Pediatric Anesthesia ISSN 1155-5645

ORIGINAL ARTICLE

Transition to propofol after sevoflurane anesthesia to

prevent emergence agitation: a randomized controlled trial
David Costi1,2, James Ellwood1, Andrew Wallace1, Samira Ahmed1, Lynne Waring1 & Allan Cyna1,2
1 Department of Paediatric Anaesthesia, Women’s and Children’s Hospital, Adelaide, SA, Australia
2 Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia

What is already known

• Propofol infusion throughout maintenance of anesthesia can be effective in reducing emergence agitation (EA)
in children compared to sevoflurane anesthesia. However, there are mixed results of efficacy when propofol is
administered as a 1 mg
kg 1 bolus at the conclusion of sevoflurane anesthesia.
What this article adds

• A short transition to propofol 3 mg
kg 1

over 3 min at the end of sevoflurane anesthesia is an effective means
of reducing EA in children undergoing magnetic resonance imaging (MRI) scans.
Implications for translation

• Anesthetists can use this simple highly effective intervention for reducing EA in children after sevoflurane anes-
thesia. Further research could assess this intervention in a surgical setting, as part of a multimodal approach to
EA prevention, or directly against other propofol interventions.

Keywords
child; emergence; agitation; delirium;
propofol; sevoflurane
Correspondence
David Costi, Department of Paediatric
Anaesthesia, Women’s and Children’s
Hospital, 72 King William Road, North
Adelaide 5006, SA, Australia
Email: david.costi@health.sa.gov.au
Section Editor: Brian Anderson
Accepted 15 December 2014
doi:10.1111/pan.12617
Summary
Background: Emergence agitation (EA) is a common behavioral disturbance
after sevoflurane anesthesia in children. Propofol 1 mg
kg 1 bolus at the end
of sevoflurane anesthesia has had mixed results in reducing the incidence of
EA, whereas propofol infusion throughout anesthesia maintenance seems
effective but is more complex to administer. If a simple, short transition to
propofol anesthesia was found to be effective in reducing EA, this could
enhance the recovery of children following sevoflurane anesthesia. We there-
fore aimed to determine whether transition to propofol over 3 min at the end
of sevoflurane anesthesia reduces the incidence of EA in children.
Methods: In this prospective randomized controlled trial, 230 children aged
1–12 years, undergoing magnetic resonance imaging (MRI) scans under sevo-
flurane anesthesia were randomized to receive either propofol 3 mg
kg 1 over
3 min (propofol group), or no propofol (control group), at the end of sevoflu-
rane anesthesia. EA was assessed by a blinded assessor using the Pediatric
Emergence Anesthesia Delirium (PAED) scale and the Watcha scale until
30 min after emergence. EA on the PAED scale was defined as a PAED score
>12. EA on the Watcha scale was defined as a score ≥3. Times to emergence,
postanesthesia care unit (PACU) discharge, and discharge home were also
recorded.
Results: Data were analyzed for 218 children. The incidence of EA was lower
in the propofol group on both PAED (29% vs 7%; relative risk = 0.25; 95%
confidence interval 0.12–0.52; P < 0.001) and Watcha (39% vs 15%; relative
risk = 0.37; 95% confidence interval 0.22–0.62; P < 0.001) scales. Duration

© 2015 John Wiley & Sons Ltd 1

Propofol to prevent emergence agitation D. Costi et al.

and severity of EA were also reduced in the propofol group. Preplanned sub-
group analyses for midazolam premedication, preexisting cognitive or behav-
ioral disturbance, and age group did not alter our findings. Emergence time
and time in PACU were both increased by a mean of 8 min in the propofol
group (P < 0.001) with no difference in time to discharge home.
Conclusions: Transition to propofol at the end of sevoflurane anesthesia
reduces the incidence of EA and improves the quality of emergence. There is
a small increase in recovery time, but no delay in discharge home.

Registry (ANZCTR Trial ID ACTRN12610000025033).

