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Objectives: Emergence agitation is a negative behavior commonly recorded after pediatric tonsillectomy. We investigated the efficacy of preoperative premedication with oral transmucosal buccal dexmedetomidine on the incidence and severity of emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia., Methods: Ninety patients aged (3-6 years), ASA I-II were enrolled into three groups (n = 30) to receive oral transmucosal dexmedetomidine 0.5 μg.kg -1 (Group DEX I), 1 μg.kg -1 (Group DEX II) or saline placebo (Group C). Our primary endpoint was the Watcha agitation score at emergence in PACU. Secondary outcomes were preoperative sedation score, intraoperative hemodynamics, postoperative Objective Pain Scale (OPS) and adverse effects., Results: The patients' demographics, preoperative sedation scores and extubation time showed no difference between groups. Significant differences between groups in incidence and frequency distribution of each grade of Watcha score were evident at 5 minutes (p = 0.007), 10 minutes (p = 0.034), 30 minutes (p = 0.022), 45 minutes (p = 0.034) and 60 minutes (p = 0.026), postoperatively with significant differences between DEX I and II groups. DEX groups showed lower OPS scores at 5 minutes (p = 0.011), 10 minutes (p = 0.037) and 30 minutes (p = 0.044) after arrival at PACU, with no difference between DEX I and II groups. Patients in DEX II group exhibited lower intraoperative mean heart rate at 15 minutes (p = 0.020), and lower mean arterial pressure at 30 minutes, (p = 0.040), 45 minutes (p = 0.002) and 60 minutes (p = 0.006) with no significant differences between groups in other time points., Conclusion: This study demonstrates the clinical advantage and the simple technique of oral transmucosal DEX premedication for emergence agitation in preschool children undergoing tonsillectomy under sevoflurane anesthesia compared with saline placebo., Trial Registration: Clinical Trials.gov trial registry: NCT02720705., (Copyright © 2019 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Objectives: The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2mg.kg -1 ) administered 30min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5mg.kg -1 ) and saline placebo., Methods: One hundred children aged (7-12) years were randomly allocated in four groups (n=25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5mg.kg -1 (Group K-IV), Nebulized Ketamine 1mg.kg -1 (Group K-N1) or 2mg.kg -1 (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24h postoperative., Results: The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9±60.5min, 95% CI 375.9-425.87) and K-N2 (455.5±44.6min, 95% CI 437.1-473.9) groups compared with Group K-IV (318.5±86.1min, 95% CI 282.9-354.1) and Group C (68.3±21.9min, 95% CI 59.5-77.1; p<0.001), with a significant difference between K-N1 and K-N2 Groups (p<0.001). The total consumption of IV paracetamol in the first 24h postoperative was reduced in Group K-IV (672.6±272.8mg, 95% CI 559.9-785.2), Group K-N1 (715.6±103.2mg, 95% CI 590.4-840.8) and Group K-N2 (696.6±133.3mg, 95% CI 558.8-834.4) compared with Control Group (1153.8±312.4mg, 95% CI 1024.8-1282.8; p<0.001). With no difference between intravenous and Nebulized Ketamine Groups (p=0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p<0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects., Conclusion: Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine., (Copyright © 2019. Publicado por Elsevier Editora Ltda.)

Background and Objective: Emergence agitation is a postoperative negative behavior that affects mainly children. We studied the effect of two different doses of dexmedetomidine on the incidence and degree of EA in children undergoing strabismus surgery., Methods: 90 patients were allocated into three equal groups; patients received 0.5μg.kg -1 of dexmedetomidine in high Dex group, 0.25μg.kg -1 of dexmedetomidine in low Dex group, or normal saline in the placebo group. All drugs were received with the closure of the conjunctiva before the end of the surgery. Pediatric Anesthesia Emergence Delirium (PAED) scale was used to evaluate the agitation, and Face, Legs, Activity, Cry, Consolability (FLACC) scale was used for pain assessment. Adverse effects of dexmedetomidine and recovery times were recorded., Results: The incidence of agitation was significantly lower in high Dex group compared to other groups and it was significantly lower in low Dex group compared to placebo group. The median (range) of FLACC score was significantly lower in both Dex groups compared to placebo group. Recovery times; time from removal of laryngeal mask to eye opening and time stay in post anesthesia care unit was significantly longer in high Dex group compared to other groups. No significant bradycardia or hypotension was recorded. Recovery time was significantly longer in high Dex group compared to the other two groups., Conclusion: Dexmedetomidine (0.5μg.kg -1 ) before emergence from general anesthesia resulted in a reduction in the incidence of emergence agitation compared to a dexmedetomidine (0.25μg.kg -1 ) but on the expense of recovery times without adverse effects., (Copyright © 2018. Publicado por Elsevier Editora Ltda.)

Objectives: We conducted this study to investigate the safety and analgesic efficacy of the addition of Ketamine to Bupivacaine in bilateral extra-oral infra-orbital nerve block in children undergoing cleft lip surgeries., Methods: Sixty patients were randomly allocated into two groups (n=30), Group B received infra-orbital nerve block with 2mL of 0.25% Bupivacaine and Group BK received 0.5mg.kg -1 Ketamine for each side added to 1mL of 0.5% Bupivacaine solution diluted up to 2mL solution to 0.25% Bupivacaine concentration. Assessment parameters included; hemodynamics, recovery time, time to first oral intake, postoperative Faces Legs Activity Cry Consolability (FLACC) scores, Four-point Agitation scores, analgesic consumption and adverse effects., Results: Patients in Group BK showed lower postoperative FLACC scores during all recorded time points (p<0.0001). Two patients in Group BK versus 12 in Group B requested for postoperative rescue analgesia (p<0.001). There were no differences between groups in time, minutes (min), to first request for rescue analgesia. Patients in Group BK reported lower analgesic consumption (366.67±45.67 vs. 240.0±0.0mg, p<0.04). The time to first oral intake was significantly reduced in Group BK (87.67±15.41 vs. 27.33±8.68min, p<0.001). Lower postoperative Agitation scores were recorded in Group BK patients that reached a statistical significance at 45min (0.86±0.11 vs. 0.46±0.16, p<0.04) and in the first hour (h) postoperatively (1.40±0.17 vs. 0.67±0.14, p<0.003). Higher parent satisfaction scores were recorded in Group BK (p<0.04) without significant adverse effects., Conclusions: The addition of Ketamine to Bupivacaine has accentuated the analgesic efficacy of infra-orbital nerve block in children undergoing cleft lip repair surgeries., (Copyright © 2018 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)