Anesthesiology 2007; 107:733– 8 Copyright © 2007, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

A Single Dose of Propofol at the End of Surgery for the

Prevention of Emergence Agitation in Children Undergoing
Strabismus Surgery during Sevoflurane Anesthesia
Marie T. Aouad, M.D.,* Vanda G. Yazbeck-Karam, M.D.,† Viviane G. Nasr, M.D.,‡ Mohamad F. El-Khatib, Ph.D.,*
Ghassan E. Kanazi, M.D.,* Jamal H. Bleik, M.D.§

Background: Emergence agitation in children after sevoflu- thetic phenomenon, which makes comparisons of the
rane is common. Different drugs have been used to decrease its results between studies difficult.
occurrence with variable efficacy. The authors compared the
It is well known that avoiding sevoflurane and using
incidence and severity of emergence agitation in children who
received a single dose of propofol at the end of strabismus propofol-based anesthetics is associated with a smoother
surgery versus children who received saline. recovery profile.11,12 However, despite the fact that propo-
Methods: In this prospective, randomized, double-blind fol-based anesthesia allows for a smoother recovery as com-
study, the authors enrolled 80 healthy children aged 2– 6 yr. The pared with sevoflurane in children, maintenance with
children were randomly allocated to the propofol group (n ⴝ sevoflurane remains a common practice in many institu-
41), which received 1 mg/kg propofol at the end of surgery, or
tions. Among all inhalational anesthetics, sevoflurane is
to the saline group (n ⴝ 39), which received saline.
Results: The mean scores on the Pediatric Anesthesia Emer- considered the agent of choice for induction and mainte-
gence Delirium scale were significantly lower in the propofol nance of anesthesia in children and enjoys wide accep-
group compared with the saline group (8.6 ⴞ 3.9 vs. 11.5 ⴞ 4.5; tance among pediatric anesthesiologists. Our hypothesis is
P ⴝ 0.004). Also, the incidence of agitation was significantly that in children receiving sevoflurane for induction and
lower in the propofol group compared with the saline group maintenance of anesthesia, the administration of a single
(19.5% vs. 47.2%; P ⴝ 0.01). A threshold score greater than 10
dose of propofol just at discontinuation of sevoflurane
on the Pediatric Anesthesia Emergence Delirium scale was
the best discriminator between presence and absence of would decrease the incidence of emergence agitation with-
emergence agitation. Times to removal of the laryngeal mask out delaying emergence from anesthesia or discharge from
airway (10.6 ⴞ 1.5 vs. 9.4 ⴞ 1.9 min; P ⴝ 0.004) and emer- the postanesthesia care unit (PACU).
gence times (23.4 ⴞ 5.7 vs. 19.7 ⴞ 5 min; P ⴝ 0.004) were We designed this prospective, randomized, double-
significantly longer in the propofol group. However, discharge blind study to test this hypothesis. We compared the
times were similar between the two groups (propofol: 34.1 ⴞ
incidence and severity of emergence agitation as well as
8.4 min; saline: 34.9 ⴞ 8.6 min). More parents in the propofol