Introduction
Following sevoflurane anesthesia in young children,
postoperative behavioral disturbance known as emer-
gence agitation (EA) or emergence delirium (ED) has
long been recognized as a common problem during early
recovery. Although the terms EA and ED are frequently
used interchangeably, recent research would suggest that
ED likely represents a subset of EA with true delirium
occurring in a relatively low proportion of patients with
EA (1,2). The incidence of EA in children after sevoflu-
rane anesthesia is reported to be as low as 10% and as
high as 80% (3). Risk factors for EA in children have
been reported to include sevoflurane or desflurane anes-
thesia and younger age; however, the precise etiology is
unknown (3,4). EA can cause self-injury, disruption of
the dressing, surgical incision, or indwelling catheters,
and EA can result in parental and staff dissatisfaction
with the anesthetic.
Propofol is one of the many pharmacological inter-
ventions that can reduce the incidence of EA after sevo-
flurane anesthesia (5,6). Most propofol EA trials
showing a benefit delivered propofol by infusion
throughout the maintenance of anesthesia (5,6). A smal-
ler number of studies have investigated a simple
1 mg
kg 1 propofol bolus at the end of sevoflurane
anesthesia with mixed results in reducing EA (7–10).
The simple approach of transitioning to propofol at the
end of sevoflurane anesthesia manually administered
from a syringe has been described as a strategy to reduce
EA (11). This is a common practice in our institution
which had not been formally investigated previously.
The aim of this randomized double-blinded study was
to determine whether transition to propofol for 3 min at
the end of sevoflurane anesthesia reduces the incidence
of EA in children.
Methods
This study was approved by the Women’s and
Children’s Health Network Human Research Ethics
Committee (approval number REC2216/10/12) and reg-
istered with the Australian New Zealand Clinical Trials
After obtaining written informed parental consent, chil-
dren aged 1–12 years (ASA I-II) undergoing magnetic
resonance imaging (MRI) scans under general anesthe-
sia were randomized to the treatment (transition to
propofol) or control (no intervention) group. The ran-
dom sequence was generated using a computer-gener-
ated random number table in blocks of 25. Group
allocation was concealed using sequentially numbered,
opaque, sealed envelopes. Each envelope contained the
group allocation with instructions for the treating anes-
thetist. Intervention was completed by the treating anes-
thetist in the MRI suite prior to transfer to the
postanesthesia care unit (PACU). Exclusion criteria
were the performance of any other painful procedure;
pupillary dilatation for ophthalmologic examination
under the same anesthetic; allergy to propofol or egg
product; or a family history of malignant hyperthermia.
Anesthesia technique
Oral midazolam premedication was administered at the
discretion of the treating anesthetist (0.5 mg
kg 1, maxi-
mum 15 mg). Parents were present at induction of anes-
thesia in the MRI suite adjacent to the MRI scanner.
Anesthesia induction was with either inhalational sevo-
flurane and nitrous oxide or intravenous (i.v.) propofol,
at the discretion of the treating anesthetist. An i.v. can-
nula was inserted after inhalational induction. Anesthe-
sia was maintained with sevoflurane in an air and
oxygen mix via a laryngeal mask airway. Patients ran-
domized to the propofol group received propofol
3 mg
kg 1 i.v. over 3 min at the end of sevoflurane anes-
thesia in the following manner: sevoflurane was ceased
at completion of the MRI scan and the fresh gas flow
increased to 6 l
min; propofol 1 mg
kg 1 i.v. bolus was
given prior to the patient leaving the scan room with a
further 2 mg
kg 1 administered manually over the next
3 min in the MRI suite; the i.v. cannula was then flushed
with saline; and the patient transferred to the PACU.
Patients randomized to the control (no intervention)
group had sevoflurane ceased at the end of the MRI
scan and were transferred to the PACU. Laryngeal

