Emergence agitation after cataract surgery in children: a comparison of midazolam, propofol and ketamine

OBJECTIVES: The aim of this study was to determine whether the concurrent use of either of a subhypnotic dose of midazolam, propofol or ketamine with fentanyl just before discontinuing the sevoflurane anesthesia would effectively sedate the children as they recovered and significantly decrease the incidence and severity of emergence agitation and would not delay patient awakening and discharge. BACKGROUND: Postoperative emergence agitation may occur in children after general anesthesia with volatile anesthetics. Children who undergo cataract surgery after sevoflurane induction and sevoflurane-remifentanil maintenance may experience this type of agitation. METHODS/MATERIALS: In 120 un-premedicated children aged 1-7 years, mask induction with sevoflurane was performed and they were then randomly assigned to one of the three antiagitation postoperative groups (n = 40). We studied the postoperative antiagitation effects of subhypnotic doses of midazolam combined with fentanyl, propofol with fentanyl or ketamine with fentanyl administered just before discontinuing the sevoflurane anesthesia. A score for the level of agitation can be assigned based on the recovery mental state (RMS) scale and the recently published pediatric anesthesia emergence delirium scale (PAED). Postoperative factors assessed included emergence behaviors, the time to eye opening, the time to discharge from the postanesthesia care unit (PACU) to the ward. RESULTS: There were significantly more agitated children in the ketamine-group when compared to the midazolam-group or to the propofol-group at all time P < 0.05), especially at 10 and 15 min. The PAED scale showed a significant advantage for midazolam-fentanyl [5 (2-15)] and propofol-fentanyl [6 (3-15)] versus ketamine-fentanyl [10 (3-20)] (P < 0.05). The time to discharge from the PACU to the ward was not significantly different among the groups. CONCLUSIONS: Intravenous administration of a subhypnotic dose of midazolam or propofol in addition to a low dose of fentanyl just before discontinuing the sevoflurane anesthesia was both effective on decreasing the incidence and severity of emergence agitation in children undergoing cataract extraction without significant delaying recovery time and discharge. The effect of midazolam was clearer than that seen with propofol.