Reducing Emergence Agitation in Pediatric Patients: Intravenous vs Inhaled Anesthetics

This extended literature review assesses the effectiveness of total intravenous anesthesia (TIVA) and inhalational anesthesia (IA) in reducing emergence agitation in pediatric patients. The research question addressed is whether the use of inhaled anesthetics increases the incidence of emergence agitation in pediatric patients when compared with intravenous anesthetics. The review identifies nine relevant studies and concludes that inhaled anesthetics increase the incidence of emergence agitation in pediatric patients. The article discusses the advantages and disadvantages of both modes of anesthesia administration and highlights the need for further research in this area.

Running head: EXTENDED LITERATURE REVIEW
The use of intravenous anesthetic to reduce emergence agitation among pediatric patients when
compared to inhaled anesthetics
Name of student:
Name of university:
Author note:

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Abstract
A considerable proportion of pediatric patient population scheduled for undergoing surgical
procedures with the help of general anesthesia are found to be experiencing emergence agitation
(EA). The condition causes distress and agony to the patient, in addition to increased burden on
healthcare staffs and increased healthcare expenditure. Reduction of EA is therefore critical for
providing compassionate care and preventing undesirable outcomes. The extended literature
review was aimed at carrying out a significant assessment of existing literature on effectiveness
of total intravenous anesthesia (TIVA) and inhalational anesthesia (IA) in reducing emergence
agitation in pediatric population. The research question to be addressed was “Does the use of
inhaled anesthetics increase the incidence of emergence agitation in pediatric patients when
compared with intravenous anesthetics”? A focused literature research was carried out by
utilizing important electronic databases and appropriate keywords. Nine studies were identified
in total that were relevant to the research. All of the studies were randomized controlled trials,
which are reliable and trustworthy form of study. Most of the studies pointed out that the use of
inhaled anesthetics increase the incidence of emergence agitation in pediatric patients when
compared with intravenous anesthetics. There is however a need of well constructed studies in
future in the same alignment that would contribute to valuable clinical information, supporting
change in practice.

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Table of Contents
Introduction......................................................................................................................................5
Background..................................................................................................................................5
Research question......................................................................................................................11
Research aim..............................................................................................................................12
Research objectives...................................................................................................................12
Significance of study.................................................................................................................13
Relevance of the research for practice.......................................................................................13
Methodology..................................................................................................................................16
Initial scope................................................................................................................................16
Systematic review of literature..................................................................................................16
Exploring the search term..........................................................................................................17
Cochrane Library search............................................................................................................18
Bibliographic Aids.....................................................................................................................20
Inclusion and Exclusion Criteria of the Search Strategy...........................................................20
Search outcomes........................................................................................................................22
Limitations of the search...........................................................................................................25
Study Design: Qualitative Descriptive Method.........................................................................26
Generalizability of the study......................................................................................................26
Results............................................................................................................................................27

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Discussion......................................................................................................................................32
Conclusion.....................................................................................................................................42
References......................................................................................................................................46
Appendix 1.....................................................................................................................................53
Appendix 2.....................................................................................................................................54
Appendix 3.....................................................................................................................................56
Appendix 4.....................................................................................................................................61

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Introduction
Background
Emergence agitation is a post anesthetic phenomenon suffered by patients in the initial
phase of general anesthesia recovery, whose primary characteristics include confusion, agitation,
possible violent behavior and disorientation. While pediatric patients are at more risk of suffering
from emergence agitation, the incidence in adults is also noteworthy. Emergence agitation has
been known to lead to drastic results like removal of catheters, self-extubation, hemorrhage, and
serious physical injuries (Kim et al. 2015). According to Kwak et al. (2010) a child suffering
from emergence delirium or emergence agitation is found to be in a dissociated state of
consciousness wherein the individual is found in an uncompromising, incoherent, irritable, and
uncooperative stage, wherein he is inconsolably crying, kicking or thrashing.
Coined first in the early 1960s, the term emergence agitation has been in clinical use for
describing the condition in which patients experience varied behavioral disturbances at the time
of early emergence from anesthesia. Though the condition is not to be perceived as new
phenomena when speaking on the clinical grounds, there is a growing interest in the topic since
the incidence is found to be increasing at a rapid rate in the past few years. Agitation is referred
to the state of mental distress and mild restlessness arising from a number of sources. In the
clinical field, agitation among patients might be experienced due to varied sources such as
anxiety, pain, and physiological compromise. The condition is characterized by disorientation
and alterations in perceptual ability such as hyperactive motor behavior and hypersensitivity to
stimuli as a result of undergoing anesthesia in a clinical setting (Hoff et al. 2015). The terms
emergence delirium and emergence agitation have often been used in an interchangeable manner

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in most of the literature discussing about the same research topic. The rationale is that it is
challenging to differentiate cognitive impairment in children in relation to emergence agitation
which is pivotal for carrying out an appropriate diagnosis of emergence agitation (Aouad and
Nasr 2005).
Nasar and Hannallah (2011) explained the relationship between emergence agitation and
maladaptive behavior. Maladaptive behavior for a considerable time frame can follow as a result
of emergence agitation regarding which it has been hypothesized that duration of anesthesia,
hypnotic depth, and type of anesthesia are related to the condition. Kain et al. (2005) suggested
that individuals of emergence delirium are at increased risk of suffering from apathy, sleep
disturbances, eating problems and separation anxiety, which is seven times higher. The
researchers also reported that 54% of children who undergo anesthesia demonstrate negative
behavioral responses after about 2 weeks of surgery which can last up to 6 months or one year.
As opined by Reduque and Verghese (2012) the statistics indicating the incidence of
emergence agitation in pediatric population is wide ranging, as the figures range from about 2%
to around 80%. The variation has been pointed out to be a result of distinct differences in study
methodologies, such as use of different rating systems and diverse anesthetic contexts that have
been studied. Therefore, no consensus has been reached till date regarding the exact incidence of
pediatric emergence agitation even within specific groups of patients when psychological
profiles have been considered. Nevertheless, a large pool of literature highlights the major risk
factors for emergence agitation, as pointed out by the researchers. The use of short-acting
volatile anesthetics has been repeatedly linked with the higher chances of experiencing
emergence agitation. The possible risk factors encompass age, postoperative pain, rapid
emergence from anesthesia, type of surgery, temperament of the child and anxiety suffered in the

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post operative environment. Patients with age between 2 and 5 years are more likely to suffer
from the condition (Mason 2017). Otorhinolaryngological and ophthalmological surgical
procedures are indicated to augment a patient’s risk of experiencing emergence agitation, as
compared to general and urological procedures, highlighting the chance that surgeries involving
the individual’s neck and head might be presenting more chances of agitation (Whitman 2018).
Wong and Bailey (2015) pointed out that the anesthetic agent used, and the mode of
administration is the most prominent risk factor for emergence agitation. Somaini et al. (2015)
highlighted that considering the importance of mode of administration of anesthesia in relation to
incidence of emergence agitation it is appreciable to carry out research in this direction in the
coming years.
Against the above discussion it was thought to highlight the relation of mode of
administration of anesthesia with emergence agitation. The choice of suitable mode of
administration of anesthesia for pediatric patients gains prime attention in clinical practice. The
primary techniques for administration of anaesthesia are total intravenous anaesthesia (TIVA)
and inhalational anaesthesia (IA) (Cote, Lerman, and Todres 2018). TIVA has been recently
found to be a topic of discussion in the clinical field of pediatric anesthesia. The global
experience of both TIVA and IA has been noted in scattered literature. The knowledge acquired
in adult clinical practice have had limited implications for pediatric practice. Induction of general
anesthesia by inhalation route had been the generally accepted and widely used technique for
administering anesthesia in pediatric population. It has received more attention in the recent few
years with advancement in research. The safety of the technique had been under continuous
scrutiny to understand the exact clinical outcomes. On the other hand, the intravenous induction
of anesthesia has also been reviewed for scope of improvement. A crucial prerequisite for

