Effect of Intranasal versus Intravenous Fentanyl on the Emergence Agitation after Sevoflurane Anesthesia in Children Undergoing Bilateral Myringotomy: A Prospective Randomized Controlled Double-Blinded Study

Abstract Background: Bilateral myringotomy and tube insertion for pressure equalization (BMT) is a common pediatric surgical procedure that is often associated with pain-related behavior (agitation) and/or discomfort (emergence delirium) in the post-anesthesia care unit (PACU). Emergence delirium (ED) is a set of perceptual problems that mostly affect pre-school children after recovery from general anesthesia. It involves hallucinations and disorientation. The cause of ED may be due to the growing use of recent volatile agents such as sevoflurane. Aim of Study: This randomized controlled double-blinded study is conducted to compare the effect of intranasal fentanyl in a dose of (2mg/kg) and intravenous fentanyl in a dose of (2.5mg/kg) on sevoflurane induced ED in children undergoing BMT and the need for adding sedatives and/or analgesics. Patients and Methods: Forty-eight children (1-5 years), ASA physical status I and II undergoing BMT were studied. After anesthesia induction with sevoflurane and endotracheal intubation, children were classified randomly into two groups (24 children each), Group IVF (Intravenous Fentanyl Group) and Group INF (Intranasal Fentanyl Group). Group IVF children received (2.5mg/kg) IV diluted in 5ml of normal saline volume with intranasal 1ml placebo, whereas Group INF children re-ceived (2mg/kg) administered intranasally (1mg/kg in each nos-tril) in a volume of 1ml of normal saline (0.5ml in each nostril) with 5ml of intravenous normal saline placebo. Anesthesia was maintained with sevoflurane at both groups and hemodynamics (heart rate, respiratory rate, O2 saturation, mean arterial blood pressure & end-tidal CO2) were recorded every 2 minutes. After discontinuation of sevoflurane, the emergence from anesthesia, postoperative pain, nausea and/or vomiting and time to fulfill discharge criteria from the PACU were assessed. Results: There were insignificant changes between the two groups in hemodynamics, emergence agitation (Watcha scale), postoperative pain (objective pain scale), the incidence of post-operative complications as nausea, vomiting, respiratory depres-sion and the need of rescue analgesics but there was significant decrease in all of these parameters at each group in comparison with baseline. Conclusion: Intranasal fentanyl at a dose of (2mg/kg) is comparable to intravenous fentanyl at a dose of (2.5mg/kg) in decreasing emergence agitation, postoperative pain, nausea, vomiting, respiratory depression and the need of rescue analge-sics without prolonging recovery time, thus preserved the rapid recovery seen with sevoflurane anesthesia.