Running Head: Literature Review

Running Head Literature Review

A literature review is a survey of scholarly sources that provides an overview of a particular topic. It generally follows a discussion of the paper’s thesis statement or the study’s goals or purpose. This sample paper was adapted by the Writing Center from Key, K.L., Rich, C., DeCristofaro, C., Collins, S. (2010). Use of Propofol and emergence agitation in children: A literature review. AANA Journal, 78(6). Retrieved from Used by permission.

Format your title page according to your university guidelines. Use level headings to organize the literature review by topic. To learn when to use et al. in a citation, see the APA Style Elements page. The goal of this literature review is to compare three categories of anesthesia techniques and their associated incidence of emergence agitation (EA) in children. The three techniques are:

1. Sevoflurane inhalational general anesthesia,
2. Propofol as an adjunct to sevoflurane inhalational general anesthesia,
3. Propofol total intravenous anesthesia (TIVA).

The reviewed literature suggests that there are advantages to the use of propofol TIVA techniques and adjunctive propofol anesthetics compared with sevoflurane inhalational anesthesia alone. This reduction in EA with propofol use in conjunction with or separately from sevoflurane has been widely documented throughout the literature (Abu-Shahwan, 2008; Aouad et al., 2005; Aouad et al., 2007).

Paper For Above instruction

Emergence agitation (EA) remains a significant concern in pediatric anesthesia, impacting patient recovery and caregiver satisfaction. With the increasing use of inhalational agents such as sevoflurane, understanding the comparative incidences of EA associated with various anesthesia techniques is vital for optimizing patient outcomes. This review synthesizes current research on three anesthetic approaches: sevoflurane inhalational anesthesia, propofol as an adjunct, and propofol TIVA, analyzing their efficacy in reducing EA in children.

Introduction

Emergence agitation was first characterized in 1961 by Eckenhoff, Kneale, and Dripps, who documented signs of hyperexcitation during the emergence phase from ether, cyclopropane, or ketamine anesthesia (Eckenhoff et al., 1961). Since then, EA has been recognized as a common complication during recovery, especially in children, manifesting as confusion, hallucinations, and restlessness (Sikich & Lerman, 2004). The incidence of EA varies widely, reported to range between 10% and 67%, depending on various factors such as age, type of surgery, and anesthetic agents used (Aouad & Nasr, 2005). The advent of modern inhalation agents like sevoflurane has been associated with increased EA episodes, prompting investigation into optimal anesthetic regimens (Bortone et al., 2006).

Sevoflurane Inhalational Anesthesia and its Impact on EA

Sevoflurane became widely used following its introduction in 1994, primarily due to its rapid induction and emergence profiles, pleasant odor, and minimal airway irritation (Baum et al., 1997; Moore et al., 2003). Despite these advantages, sevoflurane has been linked with higher rates of EA—ranging from 20% in some surgeries like ENT procedures to as high as 60% in circumcisions (Nakayama et al., 2007; Tazeroualti et al., 2007). The epileptogenic potential of sevoflurane, evidenced through clinical seizures and EEG findings during various phases, may contribute to EA behaviors (Veyckemans, 2001). The increased reports of seizure activity support the hypothesis that sevoflurane's neuroexcitative properties influence emergence phenomena.

Propofol as an Adjunct to Sevoflurane

Propofol is favored for its rapid onset, washout, and calming effects during recovery. Introduced in 1989, it has established efficacy in pediatric procedures, including outpatient settings (Kaddu et al., 2002). Numerous studies demonstrate that adding propofol to sevoflurane significantly reduces EA incidence. Abu-Shahwan (2008) reported a decrease from 26.8% with sevoflurane alone to 4.8% when combined with subhypnotic doses of propofol. Similarly, Aouad et al. (2007) found EA rates decreased from 47.2% to 19.5% with adjunct propofol use. This adjunctive approach appears to mitigate sevoflurane's neuroexcitative effects, possibly through its sedative properties, providing smoother recovery.

Propofol Total Intravenous Anesthesia and EA Reduction

Propofol TIVA, involving continuous intravenous infusion of propofol, offers a stable anesthetic profile with minimal residual sedation. In a comparative study, Cohen et al. (2003) observed a dramatic reduction in EA rates with propofol TIVA (3.7%) versus sevoflurane inhalational anesthesia (23.1%). Picard, Dumont, and Pellegrini (2000) also reported superior recovery quality with TIVA, including reduced agitation. Nakayama et al. (2007) observed a decline from 42% to 11% in EA among children aged 2–5, favoring TIVA. Uezono et al. (2000) confirmed these findings with a cohort experiencing 0% EA with propofol TIVA compared to 38% with sevoflurane. Consistent results support the hypothesis that TIVA with propofol minimizes neuroexcitative responses at emergence.