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intravenous anesthetics agents is the accessibility of the veins. Further, certain drawbacks of
intravenous administration of agents include pain experienced at the time of injection, challenges
in dosing for pediatric population and bradychardia (Davis and Cladis 2016). Sdrales and Miller
(2017) suggested that inhaled anesthetics permit healthcare professionals to monitor the
pharmacokinetics of the agent in an accurate manner. In contrast, administration of agents by
intravenous infusion is largely on the basis of assumptions, though the drug can be administered
with the help of a computer-controlled pump. Further, individual patients can suffer aberrations
as a result of the predicted values. Though there is a scope for intra-operative awareness,
underestimation of the incidence is common. Some of the complications of adhering to the
intravenous technique include pump dysfunction and paravenous infusion. In case of intravenous
technique, the advantages perceived are reduced incidence of agitation and vomiting after the
surgery. Certain drugs also require longer periods of administration. The exact time period
required for safe administration is vague under certain conditions (Frederick et al. 2016).
Holzman (2017) in this regard highlighted that inhalation agents have been considered as
the mainstay of pediatric population due to the marked advantages of the same over intravenous
agents administration. Safety aspects hold prime importance in pediatric anesthesia. Further,
children might not prefer providing access to veins in awaken condition. Some of the commonly
used anesthetic agents used for pediatric population include propofol, thiopental, remifentatil,
halothane, desflurane and sevoflurane. Inhalation agents bring in some serious disadvantages
such as agitated behavior and delirious attitude. Further, there is a vague idea regarding cerebral
stimulating pattern attributed to the agents. While propofol, thiopental, remifentatil are drugs
administered in the intravenous route, the other three, that is halothane, desflurane and
sevoflurane are to be inhaled by the patient. In pediatric population, uptake of inhaled agents

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occurs in a rapid manner as compared to intravenous administration. Determination of the agent
to be applied is reliant on a number of factors, such as age, cardiovascular stability, recovery
profile and antiemetic effect. Propofol has been the most widely used intravenous agent since the
onset time is fast as a result of appropriate blood-brain equilibration. This implies that patients
get anesthetized within a short time frame. Further, desirable recovery profile has been linked
with the agent. Among the inhalation agents, sevoflurane has been a noteworthy one owing to
low blood gas coefficient leading to smooth induction and fast recovery.
Davis and Cladis (2016) brought into focus the mode of action of intravenous anesthetics
and inhalation anesthetics in a comprehensive manner. The exact mechanism of action of
intravenous anesthetic is not definable, however what is known is that the agents have their mode
of action in relation to GABAA receptor activity. Volatile anesthetics have their mode of action
through the central nervous system. In this case the GABAA receptor activity is also of
importance. When the receptors are potentiated, there is an increase in conductance of chloride
ion, leading to post-synaptic currents and consequent inhibition of neuronal activity. The agents
have far –reaching effects on respiratory, cardiovascular and central nervous system. Novel
agents are being developed that can eliminate risk of side effects of the drugs that are structurally
related to the existing drugs.
The impact of the notable anesthetic agents, both intravenous and inhalation, on
occurrence emergence agitation, comes into focus at this juncture since this is the area of interest
for the present research. A rich pool of studies considered discussing about the relation of
anesthetic agents with emergence agitation. In the research of Costi (2015) it has been mentioned
that while inhalation induction with sevoflurone is used in cases for pediatric anesthesia, the
choice is intravenous induction when the patient is in need of rapid induction. Agents such as

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ketammine and propofol that are given intravenously reduce the risk of emergence agitation to a
large extent. Hoff et al. (2015) commented that all inhalation anesthetic agents are linked with
emergence delirium in pediatric population. Sevoflurane, though commonly used for this
purpose, demonstrates higher risk. In contrast, TIVA with remifentanil and propofol lead to
smooth recovery profile. Though prevention and mitigation of emergence delirium has been
attempted to be achieved with agents such as propofol, ketamine and benzodiazepine boluses, the
results have indicated variable success.
The focus on sevoflurane has been noteworthy across research domain as emergence
delirium has been commonly linked with application of sevoflurane. Since the condition has
been found to be common when sevoflurane is administered, a growing interest has emerged to
find novice ways in which emergence can be improved in patients who are vulnerable to the
condition. A number of pharmacological interventions such as opioid, clonidine, dexmedetomide
and ketamine have been applied in practice in past (Li, Xia and Li 2015). The medications
however bring in the risk of slow awakening, increased sedation, and side effects such as
vomiting and nausea. In contrast, intravenous agents such as propofol have been found to be
having highly desirable anti-emetic property. Further, the risk for emergence agitation has also
been found to be less in this case (Costi et al. 2014). Shi et al. (2015) also highlighted the relative
efficacies of sevoflurane and propofol as anesthetic agents for children. There has been a link
established between use of varied volatile anesthetics and transient, frequent emergence delirium
in children, manifesting disorientation and inconsolable crying. This is the reason for increased
nursing interventions and increased length of stay at clinical setting past surgery. As per the
researchers, the emergence characteristics and extent of side effects differ for the two. Pleasant
emergence is achieved with propofol, while lengthy recovery time post anesthesia is a

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disadvantage. Conversely, in case of sevoflurane the chance of emergence delirium is higher.
Further, risks of hypoxia and airway obstruction are more in case of propofol.
In summary, there remains drawback and advantages of both the intravenous and
inhalation techniques of administering anesthetics in pediatric populations. In light of the
discussion put forward, it was thought necessary to review the evidence existing about the
comparative effects of intravenous and inhalation anesthetics on incidence of emergence
agitation in pediatric population. It has been felt that it is a practice for researchers to carry out a
debate on the nuances of intravenous versus inhalation induction of anesthesia in pediatric
population. Therefore, an interest was generated to find out the effectiveness of inhaled
anesthesia and intravenous anesthesia in relation to emergence agitation. A discussion regarding
which mode is better has been perceived to be the need at the present. Inhalation anesthesia
might be denoted as the gold standard at present, however, there lies a probability that
intravenous technique would pose as the suitable alternative for particular clinical situations such
as prevention of emergence agitation in children.
Research question
The research question in all research endeavors is the fundamental element that focuses
on the study and the areas of concern. It is to be kept in mind that the research question has to be
worth investigating and contribute to value and knowledge in the field. The question has to be
significant, clear and feasible for research (Smith 2015). The research question that was
addressed through the present research was as follows-
Does the use of inhaled anaesthetics increase the incidence of emergence agitation in pediatric
patients when compared with intravenous anaesthetics?

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Research aim
It is noteworthy that that research question is in terms with the research aims and
objectives. The aim of the study has to be concisely and clearly defined. The aims act as the
statements of the desired outcomes of the study and reflect the expectations of the research. The
aspirations of the study guide the aims of the research (Flick 2015). The aim of the present
extended literature review was to explore the effectiveness in intravenous aneasthetic for
reduction of emergence agitation among pediatric patients as compared to inhaled anaesthetic.
Research objectives
Research objectives are contributory to the research aims and emphasizes on the elements of
the research aim. These are to be highly focused and be presented in a sensible manner. The most
immediate research outcomes are to be addressed in this section. The objectives of the present
research were as follows-
 To determine the effect of inhaled anesthetics in reducing the prevalence of emergence
agitation among pediatric patients
 To determine the effect of intravenous anesthetics in reducing the prevalence of
emergence agitation among pediatric patients
 To compare the effectiveness between intravenous and inhaled intravenous anesthetics in
reducing the prevalence of emergence agitation among pediatric patients
 To evaluate whether inhaled anesthetics increase the incidence of emergence agitation
when compared with intravenous anesthetics

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Significance of study
This present literature review had to report on the knowledge and ideas established
through existing literature regarding the comparative effectiveness of inhaled anesthetics and
intravenous anesthetics for addressing emergence agitation in pediatric patent population. The
literature review consisted of a comprehensive and concise summary of the significant sources of
the related research papers. The significance of the research lies in the uncovering of strengths
and weakness of the research articles present on the research topic to determine the approved
academic viewpoint on the same. The analytical features of the review were to synthesize the
existing pool of studies in an organized manner to inform practice in the clinical field of
anesthesia. It was thought necessary to trace the intellectual progression on the concerned field to
bring development in clinical practice aiming at better patient outcomes (Flick 2015). The
present research also aimed at identifying areas that would require further investigation in future
and additional exploration in the concerned field. It is to be remembered that there lays immense
scope of research on the concerned topic that can bring in significant changes in clinical practice
through policy reforms of care settings.
Relevance of the research for practice
There has been a need felt to engage in extensive research regarding the impact of
different anesthetics on the emergence agitation incidence rate among pediatric population.
Against this context, the present research would be of high significance to the service users in
clinical settings through identification of important factors that oversee the relation existing
between onset of emergence agitation and anesthetics (Costi et al. 2015). With a deep
understanding of the implications of research findings for practice emerging from the present
study, healthcare professionals would be able to adjust care plans as per the individualized needs

