Elsevier

Journal of Clinical Anesthesia

Volume 35, December 2016, Pages 90-95
Journal of Clinical Anesthesia

Original Contribution
Effects of low-dose propofol vs ketamine on emergence cough in children undergoing flexible bronchoscopy with sevoflurane-remifentanil anesthesia: a randomized, double-blind, placebo-controlled trial,☆☆,,★★,☆☆☆

https://doi.org/10.1016/j.jclinane.2016.06.025Get rights and content

Highlights

  • Fiberoptic bronchoscopy can result in cough, laryngospasm, and/or bronchospasm.

  • Propofol and ketamine suppress N-methyl-d-aspartate receptors and thus can suppress coughing.

  • Ketamine and propofol did not decrease post-FOB cough during emergence.

  • Ketamine, greater than propofol, decreased emergence agitation.

  • Ketamine lengthened recovery time in children undergoing FOB.

Abstract

Study Objective

To determine the effects of low-dose ketamine and propofol on cough during emergence and the recovery period when administered at emergence in children undergoing fiberoptic bronchoscopy for bronchoalveolar lavage (FOBL) with sevoflurane-remifentanil anesthesia.

Design

Randomized, double-blind, placebo-controlled trial.

Setting

Operating room, postoperative recovery area.

Patients

Sixty-eight children aged 1 to 8 years old undergoing elective diagnostic FOBL.

Interventions

After discontinuation of anesthetics at the end of FOBL, patients were randomly divided into 3 groups: in group K, children were administered 0.5 mg/kg of ketamine; in group P, 0.5 mg/kg of propofol; and in group C, 0.1 mL/kg of normal saline.

Measurements

Anesthesia time, procedure time, emergence time, and recovery time were recorded. Coughing and delirium scores were recorded as the patient fully emerged from anesthesia (time 0) and 5, 10, 15, and 20 minutes later.

Main Results

The percentage of children with moderate or severe cough during emergence was similar in all groups. Mean delirium scores at emergence (T0) were significantly lower in group K than those in group P and in group C (P = .0001 and P = .02). Mean delirium score at 5 minutes in group K (6 [5-10]) was significantly lower than that of group C (P = .02) and similar to that of group P. The recovery time of group K was significantly longer than that of group C and group P (P = .01 and P = .03, respectively).

Conclusions

Ketamine or propofol given at the end of sevoflurane-remifentanil general anesthesia in children undergoing FOBL did not decrease cough more than normal saline during the emergence period. Ketamine and propofol, compared to normal saline, had a beneficial effect on decreasing the incidence of emergence delirium. Ketamine lengthened recovery time.

Introduction

Children undergoing fiberoptic bronchoscopy (FOB) for bronchoalveolar lavage (FOBL) often have increased airway irritability. Stimulation within the lung by FOB can cause sensations of pain, irritation, and the urge to cough [1], [2]. Severe cough during emergence causes discomfort and may induce laryngospasm and bronchospasm in patients with hyperreactive airways [1], [2], [3], [4].

Propofol and ketamine are known for their mechanism of suppressing N-methyl-d-aspartate receptors, which results in a decrease in coughing [5], [6]. In addition, ketamine relaxes bronchiolar muscles, suppresses bronchial constriction due to histamines, and reduces tracheal and bronchial muscle spasms [7]. For these reasons, propofol and ketamine might be useful in diminishing cough. In previous studies, low-dose propofol (1 mg/kg) with 0.5 μg/kg of fentanyl before the termination of sevoflurane-remifentanil–based anesthesia was effective in decreasing the suppression of laryngospasm [8]. Similarly, small doses of propofol, but not ketamine, after sevoflurane/N2O anesthesia reduced coughing on emergence in children [9]. However, their effects on cough in children who had irritable respiratory systems undergoing FOB have not been yet evaluated.

Also in previous studies, low-dose ketamine administered at the end of surgery or just before the discontinuation of sevoflurane successfully reduced the incidence of emergence delirium (ED) in children undergoing cataract surgery, tonsillectomy-adenoidectomy, and dental repair [10], [11], [12]. Similarly, intravenous (IV) propofol before the termination of the sevoflurane-remifentanil anesthesia was both effective in decreasing the incidence and severity of ED in children who underwent cataract surgery [10]. However, their effects on reducing ED and how this relates to decreasing cough have not been yet evaluated in children undergoing FOB.

Remifentanil, together with sevoflurane anesthesia, is a widely used combination in pediatric surgery because of the rapidity of induction and emergence from anesthesia [10], [13], [14]. In previous studies, the addition of remifentanil to sevoflurane anesthesia was not shown to decrease cough during emergence and recovery from in children undergoing FOB [13], [14].

Therefore, we determined the effects of low-dose IV ketamine and propofol on cough (primary end point) and ED and whether the cough may cause delirium (secondary end-point) during emergence and the recovery period in children undergoing FOB with sevoflurane-remifentanil anesthesia.

Section snippets

Patients

This randomized, double-blind trial was approved by our university hospital institutional ethics committee (document 284/2013). Parents of children aged 1 to 8 years old were approached for obtaining consent for enrollment of their child who was scheduled to undergo elective diagnostic FOBL. Patients scheduled for FOBL who had hemoptysis, who had previously undergone FOBL, or who had a severe cough were excluded from participation. Thirty minutes before induction of anesthesia, children were

Results

One hundred six children scheduled to undergo elective diagnostic FOBL were assessed for eligibility. Sixty-eight children (n = 23 in group C, n = 22 in group P, n = 23 in group K) completed the study according to protocol (see CONSORT flow diagram, Fig. Fig. 1). Demographic characteristics and indications for FOB were similar in groups C, P, and K (Table 1). Preoperative separation scores were not significantly different between the 3 groups (1.6, 1.7, and 1.6 in groups K, P, and C,

Discussion

In this study, compared to the control group, neither ketamine nor propofol had an effect on cough upon emergence or during the recovery period. This is in contrast to those of previous studies, which found that ketamine and propofol reduced laryngospasm and coughing [8], [9]. However, all of those studies examined the incidence of cough during emergence after extubation in children with healthy respiratory systems. Most of our patients already had a reactive pulmonary tree, and FOB itself is

Acknowledgment

We would like to thank Dr Guven Olgac, FEBTCS, for his statistical analysis.

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    Disclosures: The study was funded by departmental resources.

    ☆☆

    Conflicts of interest do not preclude any of the authors from contributing to this manuscript.

    The manuscript has been read and approved by all coauthors.

    ★★

    Presented, in part, as a scientific abstract at the annual meeting of The Turkish Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care in Marmaris, April 17-20, 2014.

    ☆☆☆

    Ethics: This trial was approved by the university hospital institutional ethics committee (284/2013).

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