title: A Randomized Controlled Trial to Determine the Effect of Depth of Anesthesia on Emergence Agitation in Children.
abstract: BACKGROUND
  The cause of emergence agitation (EA) in children is unknown. Rapid emergence from inhaled anesthesia has been implicated because EA is more common with sevoflurane than with halothane. A dose-dependent effect of sevoflurane, which increases seizure-like electroencephalogram activity, has also been proposed.
  
  
  METHODS
  To determine whether depth of anesthesia as measured by bispectral index (BIS) affects EA, 40 ASA physical status I to II children aged 2 to 8 years undergoing ophthalmic surgery were enrolled in a blinded randomized controlled trial of low-normal (40-45, deep) versus high-normal (55-60, light) anesthesia. To distinguish transient irritability from severe EA, the primary outcome was first-stage postanesthesia care unit (PACU I) peak Pediatric Assessment of Emergence Delirium (PAED) score, with secondary outcomes of PAED and Face, Legs, Activity, Cry, and Consolability scores at emergence, postoperative fentanyl dose, emergence time, and discharge time. Subjects received a standard anesthesia protocol with oral midazolam followed by mask induction with sevoflurane 8%, fentanyl 1 to 1.5 μg/kg IV (then as needed), neuromuscular blockade, and endotracheal intubation. Providers titrated expired sevoflurane (in N2O 67%) from 0.5% to 3% to maintain BIS range. PAED, Richmond Agitation Sedation Scale, and Face, Legs, Activity, Cry, and Consolability scores were measured at emergence, at PACU I arrival, and during PACU I stay.
  
  
  RESULTS
  There was little difference between the groups in the primary outcome, peak PACU I PAED score (light: 7.7 ± 4.6; deep: 8.6 ± 5.3; mean difference, 0.9; 95% confidence interval, 4.1 to -2.3; effect size, 0.18). Discharge times were similar between groups. Treatment for severe EA was rare.
  
  
  CONCLUSIONS
  There was no significant effect of BIS-guided deep versus light anesthesia on severe EA.
authors.affiliation: From the *Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; †Registered Nurse Anesthesia Program, Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland; and ‡Department of Anesthesiology and Perioperative Care, University of California, San Francisco, California.
authors.forename: Heather J
authors.initials: HJ
authors.lastname: Frederick
authors.forename: Kenneth
authors.initials: K
authors.lastname: Wofford
authors.forename: Guy
authors.initials: G
authors.lastname: de Lisle Dear
authors.forename: Scott R
authors.initials: SR
authors.lastname: Schulman
mesh_terms: D000769:Anesthesia, Inhalation / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D056805:Consciousness Monitors; D005260:Female; D006801:Humans; D008297:Male; D008738:Methyl Ethers / Q000008:administration & dosage* / Q000009:adverse effects; D011446:Prospective Studies; D011595:Psychomotor Agitation / Q000175:diagnosis* / Q000517:prevention & control*; D000077149:Sevoflurane; D016037:Single-Blind Method; D016896:Treatment Outcome
chemical_list: D008738:Methyl Ethers; D000077149:Sevoflurane