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of pediatric patients. Adjustments made in the care plans would be favorable for the patients to a
great extent, leading to better patient outcomes. Additional benefits can be attributed to
generalization of the study findings. Upon completion of the research it would be possible to
draw broad inferences from the selected articles that can be applied to a large population.
Relevance of the present study is most indicated to the clinical practice of anesthesia
administration to pediatric population across care settings. Anesthesiologists are the clinical
professionals responsible for administering anesthesia as per the need of the patient and nature of
surgery to be performed. The aim of administering anesthesia is to eliminate pain due to surgery
and provide comfort post the procedure (Lerman et al. 2016). The present research would be
helpful for anesthesiologists for reducing the risk of complications post surgery through
identification of side effects of anesthesia administered in intravenous or inhaled forms. This
would be primarily related to emergence delirium in children that has been difficult to manage
across care continuum (Moncel et al. 2015).
The implications of the present study for clinical practice were thought to be noteworthy
in terms of utilization of healthcare resources. Emergence agitation has been denoted to add to
the cost of healthcare in terms of human resources, finances and morbidity. The behavior of the
patients as a result of agitation delays healing, leads to prolonged physiotherapist or entails
further surgeries for the patient. Complications might extend into the period after the discharge
from the care setting (Guo et al. 2017). Further, human resources are needed in case a patient
experiences agitation since efforts are required for restraining a patient. Healthcare professionals
are also at a risk of suffering injuries in cases patient demonstrated uncooperative and
inappropriate behavior. Due to an increased length of stay at the healthcare unit, additional
pharmaceutical costs, and costs for repair damage, there is also an increase in the patient costs

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(Christensen et al. 2017). As highlighted by Cote, Lerman and Todres (2018) emergence
agitation incidents among pediatric population cause much distress to the family members and
ultimately lead to feelings of dissatisfaction and distrust towards the care professionals. It is
therefore crucial that healthcare professionals, especially anesthetists, work in collaboration for
minimizing the risks of emergence agitation wherever possible through evidence based practice.
Amendments in care practices based on the present study would pave the way for increased
patient satisfaction as well as increased reputation of the healthcare setting.

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Methodology
Initial scope
In order to determine whether the available research articles surrounding the importance
of the use of intravenous anaesthetic in comparison to inhaled anaesthetics in paediatric care, it is
important to conduct a preliminary scoping exercise. For performing the initial scoping, Google
Scholar was selected as the main electronic database. Specific keywords were selected for
exploring the research question of the dissertation via the use of the PICO model (Appendix 1).
The review was then used to develop a list of potential keywords (Table 1). These keywords
were used in Google Scholar database search (appendix) and the publication year filter was
chosen in between 1998 to 2018 (published within the last 20 years). The time period of the
literature search through Google scholar was selected as 20 years because total intravenous
anaesthesia (TIVA) was only introduced in the paediatric care during late 1990s (Lerman and
Johr 2009). According to Parahoo (2014), the use of filters helps in the identifying most recent
and prevalent information surrounding the research topic. The initial search unveiled numerous
titles from various published journals. This randomly selected article obtained from the Google
Keyword search were screened for title and abstract and it was found that it has relevancy with
the scope of the research. Upon this initial selection and the study of the article it was deemed
accurate to progress with more specialised and more appropriate database search in order to
ensure that only relevant yet authentic paper that coincides with the scope of the research are
considered for the review discussion.

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Systematic review of literature
A systematic review of literature was selected because, as the experience and observation
of the author, there appears to be no consistent outcomes in the domain to which technique for
the initiation and maintenance of anaesthesias help in decreasing the effect of EA in children
(Kanaya et al. 2014). Thus, in order to provide suitable explanation for these discrepancies of the
results, a review of literature of the previously studied articles was done as this will enable a
detailed investigation of the topic of the research. Moreover, comparison of two techniques in
paediatric anaesthesia will help in the improvement of the generalizability and reliability of the
results (Greenhalgh 2014). Moreover, via reviewing and via analysing the methods of the
previously published journal articles, the researcher could subsequrntly arrive at an evidence-
based conclusion (Parahoo 2014).
Exploring the search term
In order to standarise the total number of searches for the review, it is crucial to use the
selection of proper keywords which were relevant to the title of the research. As mentioned by
Parahoo (2014), in order to spot appropriate literature, a permutation and combination of
associated keywords must be examined to aid proper selection of the literary articles. Different
variation of words was used in order to cover universal spellings for example within this search
“pediatric” and “paediatric” / “anesthesia” and “anaesthesia”, both were selected and this
ensured that literary articles with both spelling variations come under the search results. In order
to ensure most relevant keywords are utilised for the research, a special tool to increase the
overall potential of the keywords to retrieved relevant search articles was used. The name of the
tool is Medical Subject Headings (MeSH). MeSH was utilised a source of medical vocabulary
thesaurus to explore the potential of further keywords which can be used to search articles in the

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databases like PubMed and MEDLINE (Medical literature On-Line). The keywords were entered
in the search bar and the subsequent subheadings were displayed. These subheadings were either
relevant to the scope of the research or were already enlisted within the overall table of the
keywords which have been formulated by the PICO model (Table 1).
Table 1: PICO Keyword formulation
P = Patient I = Intervention C = Comparison/ Control O = outcome
Pediatric patients Intravenous anaesthesia Inhaled anaesthesia Emergence
agitation
Paediatric patients Total intravenous
anesthesia
Inhaled anesthesia Emergence
delirium
Children Inhalation anaesthesia/
anesthesia
Pain recovery
Child postoperative
emergence
agitation
Cochrane Library search
It was also important to known that whether any previous reviews of the current literature
had already been conducted in order to avoid the generation of replica review. This is because; in
such cases the novelty of the research decreases. To ascertain the overall novelty of the research,
the literature search of the Cochrane library was conducted (appendix 3). The Cochrane Library
houses high quality collection of evidences that are sourced independently in order to aid proper
decision making within the health care system (Cochrane Library 2016). Moreover, Cochrane

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Library Database is regarded as a reservoir healthcare effectiveness and interventions in diverse
healthcare related issues (Hagger Johnson 2014). By the use of the combination of the keys
words that align with the PICO question of the research topic, the researcher searched for any
relevant systematic reviews that matches with the chosen topic of the research and has already
been published online. The use and the implementation of the keywords was done is a specific
way such that each set of words can bring up a relevant set of papers. The below mentioned table
(table 2) highlights how the combinational use of the keywords was used in the Cochrane
Library database in order to search any previously published systematic review on the chosen
topic and how the hits yielded. The use of broader use of the keywords, led to the generation of
more results. The combinations of the keywords were used repeatedly until when the hits
provided identical or duplicate results.
Table: 2 Cochrane Search
Keywords Hits
“Emergence delirium” AND “anaesthesia” Reviews: 10 Trials: 841
AND
“emergence delirium” AND “paediatric”
AND “intravenous anaesthesia”
Reviews: 0 Trials: 40
OR
“Emergence agitation” AND “Paediatric”
AND “inhaled anaesthesia”
Reviews: 5 Trials: 35
“emergence agitation” AND “post operative”
AND “paediatric care”
Reviews: 110 Trials: 9875
AND (Date limiter: 2008 to 2018)

