Comparison of intravenous and inhalation anesthesia on postoperative behavior changes in children undergoing ambulatory endoscopic procedures
A randomized clinical trial
June 2023 by Dr Priya Sreedharan
This randomized, parallel, double-blinded clinical trial performed in an outpatient endoscopic clinic between October 2018 and December 2021 was designed to determine if intravenous anaesthesia was effective at reducing post operative behavioural changes in children undergoing ambulatory endoscopic procedures when compared to inhalational anaesthesia.
164 children between the ages of 1-12 yrs , ASA I -III, undergoing endoscopic day surgery procedures, were included and analysed in the study and randomised to receive either inhalational or intravenous maintenance of anaesthesia post induction. All children received inhalational induction with sevoflurane. The intravenous group was then maintained with propofol post placement of a peripheral intravenous cannula.
All children were assessed using a modified Yale Preoperative Anxiety Scale (mYPAS) and the parental anxiety preoperatively assessed using a 100mm Visual analog scale (VAS-anx). Post procedure emergence delirium was assessed using Paediatric Anaesthesia Emergence Delirium (PAED) scale whilst pain was assessed using FLACC scale. Severe emergence delirium (ED) was treated with a bolus of propofol (1mg/kg) and severe pain was treated with fentanyl (1ug/kg).
On days 1,7 and 14 post procedure, the parents were contacted by telephone, and the child’s behaviour was evaluated using the Post Hospitalisation Behaviour Questionnaire for Ambulatory Surgery (PHBQ-AS). The PHBQ-AS is a slightly abbreviated version of the PHBQ with 11 items including anxiety, regression, sleep and eating disorders, aggression and apathy.
They recorded a 19% incidence of ED in the intravenous group and 41% in the inhalational group in the first minute post wake up. This difference did not persist to the 5th and 10th minute post wake up with FLACC pain scores being comparable. There were no differences of note in the preoperative children’s or parental anxiety scores. They did not find any differences in the adverse behavioural outcome between the inhalational and intravenous group post procedure on day one, seven and fourteen as per the PHBQ-AS questionnaire. They did find a moderate co-relation between the occurrence of emergence delirium and the number of negative postoperative behaviours on day 7 but this was across both groups.
Take home message: ED and prolonged negative behavioural changes post procedure is a topic of much interest in the paediatric anaesthetic world and data to date suggests that the cause is multifactorial, with no magical single intervention to prevent their occurrence. Several studies have looked into the effect of the two anaesthetic techniques on post operative delirium and found that there may be benefits in the incidence of emergence delirium with intravenous techniques but the effects on prolonged post operative behavioural changes is less clear. This study found an early reduction in ED with the intravenous technique but no differences between inhalational and intravenous maintenance techniques for negative behaviours in the days following.
The did note that many of their patients were “frequent flyers” and may have exhibited less preoperative anxiety but the co-relation between ED and post procedural negative behaviour was reinforced regardless of technique.
Extrapolation of the findings in this study to the general “anxious” paediatric population undergoing painful procedures must be carefully made.