group were satisfied. the emergence and discharge times in a group of chil-
Conclusions: In children undergoing strabismus surgery, 1 dren receiving a single dose of propofol at the end of
mg/kg propofol at the end of surgery after discontinuation of surgery after discontinuation of sevoflurane versus a
sevoflurane decreases the incidence of agitation and improves second group of children receiving saline.
parents’ satisfaction without delaying discharge from the post-
anesthesia care unit.
Materials and Methods
THE occurrence of emergence agitation in children after After institutional review board (American University
sevoflurane anesthesia is common, with an incidence of Beirut, Beirut, Lebanon) approval and written in-
ranging between 10% and 80%.1,2 Different drugs such as formed consent from parents, 80 healthy children aged
nonopioid analgesics,3,4 opioids,5 benzodiazepines,6 in- 2– 6 yr, with American Society of Anesthesiologists phys-
travenous anesthetics,7 and ␣2 agonists2,8 –10 have been ical status I or II, scheduled to undergo strabismus sur-
used with variable success to allow a smooth emergence gery during general anesthesia were prospectively en-
from sevoflurane anesthesia. Also, a wide variety of mea- rolled in the study and randomly assigned by means of
surement tools have been used to assess this postanes- random numbers generated by a computer to either a
propofol group or a saline group. Exclusion criteria in-
* Associate Professor, ‡ Resident, Department of Anesthesiology, American cluded mental disease, neurologic disease, treatment
University of Beirut, Medical Center. † Clinical Associate, Department of Anes- with sedatives, full stomach, or indication for rapid se-
thesiology, American University of Beirut, Medical Center; Staff Anesthesiologist,
Department of Anesthesiology, Rizk Hospital, Beirut, Lebanon. § Ophthalmol- quence induction.
ogy Surgeon, Department of Ophthalmology, Rizk Hospital, Beirut, Lebanon. Children fasted for 8 h and received 0.5 mg/kg oral
Received from the Department of Anesthesiology, American University of midazolam 15–30 min before separation from the par-
Beirut, Medical Center, Beirut, Lebanon. Submitted for publication March 6,
2007. Accepted for publication July 20, 2007. Support was provided solely from ents. The number of children who were agitated or
institutional and/or departmental sources. combative during induction of anesthesia despite pre-
Address correspondence to Dr. Aouad: Department of Anesthesiology, Amer-
ican University of Beirut Medical Center, P.O. Box 11 0236, Beirut, Lebanon.
medication with midazolam was recorded in each group.
[email protected]. Information on purchasing reprints may be found at An electrocardiogram, pulse oximeter, noninvasive arte-
www.anesthesiology.org or on the masthead page at the beginning of this issue.
ANESTHESIOLOGY’s articles are made freely accessible to all readers, for personal use
rial blood pressure monitor, and rectal temperature
only, 6 months from the cover date of the issue. probe were attached, and an inhalational induction was