2 © 2015 John Wiley & Sons Ltd

D. Costi et al.
mask airways were removed prior to emergence. All
patients received face mask oxygen delivered by a
T-piece circuit until emergence and were monitored with
continuous pulse oximetry until discharge from the
PACU.
Outcome assessment
An outcome assessor who was blinded to group alloca-
tion observed the child from the time of arrival in the
PACU until 30 min after emergence. The time to emer-
gence was defined as the time from cessation of sevoflu-
rane or propofol administration until the first sign of
Assessed for eligibility (n = 242)
Randomized (n = 230)
Allocated to control group (n = 115)
♦ Received allocated intervention (n = 115)
Lost to follow-up (n = 0)
Analysed (n = 109)
Excluded from analysis due to:
♦ laryngospasm on emergence requiring treatment with
propofol and/or suxamethonium (n = 3)
♦ protocol violation: IV midazolam given (n = 1)
♦ assessor unavailable due to overlapping recruits (n = 1)
♦ addition of an unscheduled painful procedure (n = 1)
Figure 1 CONSORT trial flow diagram.
© 2015 John Wiley & Sons Ltd
Propofol to prevent emergence agitation
rousing (defined as the ‘onset of eye opening or purpose-
ful movement’). Upon emergence, EA was assessed
simultaneously using two scales. The Pediatric Emer-
gence Anesthesia Delirium (PAED) scale (12) (Table S1)
and Watcha scale (13) (Table S2) scores were recorded
at 5 min intervals until 30 min after emergence. EA on
the PAED scale was defined as a PAED score >12 at
any time in the 30 min after emergence (1). EA as
assessed by the Watcha scale was defined as a score ≥3
at any time in the 30 min after emergence. The primary
outcomes were the incidence of EA according to the
PAED and Watcha scales. The secondary outcomes
were peak PAED scores, emergence time, time in
Excluded (n = 12)
♦ Declined to participate
Allocated to propofol group (n = 115)
♦ Received allocated intervention (n = 114)
♦ Excluded due to tissued IV cannula with inadvertent
subcutaneous propofol administration (n = 1)
Lost to follow-up (n = 0)
Analysed (n = 109)
Excluded from analysis due to:
♦ laryngospasm on induction requiring treatment with
propofol and/or suxamethonium (n = 1)
♦ laryngospasm on emergence requiring treatment with
propofol and/or suxamethonium (n = 1)
♦ protocol violation: IV ketamine given (n = 1)
♦ assessor unblinded due to unflushed propofol visible
in IV bung (n = 1)
♦ missing data collection forms (n = 1)
3
Propofol to prevent emergence agitation D. Costi et al.

