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Background: Emergence delirium (ED) in children after general anaesthesia causes significant distress in patients, their family members, and clinicians; however, electroencephalogram (EEG) markers predicting ED have not been fully investigated.Methods: This prospective, single-centre observational study enrolled children aged 2-10 yr old under sevoflurane anaesthesia. ED was assessed according to Diagnostic and Statistical Manual of Mental Disorders (DSM) IV or 5 criteria. The relative power of low-frequency (delta and theta) and high-frequency (alpha and beta) EEG waves during the emergence period was compared between the children with and without ED. The linear relationships between the relative power and peak Paediatric Assessment of Emergence Delirium (PAED) score were investigated.Results: Among the 60 patients, 22 developed ED (ED group), whereas the other 38 did not (non-ED group). The relative power of the delta wave was higher (mean [standard deviation], 0.579 [0.083] vs 0.453 [0.090], respectively, P<0.001) in the ED group, whereas that of the alpha and beta waves was lower in the ED group, than in the non-ED group (0.155 [0.063] vs 0.218 [0.088], P=0.005 and 0.114 [0.069] vs 0.186 [0.070], P<0.001, respectively). The areas under the receiver operating characteristic curves of the relative power of the delta wave, low-to-high frequency power ratio, and delta-to-alpha ratio were 0.837 (95% confidence interval, 0.737-0.938), 0.835 (0.735-0.934), and 0.768 (0.649-0.887), respectively. The relative power of the delta wave and the two ratios had a positive linear relationship with the peak PAED scores.Conclusions: Paediatric patients developing ED have increased low-frequency (delta) frontal EEG activity with reduced high-frequency (alpha and beta) activity during emergence from general anaesthesia.Clinical Trial Registration: NCT03797274. [ABSTRACT FROM AUTHOR]

Background: Emergence agitation (EA) is a well-recognised phenomenon often observed in children following general anaesthesia. The aim of this study was to compare the incidence and severity of EA in the paediatric age group under sevoflurane or isoflurane anaesthesia using the PAED Scale (Pediatric Anaesthesia Emergence Delirium Scale) (the primary outcome) and its correlation with preinduction agitation as well as its association with pain using the FLACC (Face Legs Activity Cry Consolability) score (the secondary outcome). Method: In this randomised controlled trial, 60 children aged between 2 and 6 years were enrolled and randomly divided into two groups. All patients were induced with sevoflurane, relaxed with atracurium and the airway secured with an appropriate device. Anaesthesia was maintained with O2, N2O and sevoflurane or isoflurane. Adequate analgesia was ensured. Post-procedure, they were observed in the post-anaesthesia care unit (PACU) for development of EA. The statistical package SPSS® version 17 was used and data were analysed using Student’s unpaired t-test and a chi-square test. Statistical significance was accepted atp< 0.05. Results: The mean PAED scale was 12.9 in the sevoflurane group and 9.4 in the isoflurane group (p< 0.001). The incidence of EA was significantly related to preinduction agitation (p= 0.00). Higher FLACC scores were observed only within the initial 10 min in the sevoflurane group (p= 0.009). Conclusions: An increased incidence of EA was observed with sevoflurane maintenance anaesthesia, particularly during the initial 10–20 min of the postoperative period. EA was strongly associated with preinduction agitation, but it was poorly correlated to pain, i.e. not all patients who developed EA had a high FLACC score. [ABSTRACT FROM AUTHOR]

