Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 4  |  Page : 485-492

Dexmedetomidine infusion versus fentanyl for analgesia and prevention of emergence agitation and delirium in children undergoing adenotonsillectomy


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

Date of Submission13-Mar-2016
Date of Acceptance29-Apr-2016
Date of Web Publication12-Jan-2017

Correspondence Address:
Sanaa M Elfawal
Department of Anesthesiology, Faculty of Medicine, Ain Shams University, Aabasya, Cairo, 11517
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.198264

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  Abstract 

Background
This randomized controlled study aimed to evaluate whether an intraoperative infusion of dexmedetomidine would be a safe and effective substitute to fentanyl intraoperatively, and whether it would be effective in reducing the incidence and severity of emergence agitation and delirium in children undergoing adenotonsillectomy.
Patients and methods
This study was conducted on 70 pediatric patients, aged 3–7 years, of both sexes, of ASA I and II, who were scheduled for elective adenotonsillectomy. The patients were randomly assigned to two groups: group D (dexmedetomidine infusion group; 35 patients) received intravenous dexmedetomidine (2 μg/kg) over 10 min, followed by 0.7 μg/kg/h until 5 min before the end of the surgery, and group F (intravenous fentanyl group; 35 patients) received intravenous fentanyl 1 μg/kg as a bolus. No premedication was given to any of the patients. The number of patients in each group who needed intraoperative fentanyl, the fentanyl dose, time of administration of fentanyl, duration of surgery and anesthesia, and the time to awakening were recorded. Pain was evaluated using the objective pain scale score in the postanesthesia care unit (PACU), which was managed with rescue intravenous pethidine. Emergence agitation was evaluated in the PACU using two scales: the Pediatric Anesthesia Emergence Delirium scale and the five-point agitation scale described by Cole.
Results
The time to awakening in group D was significantly shorter compared with that in group F (P<0.05). Group D showed a statistically significantly lower maximum objective pain scale score, lower Pediatric Anesthesia Emergence Delirium score, and lower emergence agitation score compared with group F at arrival at the PACU. There was no statistically significant difference between the two groups as regards preoperative heart rate, but there was significantly lower heart rate in group D than in group F after induction (P<0.05). No side effects were observed during the first 24 h postoperatively in the two groups.
Conclusion
Dexmedetomidine is a safe and effective analgesic substitute to fentanyl intraoperatively and reduces analgesic requirements postoperatively. It is also effective in reducing the incidence and severity of emergence agitation and delirium in children undergoing adenotonsillectomy.

Keywords: analgesia, dexmedetomidine, fentanyl, sevoflurane


How to cite this article:
Elfawal SM, Eldeek AM, Kamal MM. Dexmedetomidine infusion versus fentanyl for analgesia and prevention of emergence agitation and delirium in children undergoing adenotonsillectomy. Ain-Shams J Anaesthesiol 2016;9:485-92

How to cite this URL:
Elfawal SM, Eldeek AM, Kamal MM. Dexmedetomidine infusion versus fentanyl for analgesia and prevention of emergence agitation and delirium in children undergoing adenotonsillectomy. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2017 Oct 22];9:485-92. Available from: http://www.asja.eg.net/text.asp?2016/9/4/485/198264


  Introduction Top


Adenotonsillectomy is one of the most common surgical procedures performed in children [1].

Postoperative pain can be severe after adenotonsillectomy, and providing effective and safe perioperative analgesia in this group of patients is challenging [2].

A high incidence of emergence agitation (EA) and emergence delirium in pediatric patients undergoing general anesthesia with sevoflurane associated with fast emergence adds another challenge [3].

Agitated behavior associated with emergence delirium can delay discharge from the postanesthesia care unit (PACU), decrease parent and caregiver satisfaction, and increase the overall cost to the institution [3].

Dexmedetomidine, a specific α2-adrenergic receptor agonist, has sedative, anxiolytic, and analgesic properties [4].

An intraoperative infusion of dexmedetomidine used as a substitute for fentanyl has been shown to reduce opiate use in the postoperative period in adult patients undergoing surgery [5], but clinical data on the analgesic-sparing effect of dexmedetomidine in children are conflicting and need more research [1].

The present study was conducted to evaluate whether an intraoperative infusion of dexmedetomidine would be a safe and effective analgesic substitute to fentanyl intraoperatively, reduce analgesic requirements postoperatively, and also be effective in reducing the incidence and severity of EA and delirium in children undergoing adenotonsillectomy.