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“Emergence delirium” OR “emergence
agitation” AND “paediatric” AND “inhaled
anaesthesia” OR “intravenous anaesthesia”
Reviews: 0 Trials: 35
Cochrane Library does not have an ability of refine the search of the other databases and
thus provide broad results. The results of the literature search can further be narrowed down with
the Cochrane Library and this is something important for the preliminary refining criteria.
Decreasing the date of publication of the research articles ensured that only the most relevant and
recent publications were selected. The overall results of the search are analysed with the results
chapter of the assignment. The criteria of refinement were more specific within the other
databases and thus ensuring more advanced and topic related search of paper. Hagger-Johnson
(2014) recommended that more than one database must be used to search for proper yet authentic
literary materials.
Bibliographic Aids
Search of the literary articles is important to gain access to the depth of the information
that has already been published online. Hence after Cochrane database, the search of the literary
was undertaken in electronic database like MEDLINE, CINAHL and Scopus.
Inclusion and Exclusion Criteria of the Search Strategy
According to Aveyard (2014), having a clean projection before the onset of the search of
the literary articles means that the search has a distinct focus and the valuable time is not wasted
on the irrelevant information. The proper framingn of the inclusion/exclusion criteria will further

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aid in clarification of the vision of the research (Coughlan et al. 2013). According to Polit and
Beck (2014), the inclusion and exclusion criteria is crucial in order to set the boundaries of the
review of literature and thereby helping to narrow down the overall bibliographic resources
which are available online. However, the proper use of the inclusion and exclusion criteria must
be reasonable enough and justified. This ensures the validity of the overall search of the literary
articles. For example, Parahoo (2014) has stated that selection of exclusion criteria that are too
specific may outnumber important information associated with the scope of the topic. The main
inclusion and exclusion criteria that was selected for the search of the literary articles are
highlighted below
Table: 3 – Inclusion and Exclusion Criteria (based on the PICO table)
Inclusion criteria Exclusion criteria
Articles published in English (UK/US) Articles published other than English
language
Articles published during the last 20 years
(1988 to 2018)
Articles published before 1988
Articles which are available in full-text Articles which are not available in full-text
Peered-reviewed articles Non-peered reviewed articles
Studies conducted over children between the
age group of 0 to 10 years
Studies conducted over non-human placebos
and adult human begins or children over 10
years
Studies that focused on either inhaled or
intravenous anaesthetics
Studies that contain information on the
application of other anaesthetics
RCT study Non RCT study

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Table 4: Rationale of the Refining criteria
Refining criteria Rationale
Date: 1988 to 2018 Because TIVA was introduced in paediatric
study during the late 90s and thus selection of
the papers for the last 20 years will ensure
recruitment of most relevant information in
accordance to the scope of the topic
Studies conducted over children Management of emergency delirium/
agitation among the paediatric patient via the
use of anaesthesia is a subject on its own
Language: English Due to language limitations
RCT study RCT study design helps in establishing cause
and effect relationship between the proposed
interventions and thereby allowing the
selection of clinical options through
acceptable and reasonable confidence
(Glasper and Rees 2013).
Search outcomes
The combination of the keywords was use in the three databases CINAHL, MEDLINE
and Scopus along with the use of the Boolean search operators. Use of the Boolean search

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operators helps to refine the search results (Robb and Schellenbarger 2014). In this study,
Boolean search operators, AND/ OR was used in order to contrast and combine the keywords
highlighted in table 1. This ensured that the electronic database search results are more specific
and thus helping to reduce irrelevant materials from the search hits (Polit and Deck 2014). Thus
also save a whole lot of time as it assisted in reducing the overall of articles whose abstracts
require manual screening in order to verify the relevancy of the research articles as per the scope
of the research.
Three of the electronic database used for the search of the literary articles returned
relevant literature hits and the details of the search hits from the literature is highlighted below.
The search of the literature was stopped when the references emerging from the keyword search
are found to be duplicate and no new literature was identified. This situation is known as “data
saturation”’ (Saumure and Given 2008). The search of the literary articles via the use of
keywords helped in the identification of 45 articles. Then these articles were screened against the
selected inclusion and exclusion criteria in order to decrease the total number of search. After
scrutinizing the articles based on the inclusion and exclusion criteria, the articles (35) were
screened for the titles and abstract. Screening of the titles and abstract of the 35 articles led to the
selection of the 10 main articles which were further selected for the CASP tool analysis. Critical
Appraisal Skills Programme (CASP) was selected because of its robust structuring quality and to
aid in the proper analysis of the RCT. Addressing the questions in the framework help in
understanding the research papers, critiquing and then re-structuring the discussion.
Search Results
Resource Search Terms Number of unique
articles returned
Number of relevant
articles after the

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removal of duplicates
Crochrane Database
of Systematic
Review
As per search table 25 17
Google Scholar emergence agitation
AND pediatric care
AND intravenous
anesthesia AND
inhaled anesthesia
9770 Time consuming to
reduce the article
numbers
Google Scholar "emergence
agitation" OR
"emergence
delirium" AND
"pediatric care" OR
"children" OR
"infants" AND
"intravenous
anesthesia" AND
"inhaled anesthesia"
21 0 (duplicate search
with the other
databases)
CINAHL As per the search
table
4 3
MEDLINE As per the search
table
10 10

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Scopus As per the search
table
6 5
The Search Table
Source: Created by author
Limitations of the search
The use of the inclusion and exclusion criteria for CINAHL, MEDLINE, Scopus and
Cochrane Library were limited to only last 20 years and RCT studies. This selection criteria was
undertaken due to the lack of adequate time and funding. Thus it can be said that the review will
be non-exhaustive. According to Polit and Beck (2012), criteria used to narrow down the results
1PediatricpatientsORChildrenORInfantsORPaediatricpatients2IntravenousanaesthesiaORTotalintravenousanesthesiaANDInhaledanaesthesiaOR3EmergenceagitationOREmergencedeliriumANDPainrecovery

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at times led to disadvantage as the entire search becomes non-exhaustive. Relaxing the filters of
the search might have helped to decrease the biased ratio of the search outcome.
Study Design: Qualitative Descriptive Method
In this research, the researcher will follow qualitative study design. The reason behind
this is, qualitative research approach will help the researcher to understand the issue encountered
under the clinical practice (Cresswell 2013). Selecting qualitative research design will help the
research to compare and contrast the effectiveness of intravenous and inhaled anaesthesia
towards effective recovery form emergence delirium among paediatric patient.
Generalizability of the study
Qualitative research is meant to study a specific phenomenon or issue over certain group
of population of a focused locality hence the generalizability of qualitative study is usually not
an expected trait. In this research, the researcher has used pragmatic approach in accessing the
generalizability of the research (Leung 2015). Use of systematic review of literature, constant
comparison, triangulation, documentation and proper audit will help in accessing the
generalizability of the research.

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Results
PRISM Diagram
Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) is a
special toll that helps in collation and analysis of the data in systematic literature reviews. The
following diagram represents PRISMA flow chart which aided in the organisation of the RCT
studies extracted via the search of the database.

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Records sourced via database searching
Total n=45
(CINAHL n= 4
MEDLINE n=10
Scopus n= 6
Cochrane Library n= 25
Records after duplicates removed
n=35
Records screened n=35
Records excluded
n= 10
Cochrane results n=8
Paediatric subjects n= 2
Records excluded
N= 25
15 = non RCT studies
10 = poor sample size
Full text articles accessed for
eligibility
N= 10
Articles excluded
N= 1
No equipment compariosn
Full texts included within
discussion and critique n=9

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Table: PRISMA: Article selection
Source: Created by author
Initial overall critical analysis of the evidence
Interventions used
The main articles which are selected for the review mostly conducted randomised control
trial for the in order to compare the incidence of emergence delirium (ED) among the children
with either intravenous anaesthesia or inhaled anaesthesia. In the majority of the studies, the
authors mainly used sevoflurance (SEVO) anaesthesia as the main agent behind the inhaled
anaesthesia and propofol or remifentanil anaesthesia as the main agent behind the intravenous
anaesthesia (Chandler et al. 2013). The main reason behind this is Sevoflurane agent in inhaled
anaesthesia is frequently associated with highest incidence of ED while TIVA via employing
propofol or remifentanil appears to have fast recovery.
Scale used to ascertain the rate of emergence delirium
The main mode of measuring the severity of ED used was post-operative pain measured
via Face, Legs, Activity, Cry, Consolability (FLACC) scale (Chandler et al. 2013). However,
few articles also used Pediatric Anesthesia Emergence Delirium (PAED) and the Children’s
Hospital of Eastern Ontario Scale (CHEOPS) in order to measure ED and pain respectively
(Pieters et al. 2010).
Sample size
Chandler et al. 2013 conducted their RCT study over 112 children between the age group
of 2 to 6 years who are undergoing strabismus repair. The study conducted by Pieters et al. 2010

