The effect of midazolam administration for the prevention of emergence agitation in pediatric patients with extreme fear and non-cooperation undergoing dental treatment under sevoflurane anesthesia, a double-blind, randomized study

Mari Kawai,1 Shinji Kurata,1 Takuro Sanuki,2 Gaku Mishima,1 Kensuke Kiriishi,1 Toshihiro Watanabe,1 Yu Ozaki-Honda,1 Mizuki Yoshida,1 Ichiro Okayasu,1 Terumi Ayuse,3 Naomi Tanoue,3 Takao Ayuse1–31Department of Dental Anesthesia, Nagasaki University Hospital, Nagasaki, Japan; 2Nagasaki University Institute of Biomedical Sciences, Course of Medical and Dental Sciences, Dental Anesthesiology, Nagasaki, Japan; 3Department of Special Care Dentistry, Nagasaki University Hospital, Nagasaki, JapanBackground: Sevoflurane is generally the preferred anesthetic agent for general anesthesia in pediatric patients, due to its rapid induction and recovery characteristics. However, it has been recognized that a major complication is emergence agitation when awakening from general anesthesia. The aim of this study was to evaluate the occurrence rate of emergence agitation in the operating room and postoperative recovery area following intraoperative administration of midazolam to pediatric patients under general anesthesia.Patients and methods: One hundred and twenty pediatric patients undergoing dental treatment under sevoflurane anesthesia were enrolled in this study. The patients were divided into three groups (n=40 each in the 0.1 mg/kg midazolam, 0.05 mg/kg midazolam, and control with saline groups). Midazolam or saline was injected intravenously approximately 30 minutes before the end of the dental treatment. We used the Richmond Agitation and Sedation Scale (RASS) to assess the level of sedation and drowsiness at emergence phase in the operating room. We also used the Pediatric Anesthesia Emergence Delirium Scale (PAED) to assess the level of agitation and delirium at the full recovery phase from anesthesia in the recovery area.Results: At the emergence phase, the incidence of emergence agitation in the 0.1 mg/kg midazolam group was significantly lower than in the other groups (p=0.0010). At the recovery phase, there was no significant difference among the three groups. The odds ratio between PAED score and RASS score was 4.0 using logistic regression analysis. The odds ratio between PAED score and Disability was 2.5.Conclusion: Administration of a single dose of 0.1 mg/kg midazolam dose significantly decreases the incidence of severe emergence agitation at the emergence after sevoflurane anesthesia, but not at the recovery phase. Furthermore, the evaluation of sedative and agitation condition using RASS score at emergence from anesthesia is useful to predict occurrence of agitation in the recovery phase.Keywords: emergence agitation, sevoflurane anesthesia, pediatric patients, extreme non-cooperation against dental treatmen