Anesthesiology, V 107, No 5, Nov 2007 733

734 AOUAD ET AL.

performed with sevoflurane. After achieving adequate and were analyzed as absence of agitation, and scores of
depth of anesthesia, as evidenced by the need and tol- 3 and 4 were regarded to indicate agitation and were
erance of an oral airway, an intravenous line was in- analyzed as presence of agitation. Values of the PAED
serted on the dorsum of the hand, and 1 mg/kg intrave- scale and the four-point scale were obtained each by a
nous lidocaine was injected, after which breathing was different investigator in all children; the anesthesiologist
gently assisted for approximately 90 s before the inser- assessed agitation using the PAED scale and the PACU
tion of a flexible laryngeal mask airway (LMA) (LMA- nurse using the four-point scale. Agitation was assessed
Flexible™; The Laryngeal Mask Company Limited, immediately after removal of the LMA, and continuously
Oxon, United Kingdom) via which all children received thereafter until all children were calm. The highest
controlled ventilation to maintain an end-tidal carbon scores were recorded. In the PACU, the nurse and the
dioxide between 35 and 40 mmHg. After induction of anesthesiologist who recorded measurements and obser-
anesthesia, all patients received 15 mg/kg intravenous vations were unaware of the group to which the child
paracetamol (Perfalgan; UPSA Laboratories, Agen, France) for was assigned. Also, parents and patients were blinded to
the control of postoperative pain and 1 mg/kg intrave- the treatment allocation. The following time intervals
nous dexamethasone (maximum 16 mg) for the control were recorded: duration of surgery, duration of sevoflu-
of postoperative pain,13 nausea, and vomiting. Anesthe- rane administration (from the start of induction till dis-
sia was maintained with 60% nitrous oxide in oxygen, continuation of sevoflurane), and duration of anesthesia
supplemented by an end-tidal concentration of 2–3% (from the start of induction till removal of LMA). Also,
sevoflurane. At the completion of surgery, all children the following time intervals were recorded from the time
received eye ointment in both eyes without an eye of discontinuation of sevoflurane: the time to removal of
patch. Sevoflurane and nitrous oxide were discontinued, LMA; the time to the first response to a simple verbal
and patients in the propofol group (n ⫽ 41) received 1 command, which is defined as time of emergence; and
mg/kg propofol, whereas patients in the saline group the onset and duration of agitation whenever it oc-
(n ⫽ 39) received the same volume of saline. Propofol or curred. Children’s pain was evaluated in the PACU by
saline were administered by the resident according to questioning and observing the behavior using a numer-
the group to which the patient was randomized. The ical rating scale at 5, 10, and 30 min after emergence,
anesthesiologist collecting the data was blinded to the where 0 corresponds to “no pain,” 1 to “slight pain,” 2 to
group to which the patient was assigned. The LMA was “moderate pain,” 3 to “severe pain,” and 4 to “the worst
removed whenever the child resumed adequate sponta- imaginable pain.”16 Intravenous morphine, 0.1 mg/kg,
neous breathing after separation from controlled venti- was administered to treat agitation upon parents’ re-
lation. After removal of the LMA, the child was trans- quest or to treat pain whenever pain scores were greater
ferred to the PACU. Upon arrival to the PACU, all than 2. Heart rate and blood pressure, as well as the
children were received by one of their parents, who incidence of adverse events such as vomiting, laryngo-
stayed with them until discharge. The Pediatric Anesthe- spasm, and oxygen desaturation, were noted. Children
sia Emergence Delirium (PAED) scale devised by Sikich were discharged from the PACU when hemodynamically
et al.14 (table 1) was used to assess emergence agitation. stable, fully awake, and free of pain, vomiting, or agita-
Also, emergence agitation was graded on a four-point tion. Immediately before discharge, parents were asked
scale: 1 ⫽ calm; 2 ⫽ not calm but could be easily to assess the quality of the PACU stay of their children
consoled; 3 ⫽ moderately agitated or restless and not based on the following satisfaction scale: 1 ⫽ excellent,
easily calmed; 4 ⫽ combative, excited, or disoriented, 2 ⫽ good, 3 ⫽ poor, 4 ⫽ bad.
thrashing around.15 This score was used to calculate the
incidence of agitation, where agitation scores of 1 and 2 Statistical Analysis
were regarded to represent nonproblematic behavior This study was powered on the basis of preliminary
results showing 50% incidence of emergence agitation in
Table 1. The Pediatric Anesthesia Emergence Delirium Scale the control group. A sample size of 32 in each group was
Devised by Sikich et al.14 calculated to detect a decrease in the incidence of agitation
1. The child makes eye contact with the caregiver
down to 15% with ␣ ⫽ 0.05 and ␤ ⫽ 0.2. Continuous data
2. The child’s actions are purposeful were reported as mean ⫾ SD and were analyzed using an
3. The child is aware of his or her surroundings independent sample t test, or analysis of variance for mul-
4. The child is restless tiple comparisons with least significant difference test for
5. The child is inconsolable
post hoc analysis. Categorical data were reported as per-
Items 1, 2, and 3 are reversed scored as follows: 4 ⫽ not at all, 3 ⫽ just a little, centages and were analyzed using the chi-square test or
2 ⫽ quite a bit, 1 ⫽ very much, 0 ⫽ extremely. Items 4 and 5 are scored as Fisher exact test as appropriate. Nonparametric data
follows: 0 ⫽ not at all, 1 ⫽ just a little, 2 ⫽ quite a bit, 3 ⫽ very much, 4 ⫽ such as pain scores were reported as median and inter-
extremely. The scores of each item were summed to obtain a total Pediatric
Anesthesia Emergence Delirium score. The degree of emergence delirium quartile range and were analyzed using the Mann–Whit-
increased directly with the total score. ney U test. A P value less than 0.05 was considered statis-

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PROPOFOL FOR EMERGENCE AGITATION 735

