Background: Preventing emergence delirium is a clinical goal for pediatric anesthesia, yet there is no consensus on its prevention. This study investigated the hypothesis that a continuous infusion or a single bolus of remimazolam can reduce the incidence of emergence delirium in children. Methods: A total of 120 children aged 1 to 6 yr were randomly and equally allocated into three groups: group RC, which received a continuous infusion of remimazolam at 1 mg · kg⁻¹ · h⁻¹; group RB, which received a single bolus of remimazolam at 0.2 mg · kg⁻¹ at the beginning of wound closure; and group C, which received a continuous infusion of saline at 1 ml · kg⁻¹ · h⁻¹ and a single bolus of saline at 0.2 ml · kg⁻¹ at the beginning of sutures. The primary outcome was the incidence of emergence delirium assessed by the Pediatric Anesthesia Emergence Delirium scale. Secondary outcomes included the number of rescue propofol administrations in the postanesthesia care unit, recovery time, and adverse events. Results: Emergence delirium was observed in 14 of 40 (35%) patients in group C, 2 of 40 (5%) patients in group RC (vs. group C, P = 0.001; risk ratio, 95% CI: 0.14, 0.04 to 0.59), and 3 of 39 (7.7%) patients in group RB (vs. group C, P = 0.003; risk ratio, 95% CI: 0.22, 0.07 to 0.71). Ten of 40 patients in group C, 2 of 40 patients in group RC (vs. group C, P = 0.012; risk ratio, 95% CI: 0.20, 0.05 to 0.86), and 2 of 39 patients in group RB (vs. group C, P = 0.014; risk ratio, 95% CI: 0.21, 0.05 to 0.88) needed rescue propofol. No differences in the recovery time and adverse effects were detected. Conclusions: Both continuous infusion and single bolus administration of remimazolam can effectively reduce the occurrence of emergence delirium in children. Editor’s Perspective: What We Already Know about This Topic: What This Article Tells Us That Is New:

Background: Intraoperative isoelectric electroencephalography (EEG) has been associated with hypotension and postoperative delirium in adults. This international prospective observational study sought to determine the prevalence of isoelectric EEG in young children during anesthesia. The authors hypothesized that the prevalence of isoelectric events would be common worldwide and associated with certain anesthetic practices and intraoperative hypotension. Methods: Fifteen hospitals enrolled patients age 36 months or younger for surgery using sevoflurane or propofol anesthetic. Frontal four-channel EEG was recorded for isoelectric events. Demographics, anesthetic, emergence behavior, and Pediatric Quality of Life variables were analyzed for association with isoelectric events. Results: Isoelectric events occurred in 32% (206 of 648) of patients, varied significantly among sites (9 to 88%), and were most prevalent during pre-incision (117 of 628; 19%) and surgical maintenance (117 of 643; 18%). Isoelectric events were more likely with infants younger than 3 months (odds ratio, 4.4; 95% CI, 2.57 to 7.4; P < 0.001), endotracheal tube use (odds ratio, 1.78; 95% CI, 1.16 to 2.73; P = 0.008), and propofol bolus for airway placement after sevoflurane induction (odds ratio, 2.92; 95% CI, 1.78 to 4.8; P < 0.001), and less likely with use of muscle relaxant for intubation (odds ratio, 0.67; 95% CI, 0.46 to 0.99; P = 0.046]. Expired sevoflurane was higher in patients with isoelectric events during preincision (mean difference, 0.2%; 95% CI, 0.1 to 0.4; P = 0.005) and surgical maintenance (mean difference, 0.2%; 95% CI, 0.1 to 0.3; P = 0.002). Isoelectric events were associated with moderate (8 of 12, 67%) and severe hypotension (11 of 18, 61%) during preincision (odds ratio, 4.6; 95% CI, 1.30 to 16.1; P = 0.018) (odds ratio, 3.54; 95% CI, 1.27 to 9.9; P = 0.015) and surgical maintenance (odds ratio, 3.64; 95% CI, 1.71 to 7.8; P = 0.001) (odds ratio, 7.1; 95% CI, 1.78 to 28.1; P = 0.005), and lower Pediatric Quality of Life scores at baseline in patients 0 to 12 months (median of differences, –3.5; 95% CI, –6.2 to –0.7; P = 0.008) and 25 to 36 months (median of differences, –6.3; 95% CI, –10.4 to –2.1; P = 0.003) and 30-day follow-up in 0 to 12 months (median of differences, –2.8; 95% CI, –4.9 to 0; P = 0.036). Isoelectric events were not associated with emergence behavior or anesthetic (sevoflurane vs. propofol). Conclusions: Isoelectric events were common worldwide in young children during anesthesia and associated with age, specific anesthetic practices, and intraoperative hypotension. Editor’s Perspective: What We Already Know about This Topic: What This Article Tells Us That Is New:

