Incidência de delirium do despertar em crianças submetidas à adenoidectomia com ou sem tonsilectomia sob anestesia geral e que receberam clonidina via oral como medicação pré-anestésica

Abstract

Emergence delirium (ED) is an anesthetic complication very common in children. It is characterized by a behavior and cognition changes during early postoperative period. It is presented as a disturbance of consciousness and awareness to the environment, with disorientation and perceptual alterations, including hypersensitivity to external stimuli and hyperactive motor behaviors. The incidence may be higher than 80%. Risk factors include preschool children, sevoflurane-based anesthesia, ophthalmologic and ear, nose and throat surgery. The diagnosis is clinic and based on scales. PAED (Pediatric Anesthesia Emergence Delirium) is the only one validated. Prevention is the better approach. Alpha 2 agonists, propofol and total intravenous anesthesia are the main forms of pharmacological prevention. Treatment is indicated in selected cases. This study aims to evaluate the ED incidence in children undergoing adenoidectomy with or without tonsillectomy. Were also evaluated the incidence of other postoperative complications, pain (CHEOPS, Childrens Hospital of Eastern Ontario Pain Scale), time to awake, time to discharge from post-anesthesia care unit (PACU), PAED inter-rater agreement and parental satisfaction. Methods: A prospective and observational study of ASA I or II physical status children aged one to nine. All children received oral clonidine 4 mcg.kg-1 one hour before induction. Induction was performed with nitrous oxide/oxygen and sevoflurane. After insertion of a peripheral intravenous catheter, fentanyl 2 mcg.kg-1, propofol 2 mg.kg-1 and lidocaine 2 mg.kg-1 were administered. The anesthesia was maintained with sevoflurane. The child was extubated awake. Two independent evaluators applied PAED at 1st, 10th, 20th and 30th minute and CHEOPS at 10th, 20th and 30th minute after awake. PAED and CHEOPS 10 indicate ED and pain, respectively. Results: 72 children were enrolled. The median age was 4.25 years (IQR 2575% 2,9-6,3). Thirteen children received a PAED score 10, with an overall incidence of 18%. Five children received a CHEOPS score 10. Kappa coefficient for PAED scale was 0.83 for the first minute after extubation and 1 for the others. Seven children presented laryngospasm. One child presented hypotension and another had bradycardia. One presented vomiting. Median time for awake and discharge from PACU was 18 (IQR 25-75% 15-22) and 60 (IQR 25-75% 60-68) minutes, respectively. The majority of parents reported they were very satisfied. Conclusion: ED incidence was low when compared to the literature, probably due to administration of oral clonidine as preanesthetic medication. ED is very common in pediatric anesthesia and preventive measures should be instituted in high-risk patients. PAED scale is the only one validated and inter-rater agreement was considered perfect. Although it is a self-limited complication, the impact of ED on childs behavior and cognition is not yet elucidated, and risk stratification, correct diagnosis and preventive measures are recommended.