Objective: The role of inflammation in cognitive alterations in a post-operative setting is still not fully understood. Surgical interventions can cause systemic inflammations which eventually can induce neuroinflammation. However, the main causes of functional changes after surgery are still elusive. In this study, we investigated the role of CD38, a TNFα-inducible NADH+ cyclase and hydrolase. We assume that CD38 overexpression impairs mitochondrial ATP synthesis. Within the hippocampus, the resulting cellular death could lead to cognitive impairment. Methods: Seventy-nine Wistar-HAN rats were subjected for three hours either to partial hepatectomy under sevoflurane anaesthesia ('surgery'), sevoflurane anaesthesia alone ('anaesthesia') or control. Rats were randomly selected to determine levels of CD38, TNFα, IL-6, and ATP, for GFAP immunohistochemistry and for Morris Water Maze testing. Results: Plasma TNFα and IL-6 levels were significantly higher in the surgery group in the immediate post-operative phase. GFAP expression and hippocampal CD38 concentration were significantly elevated 24 h after the intervention in the surgery group as compared to anaesthesia alone and controls. ATP levels did not differ significantly between the three groups. No treatment differences in spatial cognition parameters were found. Conclusions: Surgery in the form of partial hepatectomy activated the peripheral immune system and induced hippocampal glial activation and a CD38 increase. These changes, however, were not associated with rats' cognitive impairment ≥24 h after surgery. [ABSTRACT FROM AUTHOR]

Background: Off-pump coronary artery bypass (OPCAB) surgery carries a high risk for haemodynamic instability and perioperative organ injury. Favourable haemodynamic effects and organ-protective properties could render xenon an attractive anaesthetic for OPCAB surgery. The primary aim of this study was to assess whether xenon anaesthesia for OPCAB surgery is non-inferior to sevoflurane anaesthesia with regard to intraoperative vasopressor requirements.Methods: Forty-two patients undergoing elective OPCAB surgery were enrolled in this prospective, single-blind, randomized controlled pilot trial. Patients were randomized to either xenon (50-60 vol%) or sevoflurane (1.1-1.4 vol%) anaesthesia. Primary outcome was intraoperative noradrenaline requirements necessary to achieve predefined haemodynamic goals. Secondary outcomes included safety variables such as the occurrence of adverse events (intraoperatively and during a 6-month follow-up after surgery) and the perioperative cardiorespiratory and inflammatory profile.Results: Baseline and intraoperative data did not differ between groups. Xenon was non-inferior to sevoflurane, as xenon patients required significantly less noradrenaline intraoperatively to achieve the predefined haemodynamic goals {geometric mean 428 [95% confidence interval (CI) 312, 588] vs 1702 [1267, 2285] µg, P<0.0001}. No differences were found for safety. Significantly more sevoflurane patients developed postoperative delirium (POD) (hazard ratio 4.2, P=0.044). The average arterial pressure was lower in the sevoflurane group {median75 [interquartile range (IQR) 6] vs 72 [4] mmHg, P=0.002}. No differences were found for other haemodynamic parameters, the respiratory profile and the perioperative release of inflammatory cytokines, troponin T, serum protein S-100β and erythropoietin.Conclusions: Compared with sevoflurane, xenon anaesthesia allows a significant reduction in vasopressor administration in OPCAB surgery. Moreover, xenon anaesthesia was associated with a lower risk for POD, a finding that has to be confirmed in larger studies.Clinical Trial Registration: ClinicalTrials.gov (NCT01757106) and EudraCT (2012-002316-12). [ABSTRACT FROM AUTHOR]