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mainly included 42 children between the age group of 3 to 7 years who are undergoing
adenoidectomy and tonsillectomy. In the study of Bryan et al. (2009), 201 children were
recruited who are scheduled for the MRI brain scans under general anesthesia. KÖnig et al.
(2009) conducted double-blinded randomized control trial over 179 pediatric patients who ate
scheduled for ambulatory care. Thus, the articles, which are selected for the further critical
analysis mainly, consisted of the sample size which are more than 100. According to Spiet et al.
(2016), high sample size in the RCT study help in the reduction of achieving biased results.
However, few studies included sample size which were lower than 100 or even below 50. These
papers are selected for the critical analysis because, Springate (2011) stated that a sample size of
at least 25 to 30 cases must be replicated in RCT study in order to provide an estimate of the
random error.
The studies, which are selected for the critical analysis mainly, included children who fall
under the category of I and II of the American Society of Anesthesiologist (ASA). This category
I and II mainly constitute health person (I) and mild systematic disease (II). This selection style
of the population group among the journal articles helped the researcher to maintain the
generalizability of the study and not becoming too specific. This generalizability of the study
will help to implement the result of this systematic review towards modifying the post
anesthetics care among the pediatric patients (Sankar et al. 2014).
(Details of the selection criteria and sample size under each of the 9 studies is mentioned in
details in the tabular format in the appendix portion.)
Ethical consideration

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All the articles selected for the further critical analysis strictly abided by the ethical
considerations for recruiting child or infants in the RCT studies. As per the ethical principle of
autonomy, it is the right of the individuals to have a clear knowledge about the process of care if
it involves certain research (Zeigler 2011). Therefore, since focus group of children ranged from
0 to 15 years, the autonomy of the research process was mainly served by their parents on their
behalf. All the parents were informed about the series of the events that are going to be
conducted in the research process including the nature of the drugs that will be used to process of
anesthesia. However, in studies, which conducted double-blinded trails, the prospective outcome
of the study was not disclosed in order to reduce the biasness of the study. The risk and the
beneficial aspects of the study was also clearly explained to the parents before they provided a
signed consent to recruit their ward in the RCT. This comes under the ethical principle of
beneficence (Zeigler 2011). None of the authors of the selected study, forced to enroll the parents
to recruit their wards in the study. They also took necessary permission from the concerned
healthcare organization along with the opinion of the doctors before recruiting the target focus
and the placebo group.

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Discussion
Chandler et al. (2012) highlighted in their research paper that anesthesia such as
sevoflurane which is administered through a mask is related to an increased risk of emergence
delirium (ED) in pediatric patients. Propofol, an intravenous agent, has been noted to reduce ED,
but the previous researches had certain methodological limitations. The researchers therefore
conducted a randomized controlled trial with 112 children for comparing incidence of ED in
children after sevoflurane (SEVO) anesthesia and propofol–remifentanil total intravenous
anesthesia (TIVA). It was noteworthy that the study was a double-blinded research. The age of
the research participants was between 2 and 6 years who underwent elective strabismus surgery
under general anesthesia. Assessment of ED was carried out by the Pediatric Anesthesia
Emergence Delirium (PAED) Scale while assessment of pain was done with Face, Legs,
Activity, Cry, Consolability (FLACC) Scale. Data was retrieved for 94 patients. It was found that
incidence of ED was higher in patients given SEVO (38.3% vs 14.9%, P = 0.018) along with a
higher FLAC score (median 3 vs 1, P = 0.033). Further patients experiencing ED contributed to
higher FLACC scores. It was concluded that TIVA brings in the advantage of reduced risk of ED
in pediatric patients. TIVA further reduced post operative pain in pediatric population.
The study of Chandler et al. (2012) had considered using the PAED scale which is under
much criticism in relation to the inherent subjectivity in assessing behavior item and reliability of
observation. Since there remains a lack of tool that carries out objective data collection on ED, it
was thought desirable to conduct the research with PAED. The researchers pointed out that there
has been development of a tool on the basis of Diagnostic and Statistical Manual of Mental
Disorders IV (DSM-IV) which can be used in future studies in the same direction. The study also

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had a limitation that there was a lack of consensus between PAED score and bedside nurses
regarding which patients experienced ED. This again entailed the need for more sensitive,
reliable and specific studies.
The use of PAED scale for assessing emergence agitation was also noted in the study of
Bryan et al. (2009). The researchers pointed out that the induction incidence, side effect profile
and emergence characteristics of anesthetic agents given through laryngeal mask airway and
intravenously differ to a great extent. The researchers compared and measured the quality
between propofol, an intravenous agent, and sevoflurane, an inhalation agent, for children
undergoing MRI. The background to the study was that no randomized controlled trial had been
undertaken previously that compared the quality of the two anesthetic agents. Recruitment of 200
un-pre-medicated children aged between three years and 7 years was done. The patients were
induced with sevoflurane and the randomized for giving sevoflurane ](general anesthesia with
sevoflurane (GAS)] with the help of laryngeal mask airway (LMA) or propofol [general
anesthesia with propofol (GAP)] bolus and infusion. The outcomes measured were agitation,
respiratory complications and pausing at the time of MRI. The study reported that there was a
statistical difference between the anesthetic methods for agitation scores as highlighted by the
PAED scale. The GAP group demonstrated less agitation as compared to the GAS group. The
median and interquartile A scores were 0 (0, 4) in GAP and 3 (0, 7) in GAS groups respectively.
The researchers had conducted the research as a block-randomized plan stratified by age
which was appreciable. They also highlighted that though PAED scale has clearly stated items,
the subjectivity is under scrutiny. Further, the results were applicable for healthy outpatient
children who were to undergo normal MRI scans for brain. This implies that the results cannot
be generalized for inpatient children undergoing scan procedures or other medical processes.

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Nevertheless, the study was significant as only 9% of patients receiving sevoflurane experienced
ED in contrast to previous studies were the incidence had been reported at around 60% Bryan et
al. (2009).
Konig et al. (2009) pinpointed that volatile anesthetics are in use commonly for children
which is significantly associated with emergence delirium in different types of surgeries. It was
therefore thought noteworthy to carry out a comparison of extent of emergence delirium and
recovery quality demonstrated by children undergoing dental surgery upon administration of
sevoflurane-based anesthesia and propofol-based anesthesia. Data of 179 pediatric patients aged
2-12 years, about to undergo ambulatory dental surgery, was collected prospectively using
double-blinded randomized trial design. Standard protocol was used for randomizing into the
two groups and emergence delirium was measured with the help of the PAED score. The
secondary outcomes under scrutiny were incidence of postoperative nausea and vomiting
(PONV), number of nursing interventions required in the recovery room, and parental
satisfaction. The results in relation to the primary outcome pointed out non existence of
statistical differences in the median PAED score between the two intervention groups.
Nevertheless, it was noted that for the sevoflurane-based group only 29 out of 91 subjects had
PAED score >10while for the propofol-based group only 15 out of 91 subjects had PAED score
>10. The group being given sevoflurane demonstrated increased risk of nursing interventions in
the post operative period and increased risk of PONV.
The results of the study indicated that propofol did not lead to better effect on emergence
delirium. However, since the agent sevoflurane brings in certain side effects, it would be
beneficial to offer balanced dose of propofol instead of sevoflurane. The result of the study was
contradictory to a number of previous studies that had pointed out the propofol is of more benefit

