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Contents lists available at ScienceDirect

International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

The effect of KETODEX on the incidence and severity of emergence

agitation in children undergoing adenotonsillectomy using
sevoflurane based-anesthesia
Sally M. Hadi a,1, Amin J. Saleh a,1, Yong Zhong Tang a, Ahmed Daoud b, Xi Mei a,
Wen Ouyang a,*
a
Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha 410013, PR China
b
Department of Otorhinolaryngology, Suez Canal Authority Hospital, Ismailia, Egypt

A R T I C L E I N F O A B S T R A C T

Article history: Background: Postoperative emergency agitation (EA) is a common problem often observed in children
Received 17 December 2014 undergoing general anesthesia. The purpose of this study was to evaluate whether a bolus of
Received in revised form 10 February 2015 intraoperative low-dose ketamine followed by dexmedetomidine i.v. could reduce the incidence of EA in
Accepted 12 February 2015
children undergoing adenotonsillectomy following sevoflurane-based anesthesia.
Available online xxx
Methods: A total of 92 children undergoing adenotonsillectomy, aged 3–7 years, were randomly
allocated to receive either low-doseketamine 0.15 mg/kg followed by dexmedetomidine 0.3 mg/kg i.v.
Keywords:
(KETODEX, n = 45) or volume-matched normal saline (Control, n = 47), about 10 min before the end of
Anesthesia
Adenotonsillectomy
surgery. Anesthesia was induced and maintained with sevoflurane. Postoperative pain and EA were
Dexmedetomidine assessed with objective pain score (OPS) and the Pediatric Anesthesia Emergence Delirium scale (PAED),
Emergence agitation respectively. EA was defined as a PAED  10 points. Recovery profile and postoperative complications
Ketamine were recorded.
Children Result: The incidence and severity of EA was lower in KETODEX group than controls (11% vs. 47%) and
(2% vs. 13%), respectively (P < 0.05). The frequency of fentanyl rescue was lower in KETODEX group than
in controls (13.3 vs. 38.3%, P < 0.05). Heart rate during extubation was significantly higher in the control
group compared with children who received KETODEX (P < 0.05). The incidence of postoperative pain
was significantly less in the KETODEX group (15.5% vs. 63.8%, P < 0.05). Times to interaction and
extubation were significantly longer in the KETODEX group (P < 0.05).
Conclusion: KETODEX reduces the incidence and severity of EA in children undergoing adenotonsil-
lectomy following sevoflurane-based anesthesia and provided smooth extubation.
ß 2015 Published by Elsevier Ireland Ltd.

1. Introduction during recovery [3]. Emergency agitation is characterized by a

Adenotonsillectomy is one of the most common surgical
procedure preformed in children [1]. Sevoflurane is often used
in preschool children anesthesia because its a fast and well
tolerated inhaled agent, hemodynamically stable, low hepatotox-
icity, and rapid emergence from anesthesia. However, postsev-
flurane emergence agitation (EA) is a common phenomenon in
children with a wide incidence range up to 80% [2], depending on
the definition, assessment tools and time period of monitoring
* Corresponding author. Tel.: +86 139 749 4441.
E-mail address: ouyangwen133@vip.sina.com (W. Ouyang).
1
These authors contributed equally to this work.
short period of disorientation, agitation, delusion, hallucination,
restlessness, inconsolable crying and cognitive changes plus
memory impairment [4]. The etiology of EA remain unknown
[5]. However, there are several risk factors may be involved in EA
development, such as preschool age, pain, type of surgery
(ophthalmology or otorhinolaryngology) and inhalation agents
associated with fast emergence and duration of anesthesia [6].
Several prospective clinical trail studies suggested different
pharmacological methods for either treatment or prophylaxis from
EA after anesthesia and surgery with variable success such as
analgesics, opioids, benzodiazepines, and clonidine [2,4]. However,
the method of choice remains controversial.
Ketamine is a non-competitive N-methyl-D-aspartate receptor
antagonist an effective drug for sedation, analgesia and amnesia.

http://dx.doi.org/10.1016/j.ijporl.2015.02.012
0165-5876/ß 2015 Published by Elsevier Ireland Ltd.

