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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 330-334

Effect of intranasal dexmedetomidine versus peribulbar block on prevention of sevoflurane related emergence agitation in children undergoing unilateral strabismus surgery: A randomized, controlled study

Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission31-Aug-2018
Date of Acceptance25-Mar-2019
Date of Web Publication29-Aug-2019

Correspondence Address:
MD Tamer Y Hamawy
Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Cairo 11757
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/roaic.roaic_69_18

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Background Emergence agitation (EA) and postoperative pain and vomiting (POV) are often complicating the recovery of children after strabismus surgery under sevoflurane anesthesia. This study compared the effects of preoperative intranasal dexmedetomidine versus peribulbar local anesthetic (LA) block technique for strabismus surgery on EA and POV.
Patients and methods Seventy-five children undergoing elective unilateral strabismus surgery under sevoflurane anesthesia were randomly assigned to one of three equal groups (n=25 each). The dexmedetomidine group (group D) received intranasal dexmedetomidine 1 μg/kg preoperatively. The LA group (group L) received peribulbar 2–5 ml of LA mixture (in the form of lidocaine : bupivacaine 1 : 1 ratio) in the operable eye after induction of anesthesia. The control group (group C) received (normal saline) intravenous infusion. In the postanesthesia care unit, pediatric anesthesia emergence delirium scale, Modified Childern’s Hospital of Eastern Ontario Pain Score pain score and POV were assessed. Recovery time and postanesthesia care unit stay were also assessed.
Results Seventy-five patients completed the study, pediatric anesthesia emergence delirium scale score was significantly lower in both the local peribulbar group and the dexmedetomidine group than in the placebo group (P<0.001). Modified Childern’s Hospital of Eastern Ontario Pain Score pain scores were lower in the local group than in the dexmedetomidine group and in the control group. The incidence of POV was lower in group D (3/25) than in group L (5/25) and in the control group (8/25). Emergence time was shorter in group L compared with the other two groups.
Conclusion Peribulbar LA and intranasal dexmedetomidine seem to decrease the incidence of postoperative pain and EA in children undergoing unilateral strabismus surgery under sevoflurane anesthesia.

Keywords: dexmedetomidine, emergence agitation, peribulbar block

How to cite this article:
Hamawy TY, Abdelmalek FA, Ibrahim SA. Effect of intranasal dexmedetomidine versus peribulbar block on prevention of sevoflurane related emergence agitation in children undergoing unilateral strabismus surgery: A randomized, controlled study. Res Opin Anesth Intensive Care 2019;6:330-4

How to cite this URL:
Hamawy TY, Abdelmalek FA, Ibrahim SA. Effect of intranasal dexmedetomidine versus peribulbar block on prevention of sevoflurane related emergence agitation in children undergoing unilateral strabismus surgery: A randomized, controlled study. Res Opin Anesth Intensive Care [serial online] 2019 [cited 2023 Mar 26];6:330-4. Available from: http://www.roaic.eg.net/text.asp?2019/6/3/330/265725

  Introduction Top

Sevoflurane is the most popular inhaled anesthetic in pediatric anesthesia because it is a smooth induction drug, provides fast recovery and disturbs cardiovascular function less. One of the most common problems after anesthesia with sevoflurane in children is emergence agitation (EA), especially in strabismus surgery. EA is characterized by a period of restlessness, agitation, inconsolable crying, disorientation, delusion, hallucination, and cognitive changes with memory impairment [1]. EA in children is short lived with no after effect; however, it is a troublesome phenomenon, because it can result in injury to the patient or damage to the surgical site, leads to dissatisfaction and anxiety for the parents and requires extra nursing care with associated costs. Although this phenomenon was described in the 1960s, the problem remained attenuated during the era of halothane; however, it has resurfaced with the induction of anesthesia with sevoflurane and desflurane in pediatric practice. These less soluble, inhaled anesthetics are more often associated with postanesthesia agitation than with other volatile agents, possibly because of rapid awakening associated with their use, which may initiate EA by worsening a child’s underlying sense of apprehension when finding himself/herself in an unfamiliar environment on awakening [2],[3],[4].

