predictive of EA included time to awakening, isoflurane, and otorhinolaryngologic procedures.

Emergence agitation is a phenomenom that we observed or will observe at some point in clinical practice. The etiology of EA remains unknown. However, this study, as well as earlier studies have identified factors that are associated with EA.

Following final analysis of the data, this study showed the incidence of EA with certain surgical procedures and factors associated with EA. The investigators indicate that knowledge of the risk factors is important to appropriately manage the behaviors observed with EA. The behaviors observed with EA can be quite distressing to the child, the parent(s), and all involved in his/her care.

Comments: This study is the first to comprehensive examine the incidence of EA with certain types of surgical procedures and evaluate factors associated with it. Despite the data being subject to limitations because of study design, the results generated are truly worthy of consideration in one's clinical practice. The authors point out that additional studies are required to examine the factors associated with EA, before drawing further conclusions.

Reviewed by: Cheryl K. Gooden, MD, FAAP

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