The effect of different anesthetic drugs on the incidence of emergence delirium or agitation in pediatric surgeries

Emergence delirium (ED) and emergence agitation (EA) are induced perturbations to the mental state of an individual after anesthesia. The phenomenon and presentation can vary widely, as they are associated with several symptoms such as restlessness, confusion, and hyperactivity. Patients undergoing tonsillectomy and adenoidectomy often require the use of anesthetics and can experience EA and/or ED. Various practices have been implemented to prevent the development of this condition through different regimens of anesthetics for such procedures. However, inconsistencies exist within the literature, thus precluding a consensus on the optimal approach to mitigating the effects of EA and ED. The objective of this work was to provide a comprehensive review of the literature evaluating different anesthetic drugs and their effectiveness in lowering the postoperative EA and ED risks in pediatric patients after undergoing tonsillectomies and/or adenoidectomies. A systematic review of the literature was performed using PRISMA guidelines. The 13 studies that were selected were partitioned into different groups: single anesthetic (n=2) and combination anesthetic (n=11). Furthermore, the combination group was divided into combinations with sevoflurane (n=8), combinations with propofol (n=2), and multiple administrations of dexmedetomidine (n=1). Analysis of the data from these selected studies found that the use of a combination of anesthetic drugs decreased ED/EA when compared with solo administration. Propofol, ketamine and remimazolam were the most effective at reducing the incidence of ED/EA when combined with sevoflurane. The mechanism of action of these three drugs was similar, suggesting that combinations of GABA agonists and NMDA antagonists when combined with sevoflurane may be the most efficacious at decreasing the psycho-pathological symptoms of ED and EA. The results also suggested that; contrary to conventional wisdom; a deeper level of anesthesia achieved when combining these drugs may lead to greater alleviation of ED/EA symptoms.