Table 2. Patient Characteristics and Durations of Anesthesia were not agitated (P ⬍ 0.001). A threshold score of the
and Surgery PAED scale greater than 10 was the best discriminator
Propofol Group Saline Group between presence and absence of agitation after emer-
(n ⫽ 41) (n ⫽ 36) gence from anesthesia (fig. 1). The area under the re-
Age, yr 4.2 ⫾ 1.4 4.3 ⫾ 1.3
ceiver operating characteristic curve for the PAED scale
Weight, kg 19.2 ⫾ 4.8 18.1 ⫾ 4.6 score greater than 10 was 0.98 (fig. 2), with a true-
Sex, M/F 46/54 58/42 positive rate (sensitivity) of 0.88 and a false-positive rate
Children undergoing repeat surgery 19.5 11.2 (1-specificity) of 0.039. We also calculated the PAED
Eyes operated, one eye/two eyes 44/56 56/44
Incidence of preoperative agitation 9.7 5.5
scale scores of the children who had unilateral strabis-
Duration of surgery, min 14.1 ⫾ 4.8 16.1 ⫾ 5.8 mus surgery versus children who had bilateral strabis-
Duration of anesthesia, min 37.8 ⫾ 6.2 39.9 ⫾ 7.1 mus surgery; when treatment groups were examined
Duration of sevoflurane administration, 27.6 ⫾ 6 30.4 ⫾ 6.8 separately, there was no significant effect of bilateral
min
surgery in the propofol group. There was, however, a
Values are mean ⫾ SD, or percent. No statistical significance between the two
significant effect of bilateral surgery on the incidence of
groups. agitation in the saline group (table 4).
The time to removal of the LMA and the emergence
tically significant. The sensitivity of the PAED scale was time were significantly longer in the propofol group as
investigated using receiver operating characteristic curve compared with the saline group (P ⫽ 0.004; table 3).
methodology17; the PAED scale scores were correlated The onset and duration of agitation in those children
with the dichotomous outcome of presence or absence of who were agitated were comparable between the two
emergence agitation as per the four-point scale. groups (table 3). All agitation episodes were self-limited.
Although 0.1 mg/kg morphine was offered to children
with prolonged agitation, all parents elected to avoid
Results pharmacologic interventions and to console their chil-
Eighty children were enrolled in the study protocol dren on their own. As such, none of the patients re-
(n ⫽ 41 in the propofol group and n ⫽ 39 in the saline ceived morphine. The median of the highest pain scores
group). Three patients were excluded from the saline recorded postoperatively was 1 (1–2) in the propofol
group because of incomplete data collection. Therefore, group and 1 (1–2) in the saline group (P ⫽ 0.5). No
41 patients in the propofol group and 36 patients in the children required additional analgesics. More parents in
saline group were analyzed. the propofol group rated the quality of the PACU stay of
Patient characteristics, as well as the different dura- their children as excellent as compared with the saline
tions of anesthesia and surgery, were not statistically group (P ⫽ 0.002; table 3). No adverse events such as
significant between the two groups (table 2). laryngospasm, oxygen desaturation, or vomiting epi-
The mean scores of the PAED scale and the incidence sodes were recorded during the study period. Children
of emergence agitation were significantly lower in the in both groups had similar discharge times from the
propofol group as compared with the saline group (P ⫽ PACU (table 3).
0.004 and P ⫽ 0.01, respectively; table 3).
Of the 77 children analyzed, 25 children developed Discussion
emergence agitation (fig. 1). The mean scores of the
PAED scale of those children emerging with agitation Numerous clinical studies have shown that emergence
was 15.1 ⫾ 3.4, versus 7.4 ⫾ 2.1 in the 52 children who agitation in children is a common phenomenon after

Table 3. Characteristics of the Emergence Phase and the Recovery Phase in the Postanesthesia Care Unit

Propofol Group (n ⫽ 41) Saline Group (n ⫽ 36) P Value

PAED scale score 8.6 ⫾ 3.9 11.5 ⫾ 4.5 0.004

Incidence of agitation 19.5 47.2 0.01
Time to removal of LMA, min 10.6 ⫾ 1.5 9.4 ⫾ 1.9 0.004
Emergence time, min 23.4 ⫾ 5.7 19.7 ⫾ 5 0.004
Onset of agitation, min* 24.4 ⫾ 6.8 20.7 ⫾ 6 0.18
Duration of agitation, min* 17.5 ⫾ 6.5 15.3 ⫾ 5.4 0.38
Parents rating satisfaction excellent 75.6 41.7 0.002
Duration of PACU stay, min 34.1 ⫾ 8.4 34.9 ⫾ 8.6 0.68

Values are mean ⫾ SD, or percent. P values less than 0.05 are considered significant.
* The analysis of those two parameters includes the number of children who were agitated after emergence from anesthesia (n ⫽ 8 in the propofol group and
n ⫽ 17 in the saline group).
LMA ⫽ laryngeal mask airway; PACU ⫽ postanesthesia care unit; PAED ⫽ Pediatric Anesthesia Emergence Delirium.