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as compared to sevoflurane. But there still lies debate on this matter since there is a limitation in
studies utilizing the PAED scale, owing to which it is not possible to compare the results with
other research initiatives with different scoring systems (Konig et al. 2009).
The utility of administration of propofol in a single dose in reducing severity as well as
incidence of EA in children after sevoflurane anesthesia administration was acknowledged by
Lee et al. (2010). The researchers considered investigating the actual clinical benefit of a single
dose of propofol at 1 mg/kg for achieving reduction in EA incidence in pediatric patients
undergoing adenotonsillectomy after administering sevoflurane. 90 children set for undergoing
adenotonsillectomy, of age between 3 to 8 years were randomized to two equal groups of saline
and propofol. Prior to the surgery, all of the patients were given anesthesia in the form of
sevoflurane 2-2.5 vol% together with nitrous oxide/oxygen (50%/50%). After completion of
surgery, 1 mg/kg of propofol was administered to the intervention group while the control group
was given saline at 0.1 ml/kg. The researchers considered using the Aono’s four point scale for
measuring EA incidence and the PAED scale for measuring severity of the condition after
emergence at 5, 15 and 30 minutes interval. Statistical analysis pointed out that the incidence of
EA at the three time intervals for the propofol group were 61.4%, 27.3%, and 4.5% respectively.
In case of the saline group it was found to be at 68.2%, 29.5%, and 9.1%, respectively. No
statistical difference was found between the severity ad incidence of EA. The main inference
drawn from the research was that propofol 1 mg/kg did not have any added advantage when
administered after surgery in relation to EA for children adminstered sevoflurane anesthesia prior
to adenotonsillectomy.
The research discussed above had certain key limitation the most important one being
linked to the challenges in pointing out the difference between delirium and pain. Different

35EXTENDED LITERATURE REVIEW
analgesic modalities are to be selected for minimizing pain after surgery depending on the form
of surgery to be carried out. The researchers recommended that further investigations are needed
to highlight benefits of propofol in relation to EA when administered at different doses (Lee et
al. 2010).
Koyuncu et al. (2015) brought into focus that emergence agitation is likely to occur after
patients have been administered inhalation anesthetics such as sevoflurane, with an incidence
rate of as high as 80%. The researchers conducted a study reflecting on whether propofol
induction is beneficial for reducing the severity and incidence of EA as compared with
sevoflurane in children about to undergo surgery for inguinal hernia. Random allocation of 116
children, aged 2-12 years, was done to two groups; one group receiving 3 mg kg propofol and
one group receiving 8% sevoflurane. Standardized analgesia and treatment for agitation during
the postoperative period was given. Assessment carried out included Cole Agitation Scale for
understanding extent of agitation, Wong-Baker Faces Pain Rating Scale for understanding extent
of pain, first spontaneous eye opening time, post-anesthesia care unit (PACU) staying time, first
verbal command follow time, first analgesic requirement time and parents satisfaction. The
results indicated that the EA incidence upon arriving at PACU and at the end of the postoperative
hours were much lower for the group given propofol. The score were low in this group in all
measurement times at the first thirty minutes time of postoperative care. Further, pain scores
were determined to be lower in the group given propofol within the first 24 hours. It was inferred
from the study that propofol when given in effective doses reduced the intensity and incidence of
EA in children.
The present study, though brought into limelight valuable information regarding the
research topic, had certain limitations. The researchers considered using hemodynamical

36EXTENDED LITERATURE REVIEW
variables for indicating comparable depths of anesthesia intraoperatively. It is to be mentioned
that these variables do not hold much reliability when depth of anesthesia is being monitored.
Further, though the doses of the two anesthetic agents were accurate, they did not have
equipotency. Nevertheless, the researchers recommended that propofol can be considered as the
choice of anesthetic agent for children undergoing operations in clinical settings.
The main background of the study conducted by Cohen et al. (2003) is based on the
concept that emergence agitation is common among the children who are administered with
insoluble volatile anesthetics. The reason behind this is rapid emergence. The aim of the study
was to compare the emergence behaviour among the young children and infants who have
underwent general anaesthesia under the action of sevoflurane or propofol for the conduction of
ambulatory surgical procedures. The 53 children between the age group of 2 to 36 months and
are undergoing ambulatory surgery are selected randomly for the study. They were divided into
two groups, one group receiving sevolfurance and other group receiving propofol. The data
analysis done via Wilcoxon scores or Kruskal-Wallis test showed that both sevoflurane and
propofol enable rapid emergence from general anaesthesia. However, among them, only
sevoflurane is associated with high incidence of emergence agitation among the infants or young
children. This study over-ruled the concept that rapid emergence is associated with the process of
development of emergence agitation in pediatric care. Moreover, it also provided another new
dimension of the study, this showed that technique of administration of analgesic, and no
significant relationship with the agitation scores (Cohen et al. 2003). One of the main strength of
the study is it clearly addressed the focused issue that is the whether the association of rapid
emergence is associated with the development of emergence agitation among the infants or
children. They comparative study between the propofol and sevoflurane was focused over the

37EXTENDED LITERATURE REVIEW
target group of population. The reviewers who are assigned to review the scale of the emergence
agitation were also blinded about the desired outcomes and this further decreased the bias
quotient of the study. The study however, considered a small focus group of 53 children. This
selection of the small focus group might have effected the overall search results. However, the
selection of the group of the focus among the ambulatory group of patients further increased the
generalisibility of the data. This showed that the study is applicable to the local population or
rather say over the inpatient group of paediatric patients undergoing any surgical procedure or
therapy plan that demands anaesthesia.
The study conducted by Uezono et al. (2000) is based on the concept that sevoflurane is
associated with high rate of occurrence of emergence agitation among the pre-school children.
The aim of the study is mainly based on the hypothesis that maintenance of anesthesia with
propofol after using sevoflurane induction will help in the reduction of the incidence of this
agitated behavior in comparison to continuation of sevoflurance for the maintenance of the
anesthesia. In order to work on projected aim of the research, Uezono et al. (2000) conducted
randomized control single-blinded trial with two-period cross-over study with 16 pre-school
children (1 to 5 years old) who are undergoing repeated brief general anesthesia for their eye
checkup. After the administration of sevoflurane (inhaled), the patients were assigned randomly
to receive either propofol or sevoflurane for the anesthesia maintenance. The comparison of the
speed and the quality of recovery showed that patients who received sevoflurane for the overall
maintenance of anesthesia developed emergence agitation. On contrary, none of the patients,
who received propofol, developed emergence agitation. Though patients who received
sevoflurane for the maintenance experienced shorter span of post-operative care, patients who
received propofol showed greater range of satisfaction. Thus overall propofol scored high in the

38EXTENDED LITERATURE REVIEW
domain of effective control of emergence agitation when used anesthesia maintenance along with
higher degree of patient’s satisfaction.
One of the main limitation of the study is it has very low sample size, which might lead
to biased or error prone results. Moreover, not all the patients who entered the trial are properly
account until the end of the study as there was a drop out of two patients. Both the groups were
similar before the beginning and at the end of the study thus the reported results have
consistency. The study was also not double blinded; it was a single blinded study. A blinded yet
independent anesthesiologist examined the overall speed of the recovery. Moreover, this same-
blinded anesthesiologist was appointed to examine the quality of recovery and thus the results
can get affected via the informational bias or observation bias. As only single personnel was
recruited to study the recovery time and the quality of recovery.
The study conducted by Pieters et al. (2010) mainly revolves around the concept of
emergence delirium (ED) as a frequent complications in the post-operative care of young
children who are undergoing ENT procedure. It is hypothesized that ED is exacerbated that
sevoflurane anesthesia. On the other hand, propofol maintenance is suggested to reduce the
overall incidence of ED. The aim of the study is to conduct randomized, prospective double-
blinded study in order to examine the overall effect of sevoflurane in comparison to propofol
anesthesia on the overall quality recovery after the process of adenotonsillectomy. In order to
conduct the study, the authors recruited 42 pediatric care patients randomly who are under
maintenance with either propofol or sevoflurane. After the completion of the surgery the patients
were extubated awake and ED along with pain were examined via the use of Pediatric
Anesthesia Emergence Delirium (PAED) and the Children’s Hospital of Eastern Ontario Scale
(CHEOPS), respectively. The recorded results were analyzed statistically. The analysis of the