Please cite this article in press as: S.M. Hadi, et al., The effect of KETODEX on the incidence and severity of emergence agitation in
children undergoing adenotonsillectomy using sevoflurane based-anesthesia, Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/
10.1016/j.ijporl.2015.02.012
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Several studies demonstrated the effect of ketamine on decreasing
the incidence of EA [7]. Meanwhile, dexmedetomidine is highly
specific for a2-adrenoceptor agonist with sedative, analgesic
and anxiolytic properties without significant respiratory de-
pression at clinical dosages [8]. It has been reported that
dexmedetomidine reduces the incidence of EA in children under
sevoflurane-based anesthesia [9]. Previous reports demonstrat-
ed the use of the alpha2 agonist, dexmedetomidine, with low-
dose ketamine as a safe and effective treatment strategy to
provide adequate comfort and sedation for children patients in
several surgical procedures [10–12]. However, both ketamine
and dexmedetomidine shows a variable EA incidence ranges
based on the administration time and doses. Therefore, we
designed this prospective randomized double-blind controlled
study to test the hypothesis that low-doseketamine 0.15 mg/kg
followed by dexmedetomidine 0.3 mg/kg i.v. could reduce the
incidence of EA without deterioration of hemodynamics stability
in children undergoing adenotonsillectomy using sevoflurane
based-anesthesia.
2. Materials and methods
2.1. Patients enrollment
After approval by the Ethics Committee of 3rd Xiangya Hospital,
Hunan, China. Informed parental consent was obtained for ninety
eight aged 3–7 years old children with ASA physical status I–II and
without liver, kidney, systemic disease or bleeding who were
scheduled to undergo GA for adenotonsillectomy were enrolled.
Exclusion criteria included those children with lack of consent,
neurological or psychological disorders, or any conditions that may
influence cooperation, emergency surgery, history of allergy to the
drugs used, cardiovascular dysfunction, respiratory disease and
receipt of any analgesic or sedatives within two days before the
surgery.
2.2. Procedure
All children were fasted for 6 h before the procedure. In the
operating room standard monitoring (electrocardiography (ECG),
non-invasive blood pressure (NIBP), pulse oxygen saturation
(SpO2) and Bispectral index (BIS)) connected to patients. Patients
were not premedicated before the surgery. Anesthesia was
induced via a face-mask with oxygen–air mixture and sevoflurane
with increments of 1% at each breath up to 8%. Once consciousness
was lost, intravenous access was established and an infusion of
balanced salt solution was administered according to standard
fluid administration Guidelines. After induction, fentanyl (1 mg/
kg) was administered to all children. Thereafter, tracheal
intubation was performed after achieving sufficient depth of
anesthesia and without the use of neuromuscular blocking drugs.
After induction of anesthesia and before the surgical incision,
through double-blind method, children were assigned to one of
two groups according to a computer generated randomization
program. The random number sequence was generated by an
internet site program (http://www.random.org). The inhalation
agent was titrated to maintain the BIS score between 40 and 60,
while controlled ventilation was performed to sustain the end-
tidal carbon dioxide (ETCO2) between 35  4 mmHg, and the
baseline hemodynamic changes were kept within a 20% range.
Dexamethasone (0.2 mg/kg) were administered intravenously for
the prevention of postoperative nausea and vomiting. About 10 min
before the end of surgery, patients received either low-dose ketaimn
0.15 mg/kg followed dexmedetomidine 0.3 mg/kg i.v. (KETODEX
group, n = 45) or volume-matched normal saline (Control group,
n = 47). At the conclusion of the procedure, sevoflurane was