Anesthesiology, V 107, No 5, Nov 2007

736 AOUAD ET AL.

Fig. 1. Comparison of “no agitation” and “agitation” after emergence from anesthesia based on the Pediatric Anesthesia Emergence
Delirium (PAED) scale scores, where agitation refers to a score of 3 or 4 on the four-point scale. A threshold score of the PAED scale
greater than 10 was the best discriminator between presence and absence of agitation after emergence from anesthesia.

sevoflurane or desflurane-based anesthetics, with an in-

cidence that is significantly higher compared with halo-
thane or propofol-based anesthetics.1,3,11,12,18 –20 Three
previous studies have shown that the incidence of emer-
gence agitation after propofol maintenance of anesthesia
ranges from 0 –9%, as compared with a range of 23– 46%
after sevoflurane maintenance.11,12,21 In an attempt to
minimize emergence agitation after desflurane, Cohen
et al.22 supplemented the inhalational anesthetic with 2
mg/kg propofol at the beginning of surgery. However,
the authors did not demonstrate any reduction in the inci-
dence of emergence agitation.22 This result is expected
because propofol has a short duration of action that may
not outlast the duration of the surgery. We investigated the
effect of 1 mg/kg propofol administered after discontinua-
tion of sevoflurane at the end of surgery and found that the
PAED scale scores, as well as the incidence of emergence
agitation, were significantly decreased in the propofol
group compared with the saline group, and parental satis-
faction was significantly improved. Therefore, the timing of
short-acting interventions toward the end of surgery, such
Fig. 2. Receiver operating characteristic (ROC) curve for the as a propofol bolus, would seem to be an important factor
sensitivity (true positive) and 1-specificity (false positive) for to emphasize.
scores on the Pediatric Anesthesia Emergence Delirium scale.
For a score greater than 10, a sensitivity of 0.88 and a 1-speci- In our study, the average PAED scale score was 8.6 ⫾
ficity of 0.039 were found. 3.9 in the propofol group versus 11.5 ⫾ 4.5 in the saline

Anesthesiology, V 107, No 5, Nov 2007

PROPOFOL FOR EMERGENCE AGITATION 737

Table 4. Characteristics of the Emergence Phase and the Recovery Phase in the Postanesthesia Care Unit in Children Undergoing
Surgery in One Eye versus Two Eyes

Propofol Group Saline Group

One Eye (n ⫽ 18) Two Eyes (n ⫽ 23) One Eye (n ⫽ 20) Two Eyes (n ⫽ 16) P Value

PAED scale score 8.3 ⫾ 2.7 8.9 ⫾ 4.7 10 ⫾ 4 13.2 ⫾ 4.5 0.003

Values are mean ⫾ SD. Analysis of variance was used. P values less than 0.05 are considered significant.
Post hoc analysis with least significant difference test: P ⫽ 0.001 between propofol group–one eye and saline group–two eyes; P ⫽ 0.002 between propofol
group–two eyes and saline group–two eyes; P ⫽ 0.023 between saline group–one eye and saline group–two eyes.
PAED ⫽ Pediatric Anesthesia Emergence Delirium.