  Patients and methods Top


After obtaining approval from the Department of Anesthesia, Faculty of Medicine, Ain Shams University, and the medical ethics committee, informed consent was obtained from all patients’ parents or guardians. This study was conducted on 70 pediatric patients, aged 3–7 years, of both sexes, of ASA I and II, who were scheduled for elective adenotonsillectomy.

Patients with a known hypersensitivity to any of the study drugs, with developmental delay, cardiac and craniofacial abnormalities, anxiety disorders, chronic disabilities, or pain syndrome, and those using psychotherapeutic medications and/or anticonvulsants were excluded.

Preoperative assessment was completed by taking history from parents, performing physical examination, airway assessment, determining the ASA grade, reviewing the patient’s medications, and reviewing investigations including complete blood picture, coagulation profile, and liver, electrolytes and kidney functions.

An intravenous cannula was inserted, of size 22- or 24-G under complete aseptic conditions, either before or after sevoflurane induction according to the patient’s age and patient cooperation.

For all patients standard monitoring devices (ECG, noninvasive blood pressure, and pulse oximetry) were attached before induction of anesthesia.

Patients were randomly allocated (by means of the closed envelop method) to one of the two treatment groups:

  1. Group D patients (dexmedetomidine infusion; 35 patients) received intravenous dexmedetomidine (2 μg/kg) over 10 min, followed by 0.7 μg/kg/h until 5 min before the end of surgery.
  2. Group F patients (fentanyl; 35 patients) received intravenous fentanyl (1 μg/kg) as a bolus as soon as intravenous access was obtained. No premedication was given to any of the patients.


After preoxygenation, anesthesia was induced with 8% inspired sevoflurane and 100% oxygen through a face mask. Group D received intravenous dexmedetomidine infusion, and group F received intravenous fentanyl as an intravenous bolus, as mentioned before. Ringer’s solution was administered according to standard fluid administration guidelines. Vecuronium 0.6 mg/kg was used to facilitate tracheal intubation. After successful tracheal intubation, maintenance of anesthesia was achieved with 2–3% sevoflurane in 100% oxygen.

Lactated Ringer’s solution 15 ml/kg was administered as a fluid bolus for a 30% decrease in systolic blood pressure from baseline that is seen in two readings, and atropine 0.01 mg/kg slow intravenous for a 30% decrease in heart rate (HR). Patients in both groups received rescue fentanyl (1 μg/kg) for an increase in HR or non invasive blood pressure (NIBP) 30% above the value before the start of surgery that sustained for 5 min. Patients were mechanically ventilated with tidal volume 10 ml/kg with respiratory rate according to age. Sevoflurane was discontinued once hemostasis was achieved. Before extubation, reversal of muscle relaxation was achieved using neostigmine (0.05 mg/kg) and atropine (0.02 mg/kg). Heart rate and noninvasive blood pressure were continuously recorded intraoperatively and for 2 h postoperatively. Oxygen saturation (SpO2) was recorded intraoperatively and postoperatively every 5 min for the first 15 min, then at 15-min intervals for the next 2 h. The number of patients who needed rescue fentanyl in both groups, the fentanyl rescue dosage (μg/kg), and its time of administration as well as the duration of surgery, duration of anesthesia (min), and the time to awakening (TA), defined as spontaneous eye opening or on command, were recorded.

Pain was evaluated using the objective pain scale (OPS) score ([Table 1]) in the PACU (the higher the score, the greater the pain experience for the child). Also EA was evaluated in the PACU on the basis of two scales: the Pediatric Anesthesia Emergence Delirium (PAED) scale ([Table 2]) and a five-point scoring scale for EA described by Cole ([Table 3]), on arrival and at 5, 15, and then every 15 min for 120 min.
Table 1: Objective pain scale score [6]

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Table 2: Pediatric Anesthesia Emergence Delirium scale [7]

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Table 3: Five-point scoring scale for emergence agitation [8]

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For postoperative pain (score: >4) or severe agitation (score: 4–5) lasting more than 5 min, patients in both group were given rescue pethidine (1 mg/kg, slow intravenous over 2–5 min after dilution in 10 ml saline). The number of patients in each group who needed rescue pethidine and the pethidine dosage (mg/kg) that was given were recorded.