Please cite this article in press as: S.M. Hadi, et al., The effect of KETODEX on the incidence and severity of emergence agitation in
children undergoing adenotonsillectomy using sevoflurane based-anesthesia, Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/
10.1016/j.ijporl.2015.02.012
discontinued, and the O2 flow rate was increased to 10 L/min. The
following time intervals were recorded: The duration of anesthesia
(was measured from the start of sevoflurane induction until
endotracheal tube (EET) removal), duration of surgery (was defined
as the time between the insertion and removal of the Boyle–Davis
mouth gag), time to remove ETT (defined as time from discontinua-
tion of sevoflurane to tracheal exubation), interaction time (was
defined as spontaneous eye opening or on verbal command from
sevoflurane discontinuation) and duration of PACU stay (was
measured from arrival to PACU until discharge). Endotracheal tube
was removed when respiration was regular and adequate in rate and
depth. Study drugs were prepared and hidden behind drapes and
administrated by an independent anesthesiologist who was blinded
to the patient group allocation. Intraoperative hemodynamic data,
level of anesthesia and SpO2 were recorded by the same anesthesi-
ologist every 5 min. The anesthesiologists who performed and
maintained the anesthesia did not participate in any of the
postoperative assessments.
2.3. Observation
A blinded Postanesthesia care unit (PACU) nurse evaluated
postoperative pain and EA for 60 min. Because most of the EA
episodes occurred within 30 min of PACU arrival [6], postopera-
tive EA was evaluated at every 5 min for the first 30 min and then
every 10 min for the remaining 30 min, the Pediatric Anesthesia
Emergence Delirium (PAED) scale was used (Table 1). The PAED
scale is a reliable tool to measure EA and it has been validated in
preschool children in the post-anesthesia setting and it involves
five items (eye contact with the caregiver, purposeful action,
awareness of surroundings, restlessness and inconsolability) [13].
Each items was scored by five grade (0 to 4) according to its degree,
for a maximum of 20 points. Agitation scores 10 were regarded
as presence of agitation, and scores 15 were regarded as severe
agitation. Postoperative pain were evaluated by objective pain
score (OPS), a test used to assess pain in children, at the same time
intervals [14]. Severely agitated (score  15) patients or pain
score >4 were treated with fentanyl 1 mg/kg. Postoperative
vomiting (POV) was evaluated using a numeric rank score (0–2),
where a score of 0 = no vomiting, 1 = vomited once, and
2 = vomited twice or more. Patients with more than 2 emetic
episodes were treated with ondasteron 0.1 mg/kg. If POV still
uncontrolled, a second dose of ondasetron were given (up to a
maximum total dose of 4 mg). Nausea was not recorded as it was
difficult to assess in children. HR, NIBP, RR, and SpO2 were
recorded in the PACU every 5 min for the first 15 min, then at
15 min intervals for the remaining 45 min. Any desaturation
episode with SpO2 below 95% was noted. Complications during
the emergence period and in the PACU, such as laryngospasm,
bronchospasm bradycardia, respiratory depression, hypotension
and vomiting, were recorded and managed appropriately.
Children were discharged from the PACU when they were calm
and had an Aldrete score of 9 [15].
Table 1
Pediatric anesthesia emergence delirium (PAED) score.
Behavior Not Just Quite Very Extremely
at all a little a bit much
Makes eye contact 4 3 2 1 0
Actions are purposeful 4 3 2 1 0
Aware of surroundings 4 3 2 1 0
Restless 0 1 2 3 4
Inconsolable 0 1 2 3 4
1—Calm; 2—not calm but could be easily consoled; 3—moderately agitated or
restless and not easily calmed; 4—combative, excited, thrashing around.
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3. Statistical analysis Table 2