PACU, and time to hospital discharge. We performed Table 1 Demographics of study participants
preplanned subgroup analyses of the incidence of EA Control Propofol
for the presence or absence of midazolam premedica- group group
tion, age group, and the presence or absence of a preex- (n = 109) (n = 109)
isting cognitive or behavioral disturbance (defined by
Sex, n
medical record diagnosis and/or parental verbal report,
Female 48 51
e.g., developmental delay, autism). Male 61 58
Age (years), 4.1  2.8 4.0  2.4
mean  SD
Statistical analysis
Median (IQR) 3.5 (1.9, 5.4) 3.7 (2.3, 5.2)
A recent prospective audit of the incidence of EA in our Age groups, n
institution was found to be 32% (1). A sample size cal- 1–6 years 92 98
≥7 years 17 11
culation showed that 216 patients (108 in each group)
Weight (kg), 18.0  7.3 17.7  7.0
would be required to show a reduction in the incidence mean  SD
of EA to 15% with a power of 80% and an a of 0.05. Median (IQR) 16.2 (12.7, 21.4) 16.3 (13.0, 20.6)
We recruited 230 patients to allow for protocol viola- Cognitive or behavioral 30 31
tions and exclusions. disorder, n
Continuous data were checked for normality using Premedication, n 12 10
the Shapiro–Wilk test. Demographics and group com- Induction type, n
Inhalational 106 105
parisons of continuous variables were conducted using
Intravenous 3 4
Mann–Whitney U-tests for nonnormally distributed Anesthetic durationa 73  25 65  20
data, with mean  SD or median (interquartile range) (min), mean  SD
reported. Incidence of EA and group comparisons of Median (IQR) 67 (56, 85) 62 (54, 74)
categorical data are reported as frequency and percent- MRI region scanned, n
age, using chi-squared analysis. A logistic regression Head 78 86
model with EA as our binary-dependent outcome vari- Head and spine 7 4
Spine 12 7
able was performed with emergence propofol (yes/no),
Other 12 12
midazolam premedication (yes/no), preexisting cognitive
or behavioral disturbance (yes/no), age (continuous), SD, standard deviation; IQR, interquartile range; MRI, magnetic reso-
and induction technique (i.v. or inhalational) as indepen- nance imaging.
a
dent predictor variables. Unadjusted (crude) odds ratios In contrast to all other baseline parameters, there was a statistical
difference in mean and median anesthetic duration of 8 and 5 min,
were obtained for each individual predictor and an over-
respectively.
all logistic regression was then run with all predictors
together to obtain adjusted odds ratios. P < 0.05 was
considered statistically significant. All statistical analyses
were performed using IBM SPSS Statistics for WINDOWS, Figure 2 illustrates the distribution of peak PAED
Version 20.0. (IBM Corp., Armonk, NY, USA). scores showing that children in the propofol group were
far more likely to have a zero PAED score throughout
their PACU stay (21% vs 9% P = 0.014). Figure 2 also
Results
shows a grouping of very high PAED scores in controls
A total of 230 children were randomized from January which is absent in the propofol group. Figure 3 shows
2010 to September 2013, of which 218 were analyzed the influence of time after emergence on the proportion
(Figure 1). The demographics of the two groups were of children with EA (as defined by the PAED score
comparable (Table 1). >12). Unlike the control group, no children in the prop-
Emergence agitation and recovery outcomes are pre- ofol group had PAED scale EA beyond 15 min after
sented in Table 2. The overall incidence of EA was emergence.
lower in the propofol group when measured by both Preplanned subgroup analyses of premedication and
PAED (29% vs 7%, P < 0.001) and Watcha (39% vs preexisting cognitive or behavioral disorder are consis-
15%, P < 0.001) scales. Peak PAED scores were also tent with the finding that propofol is effective in reduc-
significantly lower in the propofol group (P < 0.001). ing the incidence of EA in these patient subgroups
The emergence times and PACU times were a mean of (Table 2). With logistic regression, we found that no
8 min longer in the propofol group, but there was no emergence propofol was the only predictor associated
difference in time to discharge home (Table 2). with a higher incidence of EA (Table 3).

4 © 2015 John Wiley & Sons Ltd

D. Costi et al. Propofol to prevent emergence agitation

Table 2 Emergence agitation and recovery time outcomes

Control Propofol P-value Risk ratio (95% CI)

Emergence agitation (all patients)

PAED scale EA, number (%) of cases 32/109 (29) 8/109 (7) <0.001 0.25 (0.12–0.52)
Watcha scale EA, number (%) of cases 43/109 (39) 16/109 (15) <0.001 0.37 (0.22–0.62)
Peak PAED scores, median (IQR) 10 (6, 13) 6 (2, 10) <0.001
PAED scale EA subgroups
Exclusion of potential confounders (%)a 22/70 (31) 6/71 (8) <0.001 0.27 (0.12–0.62)
No premedication (%) 28/97 (29) 8/99 (8) <0.001
Midazolam premedication (%) 4/12 (33) 0/10 (0) 0.04
No PCBD (%) 26/79 (33) 7/78 (9) <0.001
PCBD (%) 6/30 (20) 1/31 (3) 0.04
Recovery times (min), mean  SD
Emergence time 9  10 17  10 <0.001
Time in PACU 27  13 35  15 <0.001
Time to hospital discharge 99  48 95  36 0.573

CI, confidence interval; EA, emergence agitation; PAED, Pediatric Anesthesia Emergence Delirium; IQR, interquartile range; SD, standard devia-
tion; PACU, postanesthesia care unit.
a
Preexisting cognitive or behavioral disorder (PCBD) and/or midazolam premedication and/or intravenous induction.