Resumo Justificativa e objetivos A incidência de agitação é um problema pós‐anestésico comum em crianças após a anestesia com sevoflurano. Nosso objetivo foi comparar os efeitos de cetamina e midazolam administrados por via intravenosa, antes do término da cirurgia, para prevenir a incidência de agitação em crianças submetidas ao bloqueio caudal para alívio da dor sob anestesia com sevoflurano. Métodos Foram inscritos no estudo 62 pacientes pediátricos, entre 2‐7 anos, estado físico classificado de acordo com a Sociedade Americana de Anestesiologistas (ASA: I ), programados para correção de hérnia inguinal, circuncisão ou orquidopexia. A anestesia foi induzida com sevoflurano a 8% em uma mistura de oxigênio (50%) e óxido nitroso (50%). Depois de atingir a profundidade adequada da anestesia, uma máscara laríngea foi colocada e, em seguida, o bloqueio caudal foi feito com bupivacaína a 0,25% (0,75 mL kg −1 ). No fim da cirurgia, cetamina (0,25 mg kg −1 ), midazolam (0,03 mg kg −1 ) e solução salina foram administrados aos grupos cetamina, midazolam e controle, respectivamente. A incidência de agitação foi avaliada com a escala Paediatric Anaesthesia Emergence Delirium (PAED) e a dor no período pós‐operatório avaliada com a escala modificada Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS). Resultados e conclusões Os escores de dor da escala modificada mCHEOPS foram maiores no grupo controle do que nos grupos cetamina e midazolam. Os escores PAED foram semelhantes entre os grupos. Os escores dessas duas escalas mostraram uma diminuição significativa do tempo em todos os grupos durante o acompanhamento em sala de recuperação pós‐anestesia. O presente estudo resultou em escores satisfatórios da escala PAED, que ficaram abaixo de 10 em todos os grupos. Como conclusão, tanto cetamina quanto midazolam, adicionados ao bloqueio caudal sob anestesia com sevoflurano, não mostraram efeitos adicionais sobre a incidência de agitação. Além disso, o alívio da dor ainda parece ser o principal fator na prevenção da incidência de agitação após anestesia com sevoflurano. Background and objectives Emergence agitation is a common postanaesthetic problem in children after sevoflurane anaesthesia. We aimed to compare the effects of ketamine and midazolam administered intravenously, before the end of surgery, for prevention of emergence agitation in children who received caudal block for pain relief under sevoflurane anaesthesia. Methods 62 American Society of Anesthesiologists patient classification status I children, aged 2–7 years, scheduled for inguinal hernia repair, circumcision or orchidopexy were enrolled to the study. Anaesthesia was induced with sevoflurane 8% in a mixture of 50% oxygen and nitrous oxide. After achieving adequate depth of anaesthesia, a laryngeal mask was placed and then caudal block was performed with 0.75 mL kg −1 , 0.25% bupivacaine. At the end of the surgery, ketamine 0.25 mg kg −1 , midazolam 0.03 mg kg −1 and saline were given to ketamine, midazolam and control groups, respectively. Agitation was assessed using Paediatric Anaesthesia Emergence Delirium scale and postoperative pain was evaluated with modified Children's Hospital of Eastern Ontario Pain Scale. Results and conclusions Modified Children's Hospital of Eastern Ontario Pain Scale scores were found higher in control group than in ketamine and midazolam groups. Paediatric Anaesthesia Emergence Delirium scores were similar between groups. Modified Children's Hospital of Eastern Ontario Pain Scale and Paediatric Anaesthesia Emergence Delirium scores showed a significant decrease by time in all groups during follow‐up in postanaesthesia care unit. The present study resulted in satisfactory Paediatric Anaesthesia Emergence Delirium scores which are below 10 in all groups. As a conclusion, neither ketamine nor midazolam added to caudal block under sevoflurane anaesthesia did show further effect on emergence agitation. In addition, pain relief still seems to be the major factor in preventing emergence agitation after sevoflurane anaesthesia. [ABSTRACT FROM AUTHOR]

There is some evidence that propofol may reduce acute postoperative pain; however, the results are inconsistent. Furthermore, there is a paucity of information about the type of anaesthesia and chronic pain. This study was designed to evaluate the hypothesis that propofol reduces acute and chronic postoperative pain compared with sevoflurane. In a randomised, prospective, double-blind trial, we assigned 80 patients having open total abdominal hysterectomy surgery to anaesthesia with either sevoflurane or propofol. Anaesthesia was titrated to clinical needs and bispectral index values to between 40 and 60. Postoperative pain was managed with pethidine and diclofenac. Acute postoperative pain for 24 hours and chronic postoperative pain at one and three months after surgery were evaluated. The Hospital Anxiety and Depression Scale was used to evaluate patient anxiety and depression after one and three months. There were no significant differences between the groups for opioid consumption or opioid-induced side-effects. Pain scores in the first four hours were significantly higher in the sevoflurane group. Persistent surgical pain was observed less frequently (7 out of 40 patients in the propofol group and 21 out of 40 in the sevoflurane group at three months post-surgery, P <0.01) and pain scores were lower at one and three months in the propofol group (0.78±0.55 versus 2.23±0.73 for the sevoflurane group at three months post-surgery, P <0.01). Anxiety and depression scores were significantly lower in the propofol group at three months. In this study, general anaesthesia with propofol was associated with reduced early acute postoperative and persistent pain, compared to sevoflurane-based anaesthesia, among patients undergoing open abdominal hysterectomy. [ABSTRACT FROM AUTHOR]