Many drugs have been used to allow a smooth emergence from sevoflurane anesthesia, such as dexmedetomidine, which is a highly specific α2-adrenoreceptor agonist with sedative and analgesic properties without significant respiratory depression at clinical dosages [5],[6]. There is conflicting evidence of the influence of analgesia and sedation following anesthesia on EA. We hypothesized that an anesthetic technique that improves analgesia and prolongs emergence time will reduce the incidence of EA. We selected dexmedetomidine to be compared with peribulbar block in strabismus surgery for this purpose.

  Patients and methods Top

After ethical committee approval and written informed parents’ consent, this randomized prospective controlled clinical study was performed in Ain Shams University Hospitals, Cairo, Egypt, during the time period spanning from January 2015 to June 2015. Seventy-five children, American Society of Anesthesiologists physical status I and II and aged 2–10 years were scheduled for unilateral strabismus correction surgery under general anesthesia. Children with known allergy to any of the drugs used in the study and patients with any diagnosed mental, psychological, or behavioral problems were excluded from the study.

After 6 h of fasting, patients were allocated using a computer-generated randomization table into three equal groups of 25 patients each. The anesthesiologist who performed the intraoperative anesthetic care was not blinded to the group arrangement, whereas the anesthesiologist who managed the patients in the postanesthetic care unit (PACU) was blinded to the group allocation. Group D (dexmedetomidine intranasal), η=25, children received 1 μg/kg intranasal dexmedetomidine 30 min before induction of general anesthesia. Group L (local group), η=25, children received peribulbar injection of 2–5 ml of local anesthetic (LA) mixture in the form of lidocaine: bupivacaine (1 : 1 ratio) after induction of anesthesia and before surgical draping. Group C (control group), η=25, children received only general anesthesia. No premedication was given; anesthesia was induced by sevoflurane, which was increased gradually to 8% with 100% oxygen via a face mask. ECG, SPO2, and NIBP were attached, an intravenous line was established thereafter, and then a laryngeal mask airway of suitable size was inserted (according to age and weight). All patients received dexamethasone 0.15 mg/kg as prophylaxis against postoperative nausea and vomiting (PONV) and intravenous infusion of paracetamol 15 mg/kg for supplemental analgesia over 15 min. Patients were positioned and draped for squint surgery. Anesthesia was maintained with 1.5–2 MAC level of sevoflurane in 50% mixture of oxygen and air. Spontaneous breathing was maintained and monitored with end-tidal CO2 and sevoflurane throughout the entire procedure.

Fentanyl 1 μg/kg was administered if the heart rate of the patient increased by more than 20% during surgery, and these patients were excluded from the study, as fentanyl may reduce the incidence of EA. At the end of surgery, sevoflurane was discontinued, and laryngeal mask airway was removed in a deep plane of anesthesia, with the administration of 100% oxygen by face mask. After emergence, the patients were followed-up in the PACU until they were ready for discharge when they reached a score of 9 in the Modified Aldrete’s Score [7].

Patients were observed for 1 h and assessed for both the incidence and the severity of EA on four occasions by the anesthetist who was blinded to the drugs used : T0=upon admission to PACU, T5=at 5 min, T15=at 15 min, T30=at 30 min. The incidence of EA was evaluated using pediatric anesthesia emergence delirium scale (PAEDS), as shown in [Table 1]. The PAEDS contains five items (eye contact, purposefulness of actions, awareness of surroundings, restlessness, and consolability), each scored on a 0–4 scale, for a maximum of 20 points. A perfectly calm child scores 0, and extreme agitation corresponds to 20 points. The peak EA score was recorded. Agitation scores less than 10 were interpreted as an absence of agitation, scores more than 10 were regarded as the presence of agitation, and scores more than 15 were regarded as severe agitation [9]. Severely agitated patients were treated with 1 mg/kg propofol intravenously at the discretion of the attending anesthesiologist. A second dose of 1 mg/kg intravenous propofol was given if agitation persisted 5 min after propofol administration with a PAED score more than 15. In PACU, postoperative pain was also assessed by the Modified Children’s Hospital of Eastern Ontario Pain Score [10].
Table 1 Pediatric anesthesia emergence delirium scale [8]

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The following data were recorded:
  1. The duration of surgery.
  2. The duration of sevoflurane anesthesia (from mask induction to the discontinuation of sevoflurane inhalation).
  3. The duration of PACU stay (from arrival until discharge).
  4. Emergence time (from discontinuation of sevoflurane to first response to simple verbal command).
  5. Incidence of vomiting (if it occurred, it was treated by intravenous administration of Ondansetron 0.1 mg/kg).
  6. The incidence of intraoperative or immediate postoperative adverse effects such as bradycardia, laryngospasm or any other adverse effect like allergic reactions or oxygen desaturation were noted.