Figure 3 Proportion of children with emergence agitation (PAED

score >12) against time after emergence. PAED, Pediatric Anesthe-
sia Emergence Delirium; EA, emergence agitation.

sevoflurane anesthesia (5) show this trial to be one of the

Figure 2 Peak PAED scores for each individual patient in the first
30 min after emergence from anesthesia. PAED, Pediatric Anesthe-
sia Emergence Delirium.
Laryngospasm on emergence occurred in one patient
(1%) randomized to the propofol group and three
patients (3%) in the control group. There were no other
cases of desaturation in PACU.
Discussion
The findings of a recently published systematic review of
all randomized controlled trials (RCTs) investigating
the effects of interventions to prevent EA after
largest EA RCTs to date and the first to investigate a
short transition to propofol at the end of sevoflurane
anesthesia. This transition technique is distinct from a
1 mg
kg 1 bolus of propofol at the end of anesthesia or
an infusion throughout the maintenance of anesthesia.
This study has demonstrated that 3 mg
kg 1 of propofol
delivered over 3 min at the end of sevoflurane anesthesia
reduced the incidence of EA in children. Not only was
the incidence of EA reduced but also its severity and
duration suggesting that the overall quality of emer-
gence was improved. Although there was a small
increase in emergence and PACU times, there was no
delay to discharge home.
Propofol is effective in reducing the incidence of EA
compared to sevoflurane when administered as total

© 2015 John Wiley & Sons Ltd 5

Propofol to prevent emergence agitation
Table 3 Logistic regression for PAED scale EA
Unadjusted OR (95% CI)
No emergence propofol 5.25 (2.29–12.03)
Age 0.86 (0.74–1.01)
Preexisting cognitive or behavioral disorder 0.49 (0.20–1.17)
Premedication 0.99 (0.32–3.10)
Induction method 1.82 (0.34–9.74)
PAED, Pediatric Anesthesia Emergence Delirium; EA, emergence agitation; OR, odds ratio; CI, confidence interval.
intravenous anesthesia (TIVA) or throughout
maintenance after sevoflurane induction (5,6). These
approaches generally require the additional complexity
of an infusion pump and application of an algorithm for
infusion rate (e.g., target-controlled infusion or manu-
ally adjusted rate at certain time intervals). In our insti-
tution, anesthetists often prefer the simplicity of
manually administered propofol from a syringe incre-
mentally in doses >1 mg
kg 1 over a few minutes
toward the end of anesthesia. At the time of designing
this study, four RCTs had reported comparing the inci-
dence of EA and/or agitation scores with two showing a
benefit (7,8) and two no benefit (9,14) with propofol
1 mg
kg 1. By the completion of this study, there were
eight studies with five showing a benefit (7,8,15–17) and
three no benefit (9,10,14) with propofol 1 mg
kg 1. The
only study performed in the MRI setting was much
smaller than ours and showed a reduced incidence of
EA when EA was defined as a PAED score ≥16 (8). This
score is a very high cut-off for defining EA and had we
used this definition, our results show an even greater
effect in favor of propofol (see Figure 2).
The etiology of EA is unknown and it may be multi-
factorial. The emergence delayed by an average of 8 min
would suggest that the mechanism of action of the prop-
ofol transition may be facilitation of sevoflurane wash-
out prior to the point of emergence. We speculate that
sevoflurane-associated EA may occur within a window
of brain concentrations of sevoflurane. For example,
children may be vulnerable to EA between a brain or
endtidal concentration of 0.2% and 0.1%, and less so at
0.05% and below. It is possible that there is an intrinsic
property of propofol that accounts for its beneficial
effect in reducing EA. However, a diverse group of
agents including dexmedetomidine, clonidine, fentanyl,
and ketamine can also reduce sevoflurane EA (5,6), and
these agents all have in common with propofol the
capacity to delay emergence and facilitate sevoflurane
washout. In contrast to propofol, they all have analgesic
properties which may contribute to their effectiveness
after painful procedures; however, this is not a plausible
mechanism in the MRI setting.
6 © 2015 John Wiley & Sons Ltd
D. Costi et al.
P-value Adjusted OR (95% CI) P-value
<0.001 5.51 (2.37–12.78) <0.001
0.069 0.86 (0.73–1.01) 0.073
0.108 0.55 (0.22–1.39) 0.206
0.983 1.39 (0.39–4.89) 0.613
0.484 2.57 (0.37–18.05) 0.341
Our trial has a few limitations in the setting studied.
To improve external validity, we elected to include chil-
dren with preexisting cognitive and behavioral disorders
(the majority of which had a mild cognitive impairment
due to developmental delay), and those requiring mi-
dazolam premedication. Although this introduces other
variables, it was an a priori subgroup analysis and num-
bers were evenly distributed across the two study
groups. Reassuringly, propofol administration seems
effective in the presence or absence of these factors
(Tables 2 and 3). We did not study adverse events aside
from laryngospasm (which occurred in <3% of random-
ized subjects) and desaturation. The hemodynamic and
respiratory effects of propofol boluses ranging in doses
up to 3 mg
kg 1 administered in the presence of sevoflu-
rane anesthesia have already been well described in chil-
dren, so this was not further investigated in this study
(18). Although we did not study beyond 30 min after
emergence, it may have been useful to measure the post-
operative behavior beyond this time frame and also
some measure of parent/caregiver satisfaction. A less
obvious limitation may be the choice of EA scale. Sikich
and Lerman (12) who devised the PAED scale did not
describe a cutoff score that indicates the presence or
absence of EA or ED. Cutoff scores ranging from ≥10 to
≥16 have subsequently been used without rigorous justi-
fication for the level chosen (1). Numerous scales other
than PAED have also been used to assess EA (3). The
reason for using the Watcha scale in addition to PAED
is that it is simpler to use and provides a meaningful
clear endpoint, i.e., consolability, for the dichotomous
outcome of EA. We did not define a minimum time
frame for which a child reached an EA threshold to be
considered to have EA. A minimum time frame of
3 min (19) or 5 min (20) has been suggested previously.
In the current study, the majority of children assessed as
having EA were beyond the EA threshold in more than
one 5 min epoch.
To avoid longer emergence times or PACU stays, the
transition to propofol with concurrent cessation of sevo-
flurane could be made prior to completion of the proce-
dure. Our findings suggest that a transition 8 min prior
D. Costi et al. Propofol to prevent emergence agitation