The article discusses a study which examined whether clonidine is efficacious in reducing the incidence of agitation in children anesthetized with sevoflurane for cataract surgery. The study found that intravenous clonidine with a dosage of 1 microgram per kilogram is effective in decreasing agitation in children after sevoflurane anesthesia. This dosage is also effective in reducing midazolam premedication. Intravenous clonidine with a dosage of 2 microgram/kilogram is also effective in reducing agitation but was associated with a longer discharge time.

Summary: Background: We evaluated the effect of dexmedetomidine infusion on rocuronium dose requirement, haemodynamic parameters, and the recovery of neuromuscular blockade during sevoflurane anaesthesia in patients. Material: This randomized study was conducted on 40 ASA I–II patients. Neuromuscular block was measured by stimulation of the ulnar nerve and acceleromyograph of adductor pollicis muscle. After tracheal intubation; patients received either 1.0μ/kg over 10min followed by a maintenance 0.2μg/kg/h of dexmedetomidine (Group D)(n=20) or the same volume saline infusion (Group C)(n=20). After this, 0.6mg/kg rocuronium was given to all patients. The incremental doses of rocuronium (0.15mg/kg) were repeated to maintain muscle relaxation at the level of with T1 just positive or maximum up to 10% of its control. The variables recorded were times to recovery of T1 to 25%, 75%, and 90% of control and total dose of rocuronium used during surgery. Heart rate, and mean arterial pressure were recorded. The extubation criteria were adequate recovery of neuromuscular function as judged by TOF ratio >0.95. Results: There were significant decreases in heart rate, and mean arterial pressure in group D 15min after intubation. The times to T1 of 25% was also significantly longer in the dexmedetomidine group (54±13 vs 35±6.7min, respectively, p=0.001). There were no significant variables in recovery time between groups (T1 25–75%, 14.5±6.8 vs 12±5min, respectively, p=0.193). The time required to a 90%T1 recovery was significantly longer in the dexmedetomidine group (86±29.2 vs 58±15.3min, respectively, p=0.005). The total dose requirement of rocuronium was significantly lower in the dexmedetomidine group (61.5±4.65 vs 74±5.21mg respectively, p=0.001). Conclusion: We concluded that dexmedetomidine infusion reduced rocuronium dose requirement, decreased hemodynamic parameters during sevoflurane anaesthesia. [Copyright &y& Elsevier]

Background: Stress response to surgery is modulated by several factors, including magnitude of the injury, pain, type of procedure and choice of anaesthesia. Our purpose was to compare intra- and post-operative hormonal changes during total intravenous anaesthesia (TIVA) using propofol and remifentanil vs. sevoflurane anaesthesia in a low stress level surgical model (laparoscopy). Methods: We randomly allocated 18 patients undergoing laparoscopic surgery for benign ovarian cysts in two groups to receive either TIVA (group A=9) or sevoflurane anaesthesia (group B=9). Perioperative plasma levels of norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), cortisol and leptin were measured. Blood samples were collected pre-operatively (time 0), 30 min after the beginning of surgery (time 1), after extubation (time 2), and 2 h (time 3) and 4 h after surgery (time 4). Results: The comparative analysis between the groups shows significantly higher values of NE ( P<0.001 at time 1 and P<0.01 at time 3), E ( P<0.001 at times 1 and 2; P<0.01 at time 3 and P<0.05 at time 4), ACTH ( P<0.001 at times 1and 2; P<0.05 at time 3) and cortisol ( P<0.001 at times 1and 2; P<0.01 at time 3; P<0.05 at time 4) in group B. The serum values of leptin were not significantly different between the two groups. Conclusion: The choice of anaesthesia does not seem to affect the leptin serum levels but influences the release of stress response markers: ACTH, cortisol, NE and E. [ABSTRACT FROM AUTHOR]