group (P ⫽ 0.004). Whenever a statistically significant The improved recovery profile in the propofol group
difference is found in a health status measure, it is useful was associated with a significantly longer mean time to
to determine whether this difference is clinically rele- removal of LMA (approximately 1 min) and emergence
vant. Effect size, which is the mean change of the vari- from anesthesia (approximately 4 min) compared with
able divided by the SD of that variable, is used to inter- the saline group. This is consistent with previous studies
pret changes in health status.23,24 The effect size in our showing that the time to awakening correlates nega-
study was 0.72, which is a large health status change. tively with emergence agitation scores.14,26 However,
Therefore, the statistically significant reduction in the this statistically significant difference is of small magni-
PAED scale scores observed in our study is clinically tude and is not clinically significant. Moreover, the de-
relevant. layed removal of LMA and emergence from anesthesia
The PAED scale proposed by Sikich et al.14 is a reliable did not delay discharge; children in both groups had
and valid tool that may minimize measurement error in comparable durations of PACU stay.
the clinical evaluation of emergence agitation. However, Despite the fact that strabismus surgery is well known
the calculation of the incidence of agitation with this to cause a high incidence of postoperative nausea and
scale is not possible. Sikich et al.14 identified a threshold vomiting,27 none of our children vomited in the PACU.
value of 10, above which treatment of emergence agita- This finding may be explained by the following facts:
tion is required. Similarly, we identified a threshold value Only paracetamol, a nonopioid analgesic was adminis-
greater than 10 to discriminate between the presence tered, in addition to dexamethasone that possesses both
and absence of emergence agitation. analgesic13 and antiemetic properties. No morphine was
Ophthalmology procedures in children may be associ- administered to any of the children. Also, children stayed
ated with a high incidence of emergence agitation that for approximately half an hour in the PACU. Discharge
may be related to visual disturbances.25 Przybylo et al.25 from the PACU coincided with the end of the study
found that 44% of children have altered behavior on period. Therefore, the occurrence of delayed nausea
emergence from anesthesia after strabismus surgery. and/or vomiting may have not been recorded by the
This is comparable to the incidence of emergence agita- investigators.
tion that we found in the control group in our study. In In conclusion, the administration of a single dose of 1
addition, when we compared the incidence and severity mg/kg propofol after discontinuation of sevoflurane at
of agitation in children undergoing surgery in two eyes the end of surgery in children undergoing strabismus
versus one eye in both groups, we were able to identify surgery decreases significantly the incidence of agitation
surgery in both eyes as being associated with an in- and improves parental satisfaction without delaying dis-
creased incidence of emergence agitation only in the charge from the PACU.
saline group. In the treatment group, the administration
of propofol may have neutralized the negative effect of
bilateral surgery on emergence agitation. References
A limitation to the use of the PAED scale score in the 1. Welborn LG, Hannallah RS, Norden JM, Ruttiman UE, Callan CM: Compar-
assessment of emergence agitation after strabismus sur- ison of emergence and recovery characteristics of sevoflurane, desflurane, and
gery is the presence of the item regarding eye contact. halothane in pediatric ambulatory patients. Anesth Analg 1996; 83:917–20
2. Kulka PJ, Bressem M, Tryba M: Clonidine prevents sevoflurane-induced
Although none of our children had their eyes patched agitation in children. Anesth Analg 2001; 93:335–8
3. Johannesson GP, Floren M, Lindahl SGE: Sevoflurane for ENT-surgery in
after surgery, the presence of eye ointment may interfere children: A comparison with halothane. Acta Anaesthesiol Scand 1995; 39:
with the ability of the child to make eye contact with the 546–50
4. Davis PJ, Greenberg JA, Gendelman M, Fertal K: Recovery characteristics of
caregiver, which may be misinterpreted as high scores sevoflurane and halothane in preschool-aged children undergoing bilateral myr-
on item 1. However, the anesthesiologist recording the ingotomy and pressure equalization tube insertion. Anesth Analg 1999; 88:34–8
5. Cravero JP, Beach M, Thyr B, Whalen K: The effect of small dose fentanyl
scores did not mention having much difficulty in the on the emergence characteristics of pediatric patients after sevoflurane anesthe-
assessment of this item of the PAED scale score. sia without surgery. Anesth Analg 2003; 97:364–7