to the anticipated end of the procedure would be likely

Ethics approval
to leave emergence times unchanged. This would be
more feasible in settings other than the MRI room, Institutional ethics approval was obtained for this study
where there is easy access to the patient’s i.v. cannula to from the Women’s and Children’s Health Network
make the transition. It is likely that if pain is adequately Human Research Ethics Committee, 72 King William
controlled, this intervention would also be of value in Road, North Adelaide 5006, Australia.
reducing EA postoperatively.
Future studies could compare the current transition
Funding
strategy with the effects of propofol TIVA; propofol
maintenance after sevoflurane induction; or a propofol This work was supported by funding from a Society for
1 mg
kg 1 bolus at the end of anesthesia. Further Paediatric Anaesthesia in New Zealand and Australia
research is required to confirm whether our findings (SPANZA) Research Grant.
would be replicated in a surgical setting. It would be
important to have a trial design that includes adequate
Conflict of interest
analgesia administered to all patients so that the possi-
bility of pain acting as a confounding factor is mini- The authors report no conflicts of interest.
mized (21).
In conclusion, transition to propofol 3 mg
kg 1 over
Supporting information
3 min at the end of sevoflurane anesthesia significantly
improves the quality of emergence by reducing the inci- Additional Supporting Information may be found in the
dence, severity, and duration of EA. Although there is a online version of this article:
small increase in recovery time, there is no delay in dis- Table S1 PAED scale.
charge from hospital to home. Table S2 Watcha four-point scale.