39EXTENDED LITERATURE REVIEW
results showed that the Propofol was associated with less pain during the recovery period along
with lower incidence of postoperative nausea and vomiting (PONV). However, the nursing and
the parental satisfaction was similar in both the groups. Thus the results highlighted by the study
of by Pieters et al. (2010) is some-what different from the results highlighted by Uezono et al.
(2000). This is because; Uezono et al. (2000) showed that the use of propofol is associated with
higher rate of patient’s satisfaction but the study of Pieters et al. (2010), over-ruled such
satisfaction level between propofol and sevoflurane. However, there is also similarity between
both the results as both the study showed that the propofol is associated with less complications
in the domain of ED. However, the study conducted by Pieters et al. (2010) has its share of
limitation, one limitation that can be easily highlighted is the small sample size. Moreover, the
authors did not attempt to verify the PAED cut-off, which is regarded as the independent scale in
order to measure the severity of ED among pediatric care. However, there are certain advantage
of the study, that is it is based on the structure of double blinded trial and thus there is less rate of
achievement of biased response.
The study conducted by Nakayama et al. (2007) is mainly erected on the concept that
young age is the vulnerable age of getting affected with ED under the action of anesthesia during
the surgical procedure. This ED is most commonly witnessed during the administration of
inhaled anesthetic agent, sevoflurane. The main aim of the study is to examine the relationship
between the EA (emergence agitation) upon propofol anesthesia among pediatric group of
population. Nakayama et al. (2007) mainly conducted a RCT study over 96 pre-school children
between the age group of 2 to 5 years who are scheduled to undergo otorhinolaryngological.
These selected patients were divided into four different groups namely propofol-preschool (P-
pre), propofol-school (Pschool), sevofl urane-preschool (S-pre) and sevofl urane-school (S-

40EXTENDED LITERATURE REVIEW
school) groups. The recovery time was of EA was analyses among the four groups. The analysis
of the results highlighted that recovery time was similar in all the four groups however; the
incidence of EA is S-pre group was significantly higher than the other groups. Thus, the study
conducted by Nakayama et al. (2007) aligned with the results elucidated by Pieters et al. (2010),
Cohen et al. (2003) and Uezono et al. (2000). This is because it showed that propofol as a
superior agent in control the rate of occurrence and severity of EA in comparison to sevoflurane.
However, the study as several limitations as coined by the author himself this is because, it does
not recruited any valid tool for measuring EA. Thus the final result may be biased. Moreover,
only one blinded observer graded all the scores of the observation and this must further increased
the rate of the bias response with accordance with the single blinded study in the domain of the
information bias or observation bias. The study also excluded the children who are below 2 years
of age and this might have hampered the generalisibity of the study because, the evolved results
might not be cited in other general group of population.

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Conclusion
Emergence agitation is perceived to be of much clinical relevance in daily practice as
experienced by anesthesiologists working with pediatric patients. The condition is a transient
state of disassociation as well as restlessness after the impact of anesthesia is over not responding
to consoling measures. The risk of experiencing such agitation is more in children aged 2 to 5
years. Different causes of agitation have been postulated, such as fast emergence, short-acting
nature of volatile anesthetic agents and the features of such agents. Other risk factors such as
nature of surgical process and age of patient are also crucial. Given the significant adverse
effects of emergence agitation, the need of identifying the most effective anesthetic agent and
mode of administration for preventing and treating the condition has been considered. The debate
regarding the mode of administration of anesthetic agent in pediatric patient has drawn attention
of health science researchers continually, such as in the present case.
The present research had the prime aim of studying the effectiveness of intravenous
anesthetic in reduction of emergence agitation among pediatric patients as compared to inhaled
anesthetic. The objectives of the research were to determine the effective of each form of
anesthetic agents and understand whether inhaled anesthetics increase the incidence of
emergence agitation when compared with intravenous anesthetics. An extended and systematic
literature review was carried out in this regard with the purpose of scrutinizing the existing pool
of literature reflecting on the concerned topic. The underlying idea was to bring into limelight the
rich and valuable pool of information governing the clinical practice area of pediatric anesthesia.
The articles included in the review were randomized controlled trials which are at the top
position in hierarchy of clinical evidence, conferring high reliability. It is to be remembered that

42EXTENDED LITERATURE REVIEW
in most of the studies the choice of intravenous anesthetic agent was sevoflurane, while the
choice of inhalation anesthetic agent was propofol or remifentanil. Further, the main mode of
assessing emergence agitation was the Pediatric Anesthesia Emergence Delirium (PAED) scale.
Six studies included in the research highlighted that intravenous anesthetics such as
propofol bring in the advantage of reduced risk of emergence agitation in children when
considered for varied postoperative conditions. Two studies out of the nine researches indicated
that propofol did not lead to better effect on emergence delirium. Another surgery also indicated
that propofol did not have any benefits when administered after surgery to patients been given
inhalation anesthesia prior to surgery. Though the strength of available evidence highlighting the
effectiveness of intravenous anesthetics is noteworthy, the studies that have given contradictory
results cannot be ignored completely. The number of such research papers was small, and
therefore it would be appropriate to carry out future assessments to understand the underlying
contributory factors for such distinct results. Drawing inferences from the valuable studies
included in the review it can be concluded that intravenous anesthetics namely propofol and
remifentanil decreases the incidence of emergence agitation in pediatric population as compared
to inhalation anesthetics such as sevoflurane. The research question set at the beginning of the
research could be appropriately answered through the literature review.
At this juncture the need for future research in this alignment has to be pinpointed.
Further investigations are needed to establish the effectiveness of intravenous anesthetic agents
in reducing incidence of emergence agitation as compared to intravenous agents. Such research
has to rest upon the methodological drawbacks of the existing studies. Taking insights from the
major limitations of the existing studies, novice studies are to be conducted that close the gap in
research (Elobu et al. 2015). The frontier for explicit translational studies would be the doses of

43EXTENDED LITERATURE REVIEW
administration of the agents in pediatric population. Reviews are to explore the extent to which
agents such as propofol are safe for pediatric population. Reflecting on the research paper of
Nileshwar and Khymdeit (2016) it can be stated that research involving anesthesia has always
considered quantitative methodology instead of qualitative approach. It might be a novel
approach to consider carrying out qualitative studies in highlighting the comparative
effectiveness of intravenous and inhalation anesthesia agents in reducing undesirable incidence
such as emergence agitation. In health science research, a qualitative method would help in
understanding experiences of individuals pertaining to the research topic (Flick 2015). In the
present case this would relate to the experiences of nurses while caring for emergence agitation
in pediatric population under cases of intravenous and inhalation anesthesia administration.
Based on the findings of the research carried out at present, it can be recommended that
intravenous anesthetics such as propofol can be considered for clinical practice for pediatric
population in clinical settings. The present review included studies that considered surgeries such
as dental surgery, adenotonsillectomy and inguinal hernia. This brings into consideration the
need of understanding the utility of the agent in case of other surgeries as well (Cavuoto et al.
2014). As the trend for administering general anesthesia in case of pediatric patients is growing
at the contemporary era, results of the present literature review suggest suitable clinical
outcomes, such as reduced risk of emergence agitation and decreased pain with total intravenous
anesthesia. Anesthesia providers are to have adequate knowledge of the appropriate technique of
administering intravenous anesthesia depending on the patient condition (Beringer, Greenwood
and Kilpatrick 2014). It is recommended that anesthesiologists engage in continual research for
understanding the safe procedures of administering agents intravenously. Further, the accurate
dose for each of the intravenous agents is to be known by the professional (Lerman 2016). These

44EXTENDED LITERATURE REVIEW
steps would ensure that the plan for anesthesia is tailored as per the need of the patient. This
would eventually lead to enhanced quality of care and improved patient satisfaction. Moreover,
overall safety of the patient can also be ensured (Lauder 2015).
The administration of intravenous anesthetic agents such as propofol and remifentatil for
pediatric populations might be challenging for anesthesiologists, owing to the nature of surgery
to be undertaken for the patient. A professional approach would be therefore needed for
integrating the input of additional clinical professionals (Bartels et al. 2018). It is further
recommended that anesthesiologists consider receiving feedback from nursing professionals who
are entrusted with the responsibility of caring for children experiencing emergence agitation. The
rationale is that the nursing professionals are the first point of care provision when it comes to
addressing emergence agitation and pain post operatively, and their viewpoints and opinions are
noteworthy (Nasar and Hannallah 2011). The role that care the settings plays in this regard have
been stressed repeatedly in literature (Holt 2014). Speaking briefly, organizational commitments
in combination with individual skills would be elementary for ensuring that administration of
intravenous anesthetic agents for pediatric population is effective in reducing emergence
agitation.