Demographic data, duration of surgery and duration of anesthesia.

The primary outcome of this study was the incidence of
postsevoflurane EA in the PACU. Sample size calculation was based
on previous studies [16,17]. The sample size was designed to
evaluate the difference in the primary outcome between the two
groups. A sample size of 45 patients per group was calculated to
have at least 80% power to detect a 50% reduction in the incident
of AE.
Data were analyzed using SPSS software (version 13, Chicago,
Illinois), and are presented as number (n) or percentage (%), or
mean  sd as appropriate. Non parametric data such as pain score
and PAED score were compared between groups with Mann–Whitney
U test. Parametric data were analyzed using an unpaired Student’s
t-test. Nominal data were analyzed using either the chi-square or
Fisher’s exact test. Statistical significance was accepted for P < 0.05.
4. Result
Ninety-eight children were initially enrolled in the current
study, Six patients were subsequently excluded from the analysis
because four they were premedicated with intravenous mid-
azolam (40 mg/kg), two due to crying and two due to an upper
respiratory tract infection (URI). Therefore, a total of ninety two
patients completed the study (Fig. 1).
The clinical and demographic characteristics of the children
included in the study are presented in Table 2. There were no
significant differences between the two study groups with respect
to patient’s age, gender, height, weight, ASA physical status, the
total anesthesia time and the total surgery time (P > 0.05).
Intraoperative data are presented in Table 3. In KETODEX group,
the number of rescue fentanyl doses of 1 mg/kg was significantly
lower 6 (13.3%) patients needed rescue fentanyl in comparison
with 18 (38.3%) patients in the controls (P < 0.05). In addition, the
time for interaction from anesthetic off to eye opening and time
from anesthetic off to extubation in KETODEX group were
significantly longer than in the controls (P < 0.05). There was no
significant difference between the two groups about the Aldert
KETODEX (n = 45) Control (n = 47)
Age (years) 4.22  1.32 4.22  1.12
Sex (M/F) 23/22 24/23
Weight (kg) 18.52  4.60 18.37  5.21
ASA (I/II) 44/1 45/2
Baseline HR (beats/min) 105  13 104  16
Baseline systolic NIBP (mm Hg) 102  12.6 104  13.7
Duration of anesthesia (min) 51.4  16.2 52.2  15.6
Duration of surgery (min) 43.7  13.6 45  16.2
Values are expressed as mean  SD or number of patients. ASA = American society of
anesthesiologists; HR = heart rate; NIBP = noninvasive arterial blood pressure. There
were no significant differences among the two groups (P > 0.05).
score and time from anesthetic off till discharge from PACU
(P > 0.05). There was no significant difference in the number of
patients with SpO2 below 95% between the two study groups, 5
(11.1%) in the KETODEX and 6 (13.0) in the controls (P > 0.05).
Moreover, there was no adverse events such as vomiting,
laryngospasm, bronchospasm, hypotension, bradycardia, bleeding
or postoperative respiratory depression (respiratory rate: <16),
were noted from the KETODEX administration (P > 0.05). Heart
rate was significantly higher in the control group starting at the
time of tracheal extubation compared with children who received
KETODEX (P < 0.05) (Fig. 2). Four children more in the control
group developed tachycardia during the time of extubation.
The variables measured in the PACU are shown in Table 4. The
mean PAED scale scores were not significantly different at the time
awakening between the study groups, the sum of the items of the
PAED scale were 4 in the KETODEX group and 5 in the controls
(P > 0.05). However, the sum of the items at the PAED peak score
were significantly lower in the KETODEX (7 scores) in compare to
the control (14 scores) (P < 0.05). In addition, the incidence of EA
(PAED > 10) was significantly lower in the KETODEX 11% in
compared with that in the controls 47% (P < 0.05). Similarly, sever
EA (PAED  15) was lower in the KETODEX group 2% in compare to
the controls 13% (P < 0.05). The median of OPS maximum score
was 6 for the controls and 3 for the KETODEX (P < 0.05). Likewise,
the percentage of patients with an OPS score >4 was significantly
lower in the KETODEX group compared with that in the controls
(15.5% vs. 63.8%, P < 0.05).

5. Discussion

Results from our current study demonstrated that low-dose

ketamine 0.15 mg/kg followed by dexmedetomidine 0.3 mg/kg i.v.
(KETODEX), about 10 min before the end of surgery, significantly
decreased the incidence and severity of postsevoflurane EA in
children undergoing adenotonsillectomy. Furthermore, KETODEX

Table 3
Intraoperative, discharge from PACU and postoperative complication data.

KETODEX Control
(n = 45) (n = 47)

Rescue by fentanyl 1 mg/kg 6 (13.3)* 18 (38.3)

Time to extubation (min) 5.24  2.4* 3.14  1.6
Time to interaction (min) 10.11  2.8* 6.32  2.1
Full aldrete score (min) 23.2  11.3 21.1  13.6
Time to discharge from PACU (min) 58.8  16.5 57.9  17.2
POV (0:1:2) 31/6/3 34/7/6
SpO2 below 95% 5 (11.1) 6 (13.0)

Data are presented as mean  SD, number of patients and percentage. PACU = pos-
tanesthesia care unit; POV = postoperative vomiting; SpO2 = peripheral oxygen
Fig. 1. CONSORT flowchart showing the number of patients at each phase of the saturation.
*
study. P < 0.05.

Please cite this article in press as: S.M. Hadi, et al., The effect of KETODEX on the incidence and severity of emergence agitation in
children undergoing adenotonsillectomy using sevoflurane based-anesthesia, Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/
10.1016/j.ijporl.2015.02.012
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4 S.M. Hadi et al. / International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx

