Dexmedetomidine Injection during Strabismus Surgery Reduces Emergence Agitation without Increasing the Oculocardiac Reflex in Children: A Randomized Controlled Trial

<div><p>Objective</p><p>Dexmedetomidine is known to reduce the incidence of emergence agitation, which is a common complication after inhalational anesthesia like sevoflurane or desflurane in children. However, the dose of dexmedetomidine used for this purpose is reported variously and the most effective dose is not known. In this study, we tried to find the most effective dose of dexmedetomidine to reduce the incidence of emergence agitation in children undergoing strabismus surgery without the complications like oculocardiac reflex (OCR) or postoperative vomiting.</p><p>Methods</p><p>We randomized 103 pediatric patients aged 2–6 years and undergoing elective strabismus surgery into four groups. Anesthesia was induced with sevoflurane and maintained with desflurane. At the start of induction, dexmedetomidine, delivered at 0.25, 0.5, or 1 μg/kg, or saline was infused intravenously in the D0.25, D0.5, D1 groups, respectively. The primary outcome measure was the incidence of emergence agitation and the secondary outcome measure was the incidence of intraoperative OCR, postoperative vomiting, and desaturation events.</p><p>Results</p><p>The incidence of emergence agitation was 60, 48, 44, and 21% (<i>P</i> = 0.005) and the incidence of intraoperative OCR was 36, 36, 36, and 37% (<i>P</i> = 0.988) in the control, D0.25, D0.5, and D1 groups, respectively. And, postoperative vomiting rate and desaturation events were low in the all groups.</p><p>Conclusion</p><p>Dexmedetomidine decreased the incidence of emergence agitation without increasing intraoperative oculocardiac reflex. Dexmedetomidine delivered at 1 μg/kg was more effective at reducing emergence agitation than lower doses in children undergoing strabismus surgery under desflurane anesthesia.</p><p>Trial Registration</p><p>Clinical Research Information Service <a href="https://cris.nih.go.kr/cris/search/search_result_st01.jsp?seq=5513" target="_blank">KCT0000141</a></p></div

CONSORT flow diagram.

<p>CONSORT flow diagram.</p

Procedural characteristics including only the patients who received the intervention.

<p>Procedural characteristics including only the patients who received the intervention.</p

Change in heart rate during the study period.

<p>The horizontal line within the box is median heart rate during the study period. The edges of the box and the whiskers indicate 25–75% and 5–95% range respectively. The mean heart rate of D0.5 and D1.0 were significantly lower compared to control and D0.25 at PACU. * P < 0.05 vs. control and D0.25. Baseline = before induction; Start = start of operation; O15 = 15 min after start of operation, Removal = LMA removal, PACU = at admission to post-anesthesia care unit; Discharge = PACU discharge.</p

Change in systolic arterial pressure (SAP) during the study period.

<p>The horizontal line within the box is median SAP during the study period. The edges of the box and the whiskers indicate 25–75% and 5–95% range respectively. The mean values of SAP were not statistically different during operation and at PACU among the groups. Baseline = before induction; Start = start of operation; O15 = 15 min after start of operation, Removal = LMA removal, PACU = at admission to post-anesthesia care unit; Discharge = PACU discharge.</p

Emergence agitation, oculocardiac reflex, postoperative pain, and fentanyl use.

<p>Emergence agitation, oculocardiac reflex, postoperative pain, and fentanyl use.</p

Prevalence and risk factors for postoperative stress-related cardiomyopathy in adults

<div><p>Stress-related cardiomyopathy can develop during the postoperative period due to surgery-related stress factors. However, the prevalence and risk factors for this condition are not yet known. During a retrospective, observational study, patients older than 19 years who underwent procedures from January 2011 to December 2015 at a tertiary hospital were included. The main aim was to identify the prevalence and related risk factors for postoperative stress-related cardiomyopathy. To estimate the incidence per risk factor, univariate and multivariate Poisson regression analyses were performed. During the 5-year period, 95,840 patients older than 19 years underwent 125,314 procedures, and the prevalence of postoperative stress-related cardiomyopathy was 17.74 per 100,000 (95% confidence interval, 9.31–26.17), with an in-hospital mortality of 23.5%. As a result, three risk factors were significantly associated: preoperative American Society of Anesthesiologists classification (incidence rate ratio, 5.901 for American Society of Anesthesiologists class 1–2 [ref] versus 3–6; 95% confidence interval,1.289–27.002; <i>P</i> = 0.022); preoperative body mass index (incidence rate ratio, 1.247 for increases of 18.5 [ref] to 30; 95% confidence interval, 1.067–1.458; <i>P</i> = 0.006); and preoperative serum sodium (incidence rate ratio, 0.830 for each increase of 10 mmol/L from 130; 95% confidence interval, 0.731–0.942; <i>P</i> = 0.004). The incidence rate ratio for age for each increase of 10 years from 50 years was 1.057, but it was not statistically significant (<i>P</i> = 0.064). Our study found that the prevalence of postoperative stress-related cardiomyopathy was 17.74 patients per 100,000 adult patients over the course of 5 years, with four cases of in-hospital mortality. Factors that increased the risk of postoperative stress-related cardiomyopathy included higher American Society of Anesthesiologists class (≥3), preoperative hyponatremia, and higher preoperative body mass index.</p></div

Crude prevalence per 100,000 postoperative stress-related cardiomyopathies over the course of 5 years.

<p>ASA, American Society of Anesthesiologists; BUN, blood urea nitrogen; ICU, intensive care unit; IHD, ischemic heart disease; NU disease, neurologic disease; postop, postoperative.</p

Final risk factors for occurrence of postoperative SICMP using multivariate stepwise poisson regression analysis.

<p>Final risk factors for occurrence of postoperative SICMP using multivariate stepwise poisson regression analysis.</p