Background: Off-pump coronary artery bypass (OPCAB) surgery carries a high risk for haemodynamic instability and perioperative organ injury. Favourable haemodynamic effects and organ-protective properties could render xenon an attractive anaesthetic for OPCAB surgery. The primary aim of this study was to assess whether xenon anaesthesia for OPCAB surgery is non-inferior to sevoflurane anaesthesia with regard to intraoperative vasopressor requirements., Methods: Forty-two patients undergoing elective OPCAB surgery were enrolled in this prospective, single-blind, randomized controlled pilot trial. Patients were randomized to either xenon (50-60 vol%) or sevoflurane (1.1-1.4 vol%) anaesthesia. Primary outcome was intraoperative noradrenaline requirements necessary to achieve predefined haemodynamic goals. Secondary outcomes included safety variables such as the occurrence of adverse events (intraoperatively and during a 6-month follow-up after surgery) and the perioperative cardiorespiratory and inflammatory profile., Results: Baseline and intraoperative data did not differ between groups. Xenon was non-inferior to sevoflurane, as xenon patients required significantly less noradrenaline intraoperatively to achieve the predefined haemodynamic goals {geometric mean 428 [95% confidence interval (CI) 312, 588] vs 1702 [1267, 2285] µg, P<0.0001}. No differences were found for safety. Significantly more sevoflurane patients developed postoperative delirium (POD) (hazard ratio 4.2, P=0.044). The average arterial pressure was lower in the sevoflurane group {median75 [interquartile range (IQR) 6] vs 72 [4] mmHg, P=0.002}. No differences were found for other haemodynamic parameters, the respiratory profile and the perioperative release of inflammatory cytokines, troponin T, serum protein S-100β and erythropoietin., Conclusions: Compared with sevoflurane, xenon anaesthesia allows a significant reduction in vasopressor administration in OPCAB surgery. Moreover, xenon anaesthesia was associated with a lower risk for POD, a finding that has to be confirmed in larger studies., Clinical Trial Registration: ClinicalTrials.gov (NCT01757106) and EudraCT (2012-002316-12)., (© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background and Objectives: Emergence agitation is a common postanaesthetic problem in children after sevoflurane anaesthesia. We aimed to compare the effects of ketamine and midazolam administered intravenously, before the end of surgery, for prevention of emergence agitation in children who received caudal block for pain relief under sevoflurane anaesthesia., Methods: 62 American Society of Anesthesiologists patient classification status I children, aged 2-7 years, scheduled for inguinal hernia repair, circumcision or orchidopexy were enrolled to the study. Anaesthesia was induced with sevoflurane 8% in a mixture of 50% oxygen and nitrous oxide. After achieving adequate depth of anaesthesia, a laryngeal mask was placed and then caudal block was performed with 0.75mLkg(-1), 0.25% bupivacaine. At the end of the surgery, ketamine 0.25mgkg(-1), midazolam 0.03mgkg(-1) and saline were given to ketamine, midazolam and control groups, respectively. Agitation was assessed using Paediatric Anaesthesia Emergence Delirium scale and postoperative pain was evaluated with modified Children's Hospital of Eastern Ontario Pain Scale., Results and Conclusions: Modified Children's Hospital of Eastern Ontario Pain Scale scores were found higher in control group than in ketamine and midazolam groups. Paediatric Anaesthesia Emergence Delirium scores were similar between groups. Modified Children's Hospital of Eastern Ontario Pain Scale and Paediatric Anaesthesia Emergence Delirium scores showed a significant decrease by time in all groups during follow-up in postanaesthesia care unit. The present study resulted in satisfactory Paediatric Anaesthesia Emergence Delirium scores which are below 10 in all groups. As a conclusion, neither ketamine nor midazolam added to caudal block under sevoflurane anaesthesia did show further effect on emergence agitation. In addition, pain relief still seems to be the major factor in preventing emergence agitation after sevoflurane anaesthesia., (Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)