patients has led to the use of subjective assessment methods and

Fig. 2. Intra-operative hemodynamic changes. (A) Heart rate and (B) mean arterial
blood pressure.
Table 4
PAED scale and pain score.
KETODEX
(n = 45)
PAED scale at awakening 4 (0–17)
PEAD peak score 7 (0–19)*
Agitation, PEAD score >10 (%) 5/45 (11%)*
Sever agitation, PEAD score 15 (%) 1/45 (2%)*
OPS maximum score (range) 3 (0–10)*
OPS >4 (%) 7 (15.5%)*
Values are expressed as number of patients (percentage) and mean  SD. The
median of OPS maximum score: range (minimum–maximum). PAED = pediatric
anesthesia emergence delirium; OPS = objective pain score.
*
P < 0.05.
provide hemodynamic stability during extubation. Heart rate and
mean arterial blood pressure values remain stable during
extubation and no medication was needed for hemodynamic
stabilization in the KETODEX group. Our primary outcome was the
incidence and severity of EA. When the incidence of emergence
agitation was defined on the PAED as a 10 or more scores regarded
as presence of agitation, and scores as 15 or more were regarded as
severe agitation. KETODEX reduced the incidence and severity of
agitation when compared to the control by (89% vs. 53%) and
(2% vs. 13%), respectively. Likewise, the pain scale shows lower OPS
score in the KETODEX group (15.5% vs. 63.8%). Furthermore, 86.7%
of patients in group KETODEX didn’t require any further secure
dose of fentanyl.
Emergence agitation is a common side effect of sevoflurane in
pediatric anesthesia. Previous studies reported that the incidence
of agitation after sevoflurane anesthesia is up to 80% [2]. Further,
beside the PAED scale, another assessment tools been used in a
variety of ways as well to measure postoperative agitation in
children, yet there still no widely accepted scale for pediatric
various agitation rating system. This perhaps the reason why the
incidence of postoperative agitation reported in a varies range
between 10% and 80% in previous studies [2,6]. These studies are
difficult to compare because of their different methodology and
children undergoing a variety of procedures and preoperative
sedation. Eckenhoff et al. surveyed the postanesthetic recovery
room records of 14,436 patients given general anesthetics, and the
authors demonstrated that the reason for EA incidence is unknown
[18]. However, risk factors such as preschool age, postoperative
pain, type of surgery (ophthalmology or otorhinolaryngology) and
inhalation agents may induce this condition [19,20].
Children who were premedicated with midazolam experienced
low incidence rate of postoperative agitation according to Cole
et al. [6] and high incidence rate according to Lapin et al. [21].
Because of conflicting in these findings that may effect on the
results of our study, we decided not to use premedication with
midazolam.
Several pharmacological interventions have been shown to
reduce agitation in children after sevoflurane-based anesthesia,
such as premedication with oral midazolam or the intraoperative
administration of dexmedetomidine and ketamine [22,23]. Keta-
mine is a N-methyl-D-aspartate (NMDA) receptor antagonist with a
strong analgesic effect [24]. With small doses (<1 mg/kg),
ketamine has less respiratory depression, little effect on the blood
pressure and heart rate [25]. Further, incidence of postoperative
hallucination often associated with ketamine is also less at
small doses [26,27]. Likewise, dexmedetomidine can provide
dose-dependent sedation, analgesia, sympatholysis and without
relevant effect on the respiratory function [28]. Moreover,
dexmedetomidine administration reduces intraoperative anes-
thetic requirements, blunts the sympathetic effect of the CNS in
response to surgical stimulation and speeds postoperative recov-
ery [29]. Several previous studies suggest that the use of ketamin
Control or dexmedetomidine can lower the occurrence of EA in children
(n = 47) patients. Jia-Yao et al. showed that dexmedetomidine and
5 (0–18) ketamine appear to prevent both postoperative EA and pain
14 (3–20) [30]. Isik et al. observed that the used of prophylactic dose of 1 m/
22/47 (47%) kg dexmedetomidine reduces the incidence of EA to 4.8% in the
6/47 (13%)
treatment group compared to 47.6% in the controls after
6 (0–10)
30 (63.8%) sevoflurane based anesthesia without surgery in children [31].
Guler et al. [32] demonstrated that i.v. bolus of 0.5 mg/kg
dexmedetomidine given 5 min before the end of surgery, reduces
postoperative EA and pain scores, and provided smooth extubation
in children undergoing adenotonsillectomy and hemodynamic
stability. Furthermore, the author also found the postoperative
times to emergence and extubation were significantly longer in the
dexmedetomidine group. Our study accords well with these
findings. Results from our study demonstrated that KETODEX
administration, about 10 min before the end of surgery, provide
hemodynamic stability during extubation. Heart rate and mean
arterial blood pressure values remain stable and no medication
was needed for hemodynamic stabilization.
The recovery characteristics, time for interaction from anes-
thetic off to eye opening and time from anesthetic off to
extubation, were significantly longer in KETODEX group than in
the controls. Aouad et al. shows that the time to recovery correlates
negatively with EA scores [33]. However, the delayed extubation
and interaction times in KETODEX group did not delay discharge;
children in both groups had comparable duration of PACU stay.
The use of sevoflurane is associated with increased in the
incidence of lactate concentrations in the parietal cortical region,
which is involved in essential cognitive processes [34]. Jacob et al.
study demonstrated that higher glucose and lactate with sevo-
flurane in the human brain could reflect a greater neuronal activity
that may result in enhanced glutamate-neurotransmitter cycling,