Statistical analysis

IBM SPSS statistics (V.21.0, 2012; IBM Corp., Armonk, New York 10504, USA) was used for data analysis. Data were expressed as mean±SD for quantitative parametric measures in addition to both number and percentage for categorized data. The Student t-test was used for comparison between two independent groups for parametric data, and the χ2-test to study the association between each of two variables or for comparison between two independent groups as regards the categorized data.

A P-value of 0.05 or less was considered significant, whereas values 0.01 and 0.001 were considered highly significant.

According to a power analysis, a sample size of 35 patients per group would have an 80% power to show that the number of patients needing intraoperative rescue fentanyl and rescue pethidine in the PACU would be 50% lower in the patients receiving dexmedetomidine at a significance level of 5%.


  Results Top


There was no statistically significant difference between the two group as regards age, sex, weight, and duration of surgery and anesthesia (P>0.05) ([Table 4]).
Table 4: Demographic and operative data

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The comparison between the two groups as regards TA revealed that group D had a statistically significantly shorter TA as compared with group F (P<0.05) ([Table 4]).

The comparison between the two groups as regards postoperative maximum OPS score revealed that group D had a significantly lower OPS score compared with group F at arrival at the PACU, and then at 5, 15, 30, 45, 60, 75, and 105 min postoperatively (P<0.001). However, there was no statistically significant difference between the two groups at 90 min postoperatively, and in both groups the OPS score was 0 at 120 min postoperatively (P>0.05) ([Figure 1]).
Figure 1: Comparison between the two groups as regards maximum objective pain scale (OPS) score. Values are represented as mean±SD. PACU, postanesthesia care unit. *Statistically significant difference.

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Comparison between the two groups as regards the number and percentage of patients who required rescue fentanyl intraoperatively revealed that in group D four patients needed rescue fentanyl, which was significantly lower than the number of patients requiring rescue fentanyl in group F (13 patients) as per Pearson’s χ2-test (P=0.012) ([Table 5]).
Table 5: Comparison between the two groups as regards the n (%) of patients who required rescue fentanyl intraoperatively

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The dose of fentanyl rescue was significantly lower in group D in comparison with group F. Also the time to rescue fentanyl was significantly longer in group D in comparison with group F (P<0.01) ([Table 6]).
Table 6: Comparison between the two groups as regards the dose and time of intraoperative rescue fentanyl

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The comparison between the two groups as regards the number and percentage of patients who required rescue pethidine postoperatively revealed that in group D six patients needed rescue pethidine, which was significantly lower than the number requiring pethidine in group F (16 patients) as per Pearson’s χ2-test (P=0.010) ([Table 7]).
Table 7: Comparison between the two groups as regards the number and percentage of patients who required rescue pethidine postoperatively

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However, there was no statistically significant difference between the two groups as regards the dose of rescue pethidine postoperatively (P>0.05).

There was no statistically significant difference between the two groups as regards the preoperative and postoperative respiratory rate.

There was no statistically significant difference between the two groups as regards preoperative heart rate, but the heart rate in group D was significantly lower than that in group F after induction (P<0.05). This lower heart rate became statistically significant 10 min after induction (P<0.001) and also 50 and 60 min after induction (P<0.01). However, there was no statistically significant difference between the two groups 20, 30, and 40 min after induction (P>0.05) ([Figure 2]).
Figure 2: Comparison between the two groups as regards intraoperative heart rate. Values are represented as mean±SD. *Statistically significant difference.

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There was no statistically significant difference between the two groups as regards preoperative mean arterial pressure, but intraoperative mean arterial pressure showed that group D had a highly statistically significantly lower mean arterial pressure compared with group F after induction, as well as 60 min after induction (P<0.05). This lower mean arterial pressure was statistically significant 10 and 40 min after induction as well (P<0.01).

However, there was no statistically significant difference between the two groups 20, 30, and 50 min after induction (P>0.05) ([Figure 3]).
Figure 3: Comparison between the two groups as regards intraoperative mean arterial pressure NIBP. Values are represented as mean±SD. *Statistically significant difference.

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The comparison between the two groups as regards postoperative heart rate showed that group D had a significantly lower heart rate than group F at the time of arrival at the PACU (P<0.05). However, there was no statistically significant difference between the two groups at 5, 15, 30, 45, 60, 75, 90, 105, and 120 min postoperatively (P>0.05) ([Table 8]).
Table 8: Comparison between the two groups as regards postoperative heart rate

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The comparison between the two groups as regards postoperative mean arterial pressure (NIBP) revealed that there was no statistically significant difference between the two groups.