References
1 Bajwa SA, Costi D, Cyna AM. A compari-
son of emergence delirium scales following
general anesthesia in children. Pediatr
Anesth 2010; 20: 704–711.
2 Malarbi S, Stargatt R, Howard K et al.
Characterizing the behavior of children
emerging with delirium from general anes-
thesia. Pediatr Anesth 2011; 21: 942–950.
3 Vlajkovic GP, Sindjelic RP. Emergence
delirium in children: many questions, few
answers. Anesth Analg 2007; 104: 84–91.
4 Voepel-Lewis T, Malviya S, Tait AR. A pro-
spective cohort study of emergence agitation
in the pediatric postanesthesia care unit.
Anesth Analg 2003; 96: 1625–1630.
5 Costi D, Cyna AM, Ahmed S et al.
Effects of sevoflurane versus other general
anaesthesia on emergence agitation in chil-
dren. Cochrane Database Syst Rev 2014;
9: CD007084.
6 Dahmani S, Stany I, Brasher C et al. Phar-
macological prevention of sevoflurane- and
desflurane-related emergence agitation in
children: a meta-analysis of published stud-
ies. Br J Anaesth 2010; 104: 216–223.
7 Aouad MT, Yazbeck-Karam VG, Nasr VG
et al. A single dose of propofol at the end of
surgery for the prevention of emergence agi-
tation in children undergoing strabismus sur-
gery during sevoflurane anesthesia.
Anesthesiology 2007; 107: 733–738.
8 Abu-Shahwan I. Effect of propofol on emer-
gence behavior in children after sevoflurane
general anesthesia. Pediatr Anesth 2008; 18:
55–59.
9 Bakhamees HS, Mercan A, El-Halafawy
YM. Combination effect of low dose fenta-
nyl and propofol on emergence agitation in
children following sevoflurane anesthesia.
Saudi Med J 2009; 30: 500–503.
10 Lee CJ, Lee SE, Oh MK et al. The effect of
propofol on emergence agitation in children
receiving sevoflurane for adenotonsillectomy.
Korean J Anesthesiol 2010; 59: 75–81.
11 Fronapfel PJ. Prevention of emergence delir-
ium. Pediatr Anesth 2008; 18: 1113–1114.
12 Sikich N, Lerman J. Development and psy-
chometric evaluation of the pediatric anes-
thesia emergence delirium scale.
Anesthesiology 2004; 100: 1138–1145.
13 Watcha MF, Ramirez-Ruiz M, White PF
et al. Perioperative effects of oral ketorolac
and acetaminophen in children undergoing
bilateral myringotomy. Can J Anaesth 1992;
39: 649–654.
14 Chiba S, Shima T, Murakami N et al. Effect
of propofol on sevoflurane agitation in chil-
dren. Masui 2003; 52: 611–615.
15 Sun Y, Hu J, Xu W-Y et al. Combination
effect of tramadol and low dose propofol on
emergence agitation in children receiving
sevoflurane for adenotonsillectomy proce-
dure. J Shanghai Jiaotong Univ (Med Sci)
2010; 30: 73–75.
16 Kim YH, Yoon SZ, Lim HJ et al. Prophylac-
tic use of midazolam or propofol at the end
of surgery may reduce the incidence of emer-
gence agitation after sevoflurane anaesthesia.
Anaesth Intensive Care 2011; 39: 904–908.
17 Kim MS, Moon BE, Kim H et al. Compari-
son of propofol and fentanyl administered at
the end of anaesthesia for prevention of
emergence agitation after sevoflurane anaes-
thesia in children. Br J Anaesth 2013; 110:
274–280.
18 Lerman J, Houle TT, Matthews BT et al.
Propofol for tracheal intubation in children
anesthetized with sevoflurane: a dose-
response study. Pediatr Anesth 2009; 19: 218–
224.
19 Cravero J, Surgenor S, Whalen K. Emer-
gence agitation in paediatric patients after
sevoflurane anaesthesia and no surgery: a
comparison with halothane. Paediatr Ana-
esth 2000; 10: 419–424.
20 Cravero JP, Beach M, Thyr B et al. The
effect of small dose fentanyl on the emer-
gence characteristics of pediatric patients
after sevoflurane anesthesia without surgery.
Anesth Analg 2003; 97: 364–367.
21 Rosen HD, Cravero JP. Research on emer-
gence agitation in children. Can J Anaesth
2013; 60: 822–823.

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