Please cite this article in press as: S.M. Hadi, et al., The effect of KETODEX on the incidence and severity of emergence agitation in
children undergoing adenotonsillectomy using sevoflurane based-anesthesia, Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/
10.1016/j.ijporl.2015.02.012
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increased glycolysis, and lactate shuttling from astrocyets to
neurons or mitochondrial dysfunction [35]. Sevoflurane based-
anesthesia is associated with an increased incidence of excitatory
central nervous system phenomena [36,37]. The neuroprotection
by ketamin and dexmetomidine may occur through multimodal
approach by attenuation of excitotoxic cell death and apoptosis
after cerebral ischemia, preservation of cerebral perfusion pressure
by sympathetic nervous system stimulation and increases in blood
catecholamine levels, and suppression of inflammatory CNS
responses to injury [38–40]. The mechanism perhaps related to
the sedative and analgesic effect provided by the combination of
ketamine and dexmedetomidine. However, the possible impact
of the combination of ketamin–dexmedetomidine on the incidence
of sevoflurane induced agitation in pediatric practice should be
investigated further, possibly with the use of continuous EEG
recording.
Pain and rapid awakening after sevoflurane anesthesia has been
assumed to be a cause for the postoperative EA. Some research
reports demonstrated the effectiveness of different analgesic drugs
such as fentanyl and ketorolac when they given either as prophylaxis
or for the treatment of EA [30,41]. Liang et al. [42] investigated the
effect of small dose sufentanil or fentanyl administrated before the
end of surgery. Both drugs reduces postoperative pain in anesthe-
tized children, with no adverse effects. Likewise, in our study the
KETODEX successfully reduced the incidence of postoperative pain
in the treatment group, with no adverse effects.
Children often suffer from airway complications after tonsil-
lectomy. Rosen et al. reported that 27% of children with obstructive
sleep apnea experienced a significant respiratory distress and
oxygen desaturation and required reintubation following tonsil-
lectomy and/or adenoidectomy [43]. In our study, children in the
control group shows a changes in the HR during extubation, but
this changes did not necessitate reintubation or medication.
The relevant limitation of our study is that no patients received
any premedication before surgery. This may be the reason why
more patients in the control group experienced high incident of
postoperative EA.
6. Conclusion
The increased incidence of postoperative EA followed sevo-
flurane-based anesthesia is seen predominantly in preschool age
children undergoing adenotonsillectomy, and the goal for
anesthesiologists to have an awake, settled and comfortable child
after operation is to minimize the side effects on respiratory and
airway. Different pharmacological techniques for either treatment
or prophylaxis have been used to different succeed rate. Our study
demonstrated that an intraoperative addition of low-dose keta-
mine followed by i.v. dexmedetomidine, 10 min before the
conclusion of the surgery provided smooth extubation without
hemodynamic changes. Further, postoperative pain and opioid
requirements in the PACU were significantly reduced, and the
incidence and duration of severe EA was significantly lower,
resulting in a smooth recovery. The bolus administration of
KETODEX in this dose was safe and did not lead to an increased
incidence of side effects and provide a good analgesic and sedative
effects and without a hemodynamic changes.
Conflict of interest statement
The authors report no conflicts of interest.
Author contributions
Sallg M. Hadi, Amin J Saleh and Yong Zhong Tang made
substantial contributions to the conception and design of the
Please cite this article in press as: S.M. Hadi, et al., The effect of KETODEX on the incidence and severity of emergence agitation in
children undergoing adenotonsillectomy using sevoflurane based-anesthesia, Int. J. Pediatr. Otorhinolaryngol. (2015), http://dx.doi.org/
10.1016/j.ijporl.2015.02.012
5
study, acquisition of data, and analysis and interpretation of data.
Sally M Hadi, Amin J Saleh, Yong Zhong Tang, Ahmed Daoud, Xi Mei
and Ouyang Wen drafted the article and revised it critically for
important intellectual content. Ouyang Wen approved the final
version to be published.
Acknowledgements
The authors thank Dr Duan Kai-ming for support in conducting
this study. Sally M. Hadi and Amin J Saleh contributed equally to
this work.
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