title: Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia.
abstract: BACKGROUND
  Many children are restless, disoriented, and inconsolable immediately after bilateral myringotomy and tympanosotomy tube placement (BMT). Rapid emergence from sevoflurane anesthesia and postoperative pain may increase emergence agitation. The authors first determined serum fentanyl concentrations in a two-phase study of intranasal fentanyl. The second phase was a prospective, placebo-controlled, double-blind study to determine the efficacy of intranasal fentanyl in reducing emergence agitation after sevoflurane or halothane anesthesia.
  
  
  METHODS
  In phase 1, 26 children with American Society of Anesthesiologists (ASA) physical status I or II who were scheduled for BMT received intranasal fentanyl, 2 microg/kg, during a standardized anesthetic. Serum fentanyl concentrations in blood samples drawn at emergence and at postanesthesia care unit (PACU) discharge were determined by radioimmunoassay. In phase 2, 265 children with ASA physical status I or II were randomized to receive sevoflurane or halothane anesthesia along with either intranasal fentanyl (2 microg/kg) or saline. Postoperative agitation, Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores, and satisfaction of PACU nurses and parents with the anesthetic technique were evaluated.
  
  
  RESULTS
  In phase 1, the mean fentanyl concentrations at 10 +/- 4 min (mean +/- SD) and 34 +/- 9 min after administering intranasal fentanyl were 0.80 +/- 0.28 and 0.64 +/- 0.25 ng/ml, respectively. In phase 2, the incidence of severe agitation, highest CHEOPS scores, and heart rate in the PACU were decreased with intranasal fentanyl. There were no differences between sevoflurane and halothane in these measures and in times to hospital discharge. The incidence of postoperative vomiting, hypoxemia, and slow respiratory rates were not increased with fentanyl.
  
  
  CONCLUSIONS
  Serum fentanyl concentrations after intranasal administration exceed the minimum effective steady state concentration for analgesia in adults. The use of intranasal fentanyl during halothane or sevoflurane anesthesia for BMT is associated with diminished postoperative agitation without an increase in vomiting, hypoxemia, or discharge times.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, USA. galinkin@email.chop.edu
authors.forename: J L
authors.initials: JL
authors.lastname: Galinkin
authors.forename: L M
authors.initials: LM
authors.lastname: Fazi
authors.forename: R M
authors.initials: RM
authors.lastname: Cuy
authors.forename: R M
authors.initials: RM
authors.lastname: Chiavacci
authors.forename: C D
authors.initials: CD
authors.lastname: Kurth
authors.forename: U K
authors.initials: UK
authors.lastname: Shah
authors.forename: I N
authors.initials: IN
authors.lastname: Jacobs
authors.forename: M F
authors.initials: MF
authors.lastname: Watcha
mesh_terms: D000281:Administration, Intranasal; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000097:blood; D000762:Anesthesia Recovery Period; D018685:Anesthetics, Inhalation; D002675:Child, Preschool; D004311:Double-Blind Method; D016903:Drug Monitoring; D004432:Ear, Middle / Q000601:surgery*; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage* / Q000097:blood; D006221:Halothane; D006801:Humans; D007223:Infant; D008297:Male; D008738:Methyl Ethers; D008876:Middle Ear Ventilation; D000077149:Sevoflurane
chemical_list: D000701:Analgesics, Opioid; D018685:Anesthetics, Inhalation; D008738:Methyl Ethers; D000077149:Sevoflurane; D005283:Fentanyl; D006221:Halothane