Statistical analysis

Using PASS for sample size calculation, it was calculated that a sample size of 22 per group will achieve 80% power to detect a difference of 40% reduction in the incidence of emergency delirium between the three groups using χ2 test with a significance level (alpha) of 0.05; 25 patients per group were included to replace any dropouts.

Data were analyzed using SPSS, 21.0, for Windows (SPSS, Chicago, Illinois, USA). Analysis of variance was used to compare the three groups for quantitative parametric data, with post-hoc Tukey’s test performed if there was a significant difference among the groups; χ2 test was used for comparison of qualitative data. Continuous parametric data were presented as mean±SD, and categorical data were presented as number of patients. P values of less than 0.05 were considered statistically significant.

  Results Top

Seventy-nine patients were initially enrolled in this study. Four patients (three in the control group and one in the dexmedetomidine group) were subsequently excluded because of use of fentanyl, and hence 75 patients completed the study.

There was no significant difference between the three groups with respect to sex, age, body weight, duration of anesthesia, and surgery.

Emergence time was significantly shorter in the local group (17.28±2.8 min) than in the other two groups ([Table 2]).
Table 2 Demographic and clinical data

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The incidence of vomiting within the first hour after surgery was lower in the dexmedetomidine group (three patients) than in the local group (five patients) and in the control group (eight patients), but this was not statistically significant. The three groups were comparable as regards the incidence of other intraoperative or immediate postoperative adverse effects ([Table 3]).
Table 3 Vomiting and other adverse effects

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Pain scores, measured as maximum Modified Childern’s Hospital of Eastern Ontario Pain Score in the PACU, were significantly lower in the local group than in the dexmedetomidine group and in the control group ([Table 3]). Mean times (SD) for readiness for discharge from PACU (min) were significantly shorter (P value less than 0.001) in the local group (22.74±2.6 min) than in the dexmedetomidine group (44.2±6.21 min) and in the control group (50.4±8.15 min).

[Table 4] Pain score and mean times for readiness for discharge from PACU.
Table 4 Pain score and postanesthesia care unit stay

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The number of patients who experienced EA, defined as PAEDS more than or equal to 10, was significantly higher in the control group (13/25) than in both group D (7/25) and group L (9/25) at time of admission to PACU (T0) and remained significantly higher at T5, T15, and T30. The incidence of severe EA (PAEDS ≥15) was also higher in group C than in the other two groups at T0 (P=0.039) but was not statistically significant at T5, T15, and T30, as shown in [Table 5].
Table 5 Incidence of emergence agitation

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  Discussion Top

The results of this study showed that both peribulbar LA and intranasal dexmedetomidine premedication for children undergoing unilateral strabismus surgery under sevoflurane anesthesia reduce the incidence of EA. This study also showed that the incidence of postoperative vomiting was lower in children receiving intranasal dexmedetomidine premedication compared with the local peribulbar and control groups. Notably, the study also displayed a favorable effect of peribulbar LA on postoperative pain.

EA, postoperative pain, and postoperative nausea and vomiting are the most common undesired effects after recovery from GA in children. The incidence of EA in children showed a variation ranging from 10 to 80% [11]. The cause of EA is currently unknown. Rapid emergence from sevoflurane anesthesia is possibly a cause of EA. In the present study, we hypothesized that abolishing the pain factor with peribulbar LA injection or adding supplemental sedation and analgesia with dexmedetomidine can reduce EA in children undergoing strabismus surgery under GA.

Dexmedetomidine, a highly selective α2 adrenoceptor agonist, is both a sedative and hypnotic agent with a short half-life. At low doses, dexmedetomidine produces a sedative effect, in which patients are cooperative and arousable but remain drowsy. Many studies have shown that the intranasal route is an effective way to administer premedication and sedation to children [12]. It is a relatively easy, noninvasive route with high bioavailability and rapid onset of action, and comparable to that of intravenous administration because of the rich blood supply of the airway mucosa, and because it also bypasses the first pass hepatic metabolism [13]. In addition, this route does not require trained personnel. However, the nasal irritation and the sensation of burning can be considered as drawbacks of this route. On the basis of previous experiences, we selected a dose of intranasal dexmedetomidine of 1 μg/kg to reduce pain and EA.