With regard to the postoperative EA score, we found that there was a significantly lower EA score in group D compared with group F on arrival at the PACU, 30 and 60 min postoperatively (P<0.001), and also 5 min postoperatively (P<0.01). However, there was no statistically significant difference between the two groups at 15 min (the score in both groups was 3), 45 min (the score in both group was 2), 75, 90, 105, and 120 min postoperatively (the score in both groups was 1) (P>0.05) ([Figure 4]).
Figure 4: Comparison between the two groups as regards maximum emergence agitation score. Black solid line represents the median; the lower and upper margins of the columns are interquartile range, representing minimum and maximum values. PACU, postanesthesia care unit. *Statistically significant difference.

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There was a significantly lower PAED score in group D compared with group F on arrival at the PACU and 5, 30, 60, 75, 90, and 105 min postoperatively (P<0.001), and also at 15 and 45 min (P<0.01). However, there was no statistically significant difference between the two groups at 120 min (score of both groups=0) ([Figure 5]).
Figure 5: Comparison between the two groups as regards maximum Pediatric Anesthesia Emergence Delirium (PAED) score. Values are represented as mean±SD. *Statistically significant difference.

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Comparison between the two groups as regards occurrence of postoperative SpO2 less than 95% showed that group D had a significantly lower number of patients with SpO2 less than 95% (six patients) compared with group F (14 patients) (P=0.034) ([Figure 6]).
Figure 6: Comparison between the two groups as regards occurrence of postoperative SpO2 less than 95%. *Statistically significant difference.

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There were no instances of laryngospasm or bronchospasm after extubation in either group and no observed side effects during the first 24 h postoperatively in the two groups.


  Discussion Top


In the present study of children undergoing tonsillectomy and adenoidectomy, an intraoperative initial loading dose of 2 μg/kg dexmedetomidine followed by an infusion 0.7 μg/kg/h decreased intraoperative and postoperative opiate requirements. In addition, there was a significantly lower incidence and duration of severe EA with faster recovery in comparison with the fentanyl group, who received intraoperative intravenous fentanyl.

A high initial loading dose of dexmedetomidine (2 μg/kg) followed by a relatively high dose of continuous intraoperative infusion was given, because adenotonsillectomy is a procedure with an intense surgical stimulus, and surgery starts immediately after anesthesia.

In the present study, we aimed to use the analgesic effect of dexmedetomidine and evaluated whether a continuous infusion could be used as a substitute for bolus fentanyl. In our study, 31 patients in group D (dexmedetomidine group) did not require any other intraoperative analgesics.

Children in group D had significantly lower systolic blood pressure and heart rate for almost the entire duration for which the anesthetic was given, but none of the patients needed intervention for bradycardia or hypotension on the basis of study criteria.

Hemodynamic data in the present study are consistent with a large-scale retrospective review evaluating the sedation profile of dexmedetomidine. Mason et al. [9] evaluated the use of higher doses of dexmedetomidine (2–3 μg/kg loading dose and infusion of 1.5–2 μg/kg/h) as the sole drug for sedation in children for pediatric MRI studies and observed a decrease in HR and blood pressure, which were within 20% of the awake normal range and not associated with adverse sequelae, and reported that dexmedetomidine was useful as the sole sedative for pediatric MRI [9].

In the present study, TA was statistically lower in group D, despite the high dose of dexmedetomidine used. Shukry et al. [10] found that intraoperative infusion of low dose (0.2 μg/kg/h) of dexmedetomidine decreased the incidence and frequency of EA in children after sevoflurane-based general anesthesia without prolonging the TA.

With the use of a single bolus of dexmedetomidine (0.15–0.30 μg/ kg) instead of infusion, Ibacache et al. [11] also reported no difference in TA in comparison with placebo.

In contrast to the present study, Guler et al. [12] reported that a single dose of 0.5 μg/kg dexmedetomidine 5 min before the end of surgery significantly prolonged TA in comparison with placebo in patients undergoing adenotonsillectomy.

Evaluation of postoperative pain was complicated by the difficulty in assessing pain in young children and by the occurrence of EA. It was often difficult to distinguish between pain and EA because of the overlapping clinical picture, and pain itself can be the source of agitation.