Discussion

The collective evidence indicates that propofol, whether administered as an adjunct or via TIVA, effectively reduces EA compared with sevoflurane inhalational anesthesia. This is likely related to propofol's calming effects and potential to suppress seizure activity (Abu-Shahwan, 2008). Studies suggest that combining propofol with sevoflurane yields a synergistic benefit, decreasing EA incidence significantly, which is crucial in pediatric populations prone to agitation-related complications (Hassan et al., 2018). Nonetheless, heterogeneity in assessment scales for EA remains a challenge. Sikich and Lerman (2004) proposed the Pediatric Anesthesia Emergence Delirium (PAED) scale as a reliable, validated tool. Standardizing the assessment process across studies will enhance comparability and strengthen evidence-based practices.

Limitations and Future Directions

Despite the compelling data, the literature is limited by inconsistent measurement tools and small sample sizes in some studies. Future research should incorporate standardized, validated scales like PAED to facilitate cross-study comparison. Additionally, exploring the neurophysiological basis of EA with advanced EEG monitoring could elucidate the mechanisms by which different agents influence emergence phenomena. Larger, multicenter trials are needed to confirm optimal dosing and administration protocols, ultimately guiding safer and more effective anesthetic strategies in pediatric care.

Conclusion

In conclusion, the reviewed literature underscores that propofol, whether used as an adjunct or in TIVA, significantly reduces the incidence of emergence agitation in children. As inhalational agents like sevoflurane are associated with higher EA rates, incorporating propofol into anesthetic protocols can enhance recovery quality and patient safety. Standardization in assessment methodologies and further elucidation of underlying mechanisms will support the integration of these findings into clinical practice, ultimately improving pediatric anesthetic outcomes.

References

• Abu-Shahwan, I. (2008). Effect of propofol on emergence behavior in children after sevoflurane general anesthesia. Pediatric Anesthesia, 18(1), 55–59. https://doi.org/10.1111/j.1460-9592.2007.02376.x
• Aouad, M. T., & Nasr, V. G. (2005). Emergence agitation in children: An update. Current Opinion in Anesthesiology, 18(6), 614–619.
• Aouad, M. T., Yazbeck-Karam, V. G., Nasr, V. G., El-Khatib, M. F., Kanazi, G. E., & Bleik, J. H. (2007). A single dose of propofol at the end of surgery for the prevention of emergence agitation in children undergoing strabismus surgery during sevoflurane anesthesia. Anesthesiology, 105(5). https://doi.org/10.1097/01.anes.0000278674.77134.27
• Baum, V., Yemen, T. A., & Batum, L.. D. (1997). Immediate 8% sevoflurane induction in children: A comparison with incremental sevoflurane and incremental halothane. Anesthesia & Analgesia.
• Bortone, L., Ingelmo, P., Grossi, S., Grattagliano, C., Bricchi, C., Barantani, D., & Mergoni, M. (2006). Emergence agitation in preschool children: Double-blind, randomized, controlled trial comparing sevoflurane and isoflurane anesthesia. Pediatric Anesthesia, 16, 1138–1143. https://doi.org/10.1111/j.1460-9592.2006.01954.x
• Cohen, I. T., Finkel, J. C., Hannallah, R. S., Hummer, K. A., & Patel, K. M. (2003). Rapid emergence does not explain agitation following sevoflurane anaesthesia in infants and children: A comparison with propofol. Pediatric Anesthesia, 13(1), 63–67. https://doi.org/10.1046/j..2003.00948.x
• Kaddu, R., Bhattacharya, D., Metriyakool, K., Thomas, R., & Tolia, V. (2002). Propofol compared with general anesthesia for pediatric GI endoscopy: Is propofol better? Gastrointestinal Endoscopy, 55(1), 27-32.
• Nakayama, S., Furukawa, H., & Yanai, H. (2007). Propofol reduces the incidence of emergence agitation in preschool-aged children as well as in school-aged children: A comparison with sevoflurane. Journal of Anesthesia, 21(1), 19–23. https://doi.org/10.1007/s-x
• Veyckemans, F. (2001). Excitation phenomena during sevoflurane anaesthesia in children. Current Opinion in Anesthesiology, 14(3), 297–302.