Anesthesiology, V 107, No 5, Nov 2007

738 AOUAD ET AL.

6. Lapin SL, Auden SM, Goldsmith LJ, Reynolds AM: Effects of sevoflurane intravenous fentanyl is combined with a caudal block. Paediatr Anaesth 2003;
anaesthesia on recovery in children: A comparison with halothane. Paediatr 13:334–8
Anaesth 1999; 9:299–304 17. Vining DJ, Gladish GW: Receiver operating characteristic curves: A basic
7. Dalens BJ, Pinard AM, Letourneau DR, Albert NT, Truchon RJY: Prevention understanding. Radiographics 1992; 12:1147–54
of emergence agitation after sevoflurane anesthesia for pediatric cerebral mag- 18. Beskow A, Westrin P: Sevoflurane causes more postoperative agitation in
netic resonance imaging by small doses of ketamine or nalbuphine administered children than does halothane. Acta Anaesthesiol Scand 1999; 43:536–41
just before discontinuing anesthesia. Anesth Analg 2006; 102:1056–61 19. Cravero J, Surgenor S, Whalen K: Emergence agitation in paediatric pa-
8. Bock M, Kunz P, Schreckenberger R, Graf BM, Martin E, Motsch J: Com- tients after sevoflurane anesthesia and no surgery: A comparison with halothane.
parison of caudal and intravenous clonidine in the prevention of agitation after Paediatr Anaesth 2000; 10:419–24
sevoflurane in children. Br J Anaesth 2002; 88:790–6 20. Cravero JP, Beach M, Dodge CP, Whalen K: Emergence characteristics of
9. Ibacache ME, Munoz HR, Brandes V, Morales A: Single dose dexmedetomi- sevoflurane compared to halothane in pediatric patients undergoing bilateral
dine reduces agitation after sevoflurane anesthesia in children. Anesth Analg pressure equalization tube insertion. J Clin Anesth 2000; 12:397–401
2004; 98:60–3 21. Cohen IT, Finkel JC, Hannallah RS, Hummer KA, Patel KM: Rapid emer-
10. Guler G, Akin A, Tosun Z, Ors S, Esmaoglu A, Boyaci A: Single dose gence does not explain agitation following sevoflurane anaesthesia in infants and
dexmedetomidine reduces agitation and provides smooth extubation after pedi- children: A comparison with propofol. Paediatr Anaesth 2003; 13:63–7
atric adenotonsillectomy. Pediatr Anesth 2005; 15:762–6 22. Cohen IT, Drewsen S, Hannallah R: Propofol or midazolam do not reduce
11. Uezono S, Goto T, Terui K, Ichinose F, Ishguro Y, Nakato Y, Morita S: the incidence of emergence agitation associated with desflurane anesthesia in
Emergence agitation after sevoflurane versus propofol in pediatric patients. children undergoing adenotonsillectomy. Paediatr Anaesth 2002; 22:604–9
Anesth Analg 2000; 91:563–6 23. Cohen J: Statistical Power Analysis for the Behavioral Sciences, 2nd edi-
12. Picard V, Dumont L, Pellegrini M: Quality of recovery in children: Sevoflu- tion. Hillsdale, New Jersey, Lawrence Erlbaum Associates, 1988
rane versus propofol. Acta Anaesthesiol Scand 2000; 44:307–10 24. Kazis L, Anderson J, Meenan R: Effect sizes for interpreting changes in
13. Afman CE, Welge JA, Steward DL: Steroids for post-tonsillectomy pain health status. Med Care 1989; 27:178–89
reduction: Meta-analysis of randomized controlled trials. Otolaryngol Head Neck 25. Przybylo HJ, Martini DR, Mazurek AJ, Bracey E, Johnsen L, Cote CJ:
Surg 2006; 134:181–6 Assessing behaviour in children emerging from anesthesia: Can we apply psy-
14. Sikich N, Lerman J: Development and psychometric evaluation of the chiatric diagnostic techniques? Paediatr Anaesth 2003; 13:609–16
Pediatric Anesthesia Emergence Delirium Scale. ANESTHESIOLOGY 2004; 26. Voepel-Lewis T, Malviya S, Tait AR: A prospective cohort study of emer-
100:1138–45 gence agitation in the pediatric postanesthesia care unit. Anesth Analg 2003;
15. Aono J, Ueda W, Mamiya K, Takimoto E, Manabe M: Greater incidence of 96:1625–30
delirium during recovery from sevoflurane anesthesia in preschool boys. ANES- 27. Karanovic N, Carev M, Ujevic A, Kardum G, Dogas Z: Association of
THESIOLOGY 1997; 87:1298–300 oculocardiac reflex and postoperative nausea and vomiting in strabismus surgery
16. Kokinsky E, Nilsson K, Larsson LE: Increased incidence of postoperative in children anesthetized with halothane and nitrous oxide. Paediatr Anaesth
nausea and vomiting without additional analgesic effects when a low dose of 2006; 16:948–54

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