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LETTERS TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 98-99
 

Postoperative agitation in children: Think beyond inadequate analgesia and emergence delirium


Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission28-Aug-2020
Date of Acceptance21-Sep-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Bharat Paliwal
Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_139_20

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How to cite this article:
Paliwal B, Bhatia P, Chhabra S, Kumar R. Postoperative agitation in children: Think beyond inadequate analgesia and emergence delirium. Indian Anaesth Forum 2021;22:98-9

How to cite this URL:
Paliwal B, Bhatia P, Chhabra S, Kumar R. Postoperative agitation in children: Think beyond inadequate analgesia and emergence delirium. Indian Anaesth Forum [serial online] 2021 [cited 2021 May 9];22:98-9. Available from: http://www.theiaforum.org/text.asp?2021/22/1/98/309746




Sir,

In children <4 years, who are unable to communicate verbally, it is difficult to assess the cause of postoperative agitation[1] which may lead to unnecessary administration of opioids. We report an incidence that made us look beyond the common causes of postoperative agitation.

A 9-month-old child of 8 kg was posted for open hernia repair. Due to prolonged preceding surgery, the preoperative fasting time of the infant got extended by 2 h beyond protocol. Meanwhile, hydration was maintained by infusing Ringer lactate. The child was induced with sevoflurane and airway secured with i-gel. Caudal block with 6 ml of 0.25% ropivacaine was given using anatomical landmarks. The surgery lasted for 1 h 30 min. In the recovery room, the child had an inconsolable cry. FLACC score and emergence delirium scores were 5 and 10, respectively. Considering the possibility of an ineffective caudal block, paracetamol 15 mg/kg intravenous (iv) was given, but the situation remained unchanged. Consequently, fentanyl 10 μg iv was given. The child got sedated and stopped crying but resumed excessive crying after 30 min which again responded to another 10 μg fentanyl for a similar duration. When the child became restless again, he was allowed to take maternal breast milk. Feeding effectively made the child calm and comfortable.

The event highlights three different aspects of perioperative management. First, postoperative agitation of a child is generally attributed to pain, but prolonged fasting as a cause is often missed. A lot of work has been done on preoperative fasting, but postoperative feeding has rarely been addressed. No guidelines exist for postoperative fasting and hence, arbitrariness prevails in this aspect. Iv fluid replacement can make up for the fasting fluid deficit, but it cannot be a substitute for feeding. Hence, time since the last oral intake should not be unnecessarily prolonged. Clinical judgment can be exercised and feeding instituted as early as possible after recovery from anesthesia.

Second, while preoperative anxiety and child temperament are implicated in emergence delirium, maternal contact of a child may have a beneficial role in managing emergence delirium.

Third, studies have shown that the oral administration of sugars, by engagement of the taste sense (and possibly, activation of the endogenous opioid system), can have analgesic actions in neonates.[2] Several studies and a Cochrane review in neonates[3] have shown the efficacy of oral sucrose in reducing pain behaviors in infants (sucrose analgesia).[4] Since human beings seem unable to discriminate between the tastes of different sugars,[5] hence lactose could also promote the same intensity of analgesia as sucrose, fructose, and glucose. This could have contributed as a part in multimodal analgesia in this child. Since lactose is the major carbohydrate in milk (milk sugar), hence breastfeeding may be considered as providing “lactose analgesia” to the child analogous to term sucrose analgesia used earlier.

To conclude, prolonged fasting may cause postoperative agitation and feeding should be initiated early.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors acknowledge Dr. Anamika Purohit for technical help.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chauvin C, Schalber-Geyer AS, Lefebvre F, Bopp C, Carrenard G, Marcoux L, et al. Early postoperative oral fluid intake in paediatric day case surgery influences the need for opioids and postoperative vomiting: A controlled randomized trial. Br J Anaesth 2017;118:407-14.  Back to cited text no. 1
    
2.
Ramenghi LA, Evans DJ, Levene MI. “Sucrose analgesia”: Absorptive mechanism or taste perception? Arch Dis Child Fetal Neonatal Ed 1999;80:F146-7.  Back to cited text no. 2
    
3.
Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2004;(3):CD001069. doi: 10.1002/14651858.  Back to cited text no. 3
    
4.
Lefrak L, Burch K, Caravantes R, Knoerlein K, DeNolf N, Duncan J, et al. Sucrose analgesia: Identifying potentially better practices. Pediatrics 2006;118 Suppl 2:S197-202.  Back to cited text no. 4
    
5.
Ramenghi LA, Griffith GC, Wood CM, Levene MI. Effect of non-sucrose sweet tasting solution on neonatal heel prick responses. Arch Dis Child Fetal Neonatal Ed 1996;74:F129-31.  Back to cited text no. 5
    




 

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