Similarly, other studies showed that dexmedetomidine has both antiemetic properties and opioid-sparing effects, and it is therefore a beneficial adjunct to GA in children [14]. The antiemetic effect of dexmedetomidine may be additionally explained as a result of binding to the alpha 2 presynaptic inhibitory receptors in the locus coeruleus [15]. In our study, we included vomiting only, as it is difficult to assess nausea in children.

In this study, postoperative pain scores were higher in the control group compared with both the peribulbar and the dexmedetomidine groups, which is explained by their intrinsic analgesic properties and the sedative effect of dexmedetomidine. Peribulbar LA injection displayed a favorable effect in this aspect.

Likewise, Chen et al. [16] compared the effect of intravenous infusion of dexmedetomidine and intravenous ketamine on emergence delirium and postoperative pain and vomiting (POV) in pediatric patients and concluded that both prevent postoperative agitation and pain after sevoflurane anesthesia compared with placebo and that dexmedetomidine also prevents POV. However, this study used only the intravenous route, and the anesthetic technique used did not include any additional parenteral analgesia or sedation, which resulted in a higher incidence of EA in the placebo group.

In another context, Abdelaziz and colleagues compared the effect of intranasal midazolam and dexmedetomidine on emergence delirium in children undergoing strabismus surgery and concluded that the administration of intranasal dexmedetomidine resulted in a reduced incidence of EA and POV compared with midazolam or placebo. Similarly, they suggested that intranasal dexmedetomidine may form an effective adjunct for anesthesia with sevoflurane in children undergoing strabismus surgery [17].

The interpretation of the results of this study must take into consideration that we did not record the number of extraocular muscles that were resected and the length of resection, which may influence the postoperative pain and vomiting and thereby the EA; however, we limited our study to unilateral strabismus surgery to diminish the influence of these factors.

  Conclusion Top

The administration of peribulbar LA or intranasal dexmedetomidine to children undergoing strabismus surgery under sevoflurane anesthesia reduced the incidence of EA compared with the control group. The incidence of POV was also lower with dexmedetomidine. Both techniques were beneficial for children undergoing strabismus surgery.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Dahmani S, Stany I, Brasher C, Lejeune C, Bruneau B, Wood C et al. Pharmacological prevention of sevoflurane and desflurane − related emergence agitation in children: a meta-analysis of published studies. Br J Anaesth 2010; 104:216–223.  Back to cited text no. 4
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McGrath PJ, Johnson G, Goodman JT, Schillinger J, Dunn J, Chapman J. CHEOPS: a behavioral scale for rating postoperative pain in children. In: Fields HL, Dubner R, Cervero F, editors. Advances in pain research and therapy. Volume 9. New York: Raven Press 1985. 395–402  Back to cited text no. 10
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Antilla M, Pentilä J, Helminen A, Vuorilehto L, Scheinin H. Bioavailability of dexmedetomedine after extravascular doses in healthy subjects. Br J Clin Pharmacol 2003; 56:691–693.  Back to cited text no. 12
Yuen VM, Hui TW, Irwin MG, Yao TJ, Chan L, Wong GL et al. A randomized comparison of two intranasal dexmedetomidine doses for premedication in children. Anesthesia 2012; 67:1210–1216.  Back to cited text no. 13
Gurbet A, Basagan-Mogol E, Turker G, Ugun F, Kaya FN, Ozcan B. Intraoerative infusion of dexmedetomedine reduces perioperative analgesic requirements . Can J Anesth 2006; 53:646–652.  Back to cited text no. 14
Whittington RA, Virág L. Dexmedetomidine induced decreases in accumbal dopamine in the rat are partly mediated via the locus coeruleus. Anesth Analg 2006; 102:448–455.  Back to cited text no. 15
Chen JY, Jia JE, Liu TJ, Qin MJ, Li WX. Comparison of the effects of dexmedetomidine, ketamine, and placebo on emergence agitation after strabismus surgery in children. Can J Anaesth 2013; 60:385–392.  Back to cited text no. 16
Abdelaziz HMM, Radwa Hamdi Bakr RH, Kasem AA. Effect of intranasal dexmedetomidine or intranasal midazolam on prevention of emergence agitation in pediatric strabismus surgery: a randomized controlled study. Egypt J Anaesth 2016; 32:285–291.  Back to cited text no. 17


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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