Most investigators have used different assessment tools to try and separate pain from EA, but there was generally overlap in the scales, because a child who is restless or thrashing will score high on both scales [13].

In the present study, we did find a positive correlation between agitation and pain; group F had higher pain and EA scores than did group D. Results on the OPS, Cole scale, and PAED showed a very similar trend in both groups; scores were highest on arrival in the PACU and decreased over time. A significantly smaller number of patients needed rescue pethidine in group D, 17% in comparison with 45.7% in group F.

Because it was difficult to separate pain from EA, and the fact that the rescue drug for both agitation and pain in our study was pethidine, it was not possible to determine whether the pethidine was given for pain or for agitation.

Guler et al. [12] found that 23% of pediatric patients who received a single dose of 0.5 μg/kg dexmedetomidine before the end of adenoidectomy required opioids for analgesia in the PACU in comparison with 53% in the placebo group.

EA is a complex phenomenon, the etiology of which is multifactorial. The wide variability in the incidence of agitation in the different studies on EA may be due to the criteria used to define this phenomenon and the time in the PACU when EA was measured [13].

A single measurement may not reflect the true incidence of EA [14], and thus in the present study we took repeated measurements at frequent time intervals.

In the present study, group D had a statistically lower frequency of EA compared with group F until 30 min. At 30 min there was no incidence of EA in group D, and in group F it was 1.6%. EA lasting more than 5 min was treated with pethidine.

Guler et al. [12] reported an incidence of severe EA (17%) on arrival in the PACU similar to that of group D in our study. They used a single dose of dexmedetomidine 5 min before the end of the procedure in children undergoing adenoidectomy.

Dexmedetomidine has been used successfully as an infusion (0.2 μg/kg/h) that was continued into the postoperative period for 15 min by Shukry et al. [10] to prevent or reduce emergence delirium in children.

Also, Ibacache et al. [11] used dexmedetomidine in a single dose at the end of surgery (0.5 μg/kg) to reduce emergence delirium in children.

It must be noted that Shukry et al. [10] and Ibacache et al. [11] compared dexmedetomidine with placebo, whereas our control group received fentanyl 1 μg/kg, which also reduced EA.

In contrast to the present study, Cohen et al. [14] reported that concurrent use of a higher dose of fentanyl at 2.5 μg/kg in children receiving desflurane or sevoflurane results in a low incidence of EA.

All patients were observed continuously in the PACU for 2 h. There was a statistically significant difference in the number of patients with SpO2 below 95% in the PACU between the two groups: six in group D and 14 in group F. This could be related to the smaller requirement for opiates in the PACU in group D or to the lower incidence and duration of EA in group D.

The goal of having a child who was settled, comfortable, and less restless with application of monitors and administration of supplemental oxygen in the PACU was easier to achieve in patients who received dexmedetomidine.

A few methodological considerations of the present study need to be mentioned. The anesthesiologists (data recorder) in the operating room (OR) were not blinded to the study group. We believe that knowledge of study group assignment did not bias the conduct of the anesthetic, because the study protocol was tightly controlled, with specific criteria regarding intraoperative rescue fentanyl, sevoflurane concentration, the time to discontinue sevoflurane, extubation criteria, and use of rescue pethidine in the PACU.

The PAED is the only validated rating scale for emergence delirium. Sikich and Lerman [7] developed the PAED scale that rates emergence behavior 10 min after the child awakens and remains awake (did not fall back to sleep).

In the present study, we found this to be a potential problem because children who were asleep were receiving ratings of 4 on the first three items of the scale because they could not make eye contact, their actions were not purposeful, and they were not aware of their surroundings. Therefore, we had to rate these items as 0. Clearly, the children were not agitated if they were sleeping. That is why we used a modified version of the PAED. We used a second scale (Cole) to run concomitantly to support the findings with the modified version of the PAED.

The 1–5 scale described by Cole et al. [8] has been used in the present study and other several studies of EA. It is easy to use this scale, and defining the categories of mild or severe is clear.

In contrast to the present study, Shukry et al. [10] and Erdil et al. [15] have used the OPS to scale EA during their study on the effect of dexmedetomidine to prevent emergence delirium in children after sevoflurane-based general anesthesia and have concluded that it is perhaps not the best scale to use in a study on EA because of considerable overlap on the items being scored.

One of the pitfalls of the present study is that we did not follow up patients after they were discharged from the PACU.