Dexmedetomidine can facilitate a smooth extubation process and reduce the requirement of sevoflurane and emergence agitation when administrated perioperatively. We aimed to observe the extubation process and the recovery characteristics in pediatric patients undergoing tonsillectomy while anesthetized with either high-concentration sevoflurane alone or low-concentration sevoflurane combined with pre-medication of single dose of intravenous dexmedetomidine. Seventy-five patients (ASA I or II, aged 3–7 years) undergoing tonsillectomy were randomized into three equal groups: to receive intravenous saline (Group D0), dexmedetomidine 1 μg/kg (Group D1), or dexmedetomidine 2 μg/kg (Group D2) approximately 10 min before anesthesia. Before the end of surgery, sevoflurane were adjusted to 1.5 times, 1.0 time and 0.8 times the minimal effective concentration in groups D0, D1 and D2, respectively. The sevoflurane concentration for each group was maintained for at least 10 min before the tracheal deep-extubation was performed. The extubation event, recovery characteristics and post-op respiratory complications were recorded. All tracheal tubes in three groups were removed successfully during deep anesthesia. Nine patients in Group D0, three patients in Group D1, and two patients in Group D2 required oral airway to maintain a patent airway after extubation. The frequency of oral airway usage in groups D1 and D2 were significantly lower than that in Group D0. The percentages of patients with ED and the requirements of fentanyl in groups D1 and D2 were also significantly lower than those in Group D0. The time from extubation to spontaneous eye opening in Group D2 was longer than that in groups D0 and D1. The times of post-anesthesia care unit discharge in groups D0 and D2 were longer than that in Group D1. No other respiratory complications and vomiting were observed. A single dose of intravenous dexmedetomidine as pre-medication in combination with low-concentration sevoflurane at the end of surgery provided safe and smooth deep extubation condition and it also lowered the emergence agitation in sevoflurane-anaesthetized children undergoing tonsillectomy. Preoperative dexmedetomidine at 1 μg/kg did not prolong postoperative recovery time. Chinese Clinical Trial Registry (ChiCTR): ChiCTR-IOR-16008423 , date of registration: 06 may 2016.

Purpose: Remimazolam, an ultra-short-acting and fast-metabolized sedative, has only been sporadically investigated in children. This study was performed to determine the beneficial effects of intranasal remimazolam or dexmedetomidine on preoperative anxiety in children undergoing general surgeries. Patients and Methods: Ninety children were randomly and equally assigned to Group R (intranasal remimazolam 1.5mg kg^{− 1}), Group D (intranasal dexmedetomidine 2 mcg kg^{− 1}), and Group C (intranasal distilled water). The primary outcomes were the preoperative anxiety scores using the modified Yale preoperative anxiety scale (m-Ypas). The secondary outcomes included the cooperation behaviour of intranasal drug application, preoperative sedation levels, parental separation anxiety scores (PSAS), and mask acceptance scores (MAS). Results: Group R showed a significant low anxiety at 10 min after intranasal premedication (vs group C, P=0.010; vs group D, P = 0.002) and at anaesthesia induction (vs group C, P = 0.004). Group D showed a significantly low anxiety score only prior to anaesthesia induction (vs group C, P = 0.005). Most children in group R achieved mild sedation at 10 min (vs group C, P < 0.001; vs group D, P < 0.001), with a few progressing to deep sedation afterwards, while group D tended toward deep sedation. Compared to Group C, patients in Group R performed significantly better on the MAS (P = 0.014) and PSAS (P = 0.008). However, remimazolam did cause poor cooperation behavior to the intranasal application due to its mucosal irritation (vs group C, P = 0.001; vs group D, P = 0.010). Conclusion: Both intranasal remimazolam and dexmedetomidine can effectively alleviate preoperative anxiety in children. While intranasal remimazolam has a rapid onset, it produces only mild sedation and causes substantial nasal irritation. Trial Registration: NCT 04720963, January 22, 2021, ClinicalTrials.Gov.