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References
Aouad, M.T. and Nasr, V.G., 2005. Emergence agitation in children: an update. Current Opinion
in Anesthesiology, 18(6), pp.614-619.
Aveyard, H., 2014. Doing a literature review in health and social care: A practical guide.
McGraw-Hill Education (UK).
Bartels, D.D., McCann, M.E., Davidson, A.J., Polaner, D.M., Whitlock, E.L. and Bateman, B.T.,
2018. Estimating pediatric general anesthesia exposure: Quantifying duration and risk. Pediatric
Anesthesia.
Beringer, R.M., Greenwood, R. and Kilpatrick, N., 2014. Development and validation of the
Pediatric Anesthesia Behavior score–an objective measure of behavior during induction of
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46EXTENDED LITERATURE REVIEW
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Appendix 1
Figure
: PICO Table
Source: Created by author
PICO

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Appendix 2
Google Search with broader keywords
Keywords: emergence agitation AND pediatric care AND intravenous anesthesia AND inhaled
anesthesia
Time: 1998 to 2018
Google search results using specific keywords as identified in the PICO table
Keywords:
"emergence agitation" OR "emergence delirium" AND "pediatric care" OR "children" OR
"infants" AND "intravenous anesthesia" AND "inhaled anesthesia"
Time frame: 1998 to 2018

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Appendix 3
Critical Appraisal Skills Programme (CASP) randomised controlled trial checklist

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Appendix 4
Summary table for articles-
First
author
and date
Study design Sample Data collection
tool
Results Critique notes
Chandler
et al.
(2012)
Double
blinded,
Randomized
controlled
trial
112 children aged 2- 6
years undergoing
elective strabismus
surgery under general
anesthesia
Assessment of
ED was
carried out by
the Pediatric
Anesthesia
Emergence
Delirium
(PAED) Scale
while pain was
assessed with
Face, Legs,
Activity, Cry,
Consolability
(FLACC)
Scale.
Induction and
maintenance of
anesthesia with
propofol–
remifentanil
TIVA
decreased the
incidence of
ED when
compared to
sevoflurane in
this patient
population.
Lack of
consensus
regarding
reliability of
PAED scale
Bryan et
al.
(2009)
Randomized
controlled
trial
Two hundred
unpremedicated children
(18 months to 7 years)
scheduled for brain MRI
After
induction with
sevoflurane,
children were
The median
and
interquartile A
scores were 3
Results not
generalized
for inpatient
children

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scans randomized to
receive
sevoflurane
[general
anesthesia
with
sevoflurane
(GAS)] via
laryngeal
mask airway
(LMA) or
propofol
[general
anesthesia
with propofol
(GAP)] bolus
and infusion
for their scan.
The three
primary
outcomes of
pausing the
MRI scan (P),
agitation (A),
and respiratory
(0, 7)
in GAS and 0
(0, 4) in GAP
groups
respectively

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complications
(R) were
compared
Konig et
al.
(2009)
Double-
blinded
randomized
trial
179 pediatric patients,
who were to undergo
ambulatory dental
surgery
Subjects were
anesthetized
following
standardized
protocols for
either a
sevoflurane- or
a propofol-
based
technique. The
incidence of
emergency
delirium, as
measured by
the
Pediatric
Anesthesia
Emergence
Delirium
score, was the
primary
outcome
No difference
in the
incidence of
emergence
delirium after
both types of
anesthesia.
However, use
of sevoflurane
significantly
increased both
the risk of
PONV and the
number of
postoperative
nursing
interventions
Result of the
study in
contrast to
previous
studies
highlighting
benefits of
propofol
Lee et al. Randomized Ninety children, aged 3- Randomization The incidence The sample

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(2010). controlled
trial
8 years, undergoing
adenotonsillectomy
was done into
propofol and
saline group
(each n=45)
and 88
completed the
study
and severity of
EA were not
found to be
significantly
different
between the
two group
population
was small
Koyunco
et al.
(2015)
Randomized
controlled
trial
116 Children
undergoing inguinal
hernia were randomly
assigned to two groups
aged 2-12 years
Sevoflurane
group
received
sevoflurane
increasing
concentrations
up to 8% and
propofol group
received 3 mg
kg propofol in
induction
Propofol in
accurate dose
is effective in
reducing the
incidence and
intense of EA
in children
undergoing
inguinal hernia
and maybe
preferred in
children with
high risk of EA
Limitation
regarding
dose of
anesthesia and
effect of pain
medication
administered
before
propofol
administration
Cohen
2015
Randomised
control trial
53 children and
infants between the
group of 2 to 36
months
Objective
Pain Scale in
order to
detect the
pain and
This study
over-ruled the
concept that
rapid
emergence is
Small
sample size
which might
have
provoked the

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Steward
Recovery
Score car in
order to
detect the
recovery time
associated
with the
process of
development
of emergence
agitation in
pediatric care.
Moreover, it
also provided
another new
dimension of
the study, this
showed that
technique of
administration
of analgesic,
and no
significant
relationship
with the
agitation
scores
generation of
biased
response
Uezono Randomized 16 pre-school children the presence The Extremely

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2000 control
single-
blinded trial
with two-
period
cross-over
study
(1 to 5 years old) or absence of
emergence
agitation in
the PACU
(defined as
inconsolable
crying,
combative
behavior, or
thrashing),
was recorded
via
interviewing
the mothers
of the
children
comparison of
the speed and
the quality of
recovery
showed that
patients who
received
sevoflurance
for the overall
maintenance
of anesthesia
developed
emergence
agitation. On
contrary, none
of the
patients, who
received
propofol,
developed
emergence
agitation.
Though
less sample
size, use of
single
blinded
study and
focus group
drop outs are
the three
main
limitations
of the study
that might
have
affected the
overall
results

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patients who
received
sevoflurance
for the
maintenance
experienced
shorter span
of post-
operative
care, patients
who received
propofol
showed
greater range
of
satisfaction.
Pieters
2010
RCT double
blinded
42 paediatric care
patients (3–7 years)
who are scheduled for
elective tonsillectomy
and adenoidectom
Pediatric
Anesthesia
Emergence
Delirium
(PAED) and
the
Children’s
The analysis
of the results
showed that
the Propofol
was
associated
with less pain
No cut-offs
are measured
to verify the
PAED
results in the
study

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Hospital of
Eastern
Ontario Scale
(CHEOPS) to
measure ED
and pain
respectively
during the
recovery
period along
with lower
incidence of
postoperative
nausea and
vomiting
(PONV) in
comparison to
the group of
patients who
received
sevoflurance.
However, the
nursing and
the parental
satisfaction
was similar in
both the
groups.
Lerman
2009
RCT single
blinded trial
96 pre-school children
between the age group
No standard
tool was use
The analysis
of the results
However,
the study as

68EXTENDED LITERATURE REVIEW
of 2 to 5 years who are
scheduled to undergo
otorhinolaryngological
to measure
the pain scale
of ED
highlighted
that recovery
time was
similar in all
the four
groups
however; the
incidence of
EA is sevofl
urane-
preschool (S-
pre) was
significantly
higher than
the other
groups
(propofol-
preschool (P-
pre),
propofol-
school
(Pschool), and
sevofl urane-
several
limitations
as coined by
the author
himself this
is because, it
does not
recruited any
valid tool for
measuring
EA. Thus the
final result
may be
biased.
Moreover,
only one
blinded
observer
graded all
the scores of
the
observation
and this

69EXTENDED LITERATURE REVIEW
school (S-
school)
groups
must further
increased the
rate of the
bias
response
with
accordance
with the
single
blinded
study in the
domain of
the
information
bias or
observation
bias. The
study also
excluded the
children who
are below 2
years of age

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