  Conclusion Top


Dexmedetomidine is a safe and effective substitute to fentanyl intraoperatively. It reduces opiate requirements postoperatively and is also effective in reducing the incidence and severity of EA and delirium in children undergoing adenotonsillectomy.


  Acknowledgements Top


Dr Sanaa M. Elfawal contributed to the basic idea of the research, which was effect and safety of intrathecal midazolam when added to ropivacaine. He was responsible for collecting information regarding the research and then editing the draft written by his colleagues. He was also interested in the idea and the possibility of applying it during all types of regional anesthesia. Dr Abeer M. Eldeek contributed to the idea and scope of the research, which was exciting and challenging. He contributed to the conception of the design outline of the research and was responsible for drafting the article and revising it carefully and critically for important intellectual content. Dr Manal M. Kamal contributed to the idea and scope of the research; working as team he contributed towards convincing the patients and taking their consent as well as recording their data in the postoperative period and preparing tables and statistics regarding research content.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Patel A, Davidson M, Tran MC, Quraishi H, Schoenberg C, Sant M et al. Dexmedetomidine infusion for analgesia and prevention of emergence agitation in children with obstructive sleep apnea syndrome undergoing tonsillectomy and adenoidectomy. Anesth Analg 2010; 111:1004–1010.  Back to cited text no. 1
    
2.
McColley SA, April MM, Carroll JL, Naclerio RM, Loughlin GM Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 1992; 118:940–943.  Back to cited text no. 2
    
3.
Voepel-Lewis T, Malviya S, Tait AR. A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit. Anesth Analg 2003; 96:1625–1630, table of contents.  Back to cited text no. 3
    
4.
Hall JE, Uhrich TD, Barney JA, Arain SR, Ebert TJ. Sedative, amnestic, and analgesic properties of small-dose dexmedetomidine infusions. Anesth Analg 2000; 90:699–705.  Back to cited text no. 4
    
5.
Tufanogullari B, White PF, Peixoto MP, Kianpour D, Lacour T, Griffin J et al. Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables. Anesth Analg 2008; 106:1741–1748.  Back to cited text no. 5
    
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Hannallah RS, Broadman LM, Rice LJ. Testing the validity of an objective pain scale for infants and children. Anesthesiology 1988; 69:A770.  Back to cited text no. 6
    
7.
Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology 2004; 100:1138–1145.  Back to cited text no. 7
    
8.
Cole JW, Murray DJ, McAllister JD, Hirshberg GE. Emergence behaviour in children: defining the incidence of excitement and agitation following anaesthesia. Paediatr Anaesth 2002; 12:442–447.  Back to cited text no. 8
    
9.
Mason KP, Zurakowski D, Zgleszewski S, Prescilla R, Fontaine PJ, Dinardo JA. Incidence and predictors of hypertension during high-dose dexmedetomidine sedation for pediatric MRI. Paediatr Anaesth 2010; 20:516–523.  Back to cited text no. 9
    
10.
Shukry M, Clyde MC, Kalarickal PL, Ramadhyani U. Does dexmedetomidine prevent emergence delirium in children after sevoflurane-based general anesthesia? Paediatr Anaesth 2005; 15:1098–1104.  Back to cited text no. 10
    
11.
Ibacache ME, Muñoz HR, Brandes V, Morales AL. Single-dose dexmedetomidine reduces agitation after sevoflurane anesthesia in children. Anesth Analg 2004; 98:60–63.  Back to cited text no. 11
    
12.
Guler G, Akin A, Tosun Z, Ors S, Esmaoglu A, Boyaci A. A single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy. Paediatr Anaesth 2005; 15:762–766.  Back to cited text no. 12
    
13.
Vlajkovic GP, Sindjelic RP. Emergence delirium in children: many questions, few answers, Anesth Analg 2007; 104:84–91.  Back to cited text no. 13
    
14.
Cohen IT, Finkel JC, Hannallah RS, Hummer KA, Patel KM. The effect of fentanyl on the emergence characteristics after desflurane or sevoflurane anesthesia in children. Anesth Analg 2002; 94:1178–1181.  Back to cited text no. 14
    
15.
Erdil F, Demirbilek S, Begec Z, Ozturk E, Ulger MH, Ersoy MO. The effects of dexmedetomidine and fentanyl on emergence characteristics after adenoidectomy in children. Anaesth Intensive Care 2009; 37:571–576.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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