A lower incidence of ED and a higher parental satisfaction level were observed after TIVA. Moreover, TIVA resulted in a more comfortable postoperative period due to reduced postoperative pain, and the extubation time and recovery time were not increased. 

Rapid awakening after the use of anaesthetics has been proposed to generate emergence delirium (ED), which is an abnormal mental state that develops during the shift from unconsciousness to complete wakefulness. The prevalence of ED largely depends on various factors such as age, anaesthetic technique, surgical procedure, and administration of adjunct medication. The incidence of ED in pediatric anaesthesia is highest in children aged between 2-6 years.

The ideal anaesthetic should have fast emergence and a short recovery period. They should not have any postoperative side effects. Previous studies reported that sevoflurane (SEVO) have low blood and tissue solubility, which results in the fast elimination of outpatient anaesthesia. Recent reports propose that SEVO may be associated with a higher incidence of postoperative ED.

Propofol, also known as an ideal anaesthetic, is widely used in outpatient anaesthesia which provides smooth and fast recovery with no severe side effects. A study conducted by Chandler et al. on children aged 2-6 years reported the lower incidence of ED after total intravenous anaesthesia (TIVA) than that after SEVO anaesthesia. Also, TIVA with propofol (TIVA-p) provided more favourable results regarding recovery characteristics, including rescue medications, ED, and recovery time.

Rationale behind research:

A very few studies are available comparing the efficacy of SEVO with TIVA-p regarding recovery characteristics among children undergoing comprehensive dental treatment.

Therefore, the present randomised clinical trial compares the ED and recovery attributes after SEVO anaesthesia and TIVA-p in children undergoing outpatient dental treatment.

Objective:

To compare the incidence of ED in children who underwent full mouth dental rehabilitation under either sevoflurane (SEVO) anaesthesia or propofol-based total intravenous anaesthesia (TIVA) 

Study outcomes:

• Dental treatment procedures: The number of dental procedures, the duration of the dental operation, and the duration of anaesthesia was noted
• Post-anesthesia outcome measures: Postoperative pain, ED, recovery time, satisfaction levels of parents or guardians, and extubation time
• Primary endpoint: The primary endpoint of the study was ED. The Pediatric Anesthesia Emergence Delirium (PAED) scale is used to assess patients on the following five psychometric items:

1. the child makes eye contact with the caregiver

2. the child’s actions are purposeful

3. the child is aware of his or her surroundings

4. the child is restless

5. the child is inconsolable

• Postoperative Pain: Postoperative pain intensity was assessed using the Face, Legs, Activity, Cry, Consolability (FLACC) scale. Responses in each category are scored between 0 and 2, for a maximum total score of 10

Time period: NA

Outcomes:

• In the PACU, a statistically significant difference in the incidence of ED was observed between the groups. A total of 65.5% of the subjects in the SEVO group had PAED scores ≥10, and 3.4% of the subjects in the TIVA-p group had PAED scores ≥ 10 (P=0.00) (Figure 2)
• A statistically significant difference was observed between the groups in FLACC scores, with a higher median value in the SEVO group than in the TIVA-p group. Children who experienced ED had a higher maximum FLACC score (median=4; IQR=2–5) than children who were not affected by ED (median=2; IQR=1–3) (P<0.05) (Figure 3). A statistically significant, moderate correlation (rs=0.46, P<0.0001) was found between FLACC and PAED scores. 

• No statistically significant differences were found between the groups for extubation and recovery times (P>0.05)
• No statistically significant differences were found between the groups for heart rate, systolic arterial pressure, diastolic arterial pressure, peripheral oxygen saturation levels at PACU arrival and on discharge from the PACU (P>0.05). The global satisfaction scores of parents were significantly higher in the TIVA-p group than in the SEVO group (P<0.05). 

The present study showed a lower incidence of ED and lower pain scores (FLACC) after TIVA-p than after SEVO anaesthesia in children undergoing dental treatment.

The results of this study are very similar to the number of previous studies that states TIVA-p anaesthesia was better than SEVO. Cravero et al. did a survey and found a significantly higher incidence (80%) of emergence agitation (EA) in the SEVO group.  In a study, similar results were observed by Nakayama et al. This RCT found an ED incidence of 65.5% in the SEVO group versus 3.4% in the TIVA-p group.

The reasons for the higher incidence of ED after SEVO anaesthesia are not completely clear. Multiple hypotheses were proposed, such as epileptiform EEG changes, temporary neurological dysfunction, rapid recovery, and responses to pain. A preclinical study conducted by Yasui et al. identified an increase in noradrenaline release, which has been suggested to also lead to disorientation characterized by agitation in the early stages of recovery from anaesthesia.

Rapid and early recovery also one of the hypotheses associated with the higher incidence of ED after SEVO anaesthesia. Uezono et al. reported the shorter PACU to stay in SEVO than propofol. In contrast, Cohen et al. noted that the times to extubation and recovery were similar between SEVO and propofol groups, but that ED was significantly more common in the SEVO group.

The FLACC scores were higher in the SEVO group than in the TIVA-p group. Many studies recommend that propofol-based anaesthesia reduces postoperative pain and the need for rescue analgesia. Chandler et al. reported that TIVA-p decreased postoperative pain measured by FLACC scores. Pieters et al. used the PAED scale and showed that propofol group required less pain medication in the PACU. Similar to the study by Chandler et al., we found a significant positive correlation between FLACC and PAED scores, with lower incidences of ED and postoperative pain in the TIVA-p group.

Rapid awakening has been suggested as one of the causes of EA. In the present study, the time to extubation and the recovery time were relative in the TIVA-p and SEVO groups, which is consistent with previous articles. The current research showed lower parental satisfaction due to children behaviours, such as presenting a lousy mood and intermittent crying. The parental satisfaction levels in the TIVA-p group were higher than those in the SEVO group in this study.

In conclusion, it was revealed that TIVA-p significantly reduces the rate of ED than the SEVO anaesthesia in children undergoing dental rehabilitation.