Acupuncture for the Prevention of Emergence Delirium in Children Undergoing Myringotomy Tube Placement
Trial Snapshot
- Phase
- Not Applicable
- Status
- Completed
- Enrollment
- 100
- Locations
- 2
- Primary Endpoint
- Pediatric Anesthesia Emergence Delirium (PAED) Score
Study Overview
Brief Summary
Myringotomy tube placement is one of the most commonly performed operations in children. Emergence delirium after such procedures is common. During emergence delirium children can become both a danger to themselves and others around them, including family members and hospital staff.
The primary objective of this study is to determine if acupuncture, when used in combination with standard anesthetic management, decreases the incidence of emergence delirium in pediatric patients following myringotomy tube placement. Patients with and without premedication of midazolam will be included. A secondary objective of this study is to determine our institution's actual incidence of emergence delirium for this operation using a validated scale, the Pediatric Anesthesia Emergence Delirium (PAED) scale. We will also compare rates of emergence delirium in patients that received a premedication of midazolam versus (V) those that did not (NV).
This is a randomized double-blinded trial. We will enroll 100 children aged 1-6 years old. Premedication with midazolam will be decided by the anesthesiologist. If needed, the patient will receive a standard does of oral midazolam plus acetaminophen (V). If the patient does not require premedication with midazolam, oral acetaminophen will be given alone (NV).
Patients will then be randomized to receive either acupuncture with standard general anesthesia care (A) or to receive standard anesthetic care alone (S). Patients, their family members and recovery registered nurses (RNs) will not know if acupuncture was performed. Intraoperative anesthetic techniques will be standardized and include inhaled inductions with nitrous oxide and sevoflurane. Anesthesia maintenance will be inhaled sevoflurane and the usual pain medication ketorolac will be given intramuscularly prior to emergence. Acupuncture needles will be placed after anesthesia induction and removed prior to leaving the operating room. A total of 4 needles will be placed, one in each wrist at the Heart 7 (HT7) point and one in each ear at the Shen Men point. The needles will be inserted bilaterally to a depth of 1.8 mm.
In the PACU, a blinded study observer will evaluate the patient at four time points using the PAED scale: time of awakening and 5, 10 & 15 minutes after awakening. Follow up phone calls will be made one day and one week after surgery. Families will be asked about behavior after discharge, sleep and bed-wetting.
Detailed Description
Myringotomy tube placement is one of the most commonly performed operations in children, with almost 700,000 completed in the United States each year 1. Common anesthetic management of these cases includes inhalational anesthesia and no intravenous line placement. Sevoflurane is the inhalational agent used most commonly for induction and maintenance of these patients. Emergence delirium after sevoflurane maintenance is common. In a study of children receiving sevoflurane-based anesthetic for MRIs, 47.6% of participants had emergence agitation 2. In a comparison of different emergence delirium scales, Bajwa and colleagues detected emergence delirium in 32% of subjects using the Pediatric Anesthesia Emergence Delirium (PAED) scale 3. Emergence delirium can be distressing for both children and their caregivers. During emergence delirium children can become both a danger to themselves and others around them, including family members and hospital staff. Emergence delirium can also delay discharge from the post-operative care unit (PACU).
There has been some published evidence that intraoperative acupuncture can decrease the incidence of post-operative delirium. One study enrolled 60 children undergoing bilateral ear tube placement and randomized half of the patients to receive acupuncture at points LI-4 (he gu) and HT-7 (shen men). The acupuncture group had a lower incidence of emergence agitation than the control group at time of arrival in the PACU and during the following 30 minutes 4. This study did not include patients that had received pre-medication with midazolam. It also did not use a validated assessment for emergence delirium in children.
A small retrospective review of 12 children that received acupuncture found that 83% did not show signs of emergence delirium. These patients had needling at 3 locations (SP 6, HT 7, Liv 3) and magnets placed at the ear shen men area. The anesthetic technique used for these patients was not standardized and there was no comparison group.
The primary objective of this study is to determine if acupuncture, when used in combination with standard anesthetic management, decreases the incidence of emergence delirium in pediatric patients following myringotomy tube placement. Patients with and without premedication of midazolam will be included as it is common that children receive sedating medications to facilitate separation from their caregivers.
A secondary objective of this study is to determine our institution's actual incidence of emergence delirium after this operation. We can also compare rates of emergence delirium with or without premedication of midazolam. Emergence delirium will be evaluated using a validated pediatric delirium scale. The Pediatric Anesthesia Emergence Delirium (PAED) scale has been tested for reliability and validity in 50 children 5.
Study Design
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Parallel
- Primary Purpose
- Prevention
- Masking
- Triple (Participant, Care Provider, Outcomes Assessor)
Eligibility Criteria
- Ages
- 1 Year to 6 Years (Child)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •children ages 1 - 6 years old with ASA physical status of 1-3
- •scheduled for unilateral or bilateral myringotomy tube placement only.
Exclusion Criteria
- •use of mood altering medications, including anti-epileptic medications.
- •genetic abnormalities, including Trisomy 21 (Down syndrome).
- •children scheduled for additional surgical procedures to be done in conjunction with myringotomy tube placement.
- •Patients scheduled for an overnight admission post operatively.
Outcomes
Primary Outcomes
Pediatric Anesthesia Emergence Delirium (PAED) Score
Time Frame: 0-15 minutes after awakening from general anesthesia in the recovery room
The start of awakening will be indicated by the time point of first observed, sustained eye opening. In the Post-Anesthesia Care Unit (PACU) and Day Stay units, an observer will evaluate the patient at four time points: time of awakening, 5 minutes after awakening, 10 minutes after awakening and 15 minutes after awakening. The observer will use the Pediatric Anesthesia Emergence Delirium (PAED) evaluation tool evaluate each child for emergence delirium.
Secondary Outcomes
- Behavior Disturbances on Post-Operative Day 1 (POD1)(24 hours)
- Behavior Disturbances one week after surgery (POD 7)(7 days)
Investigators
Christine Martin
Assistant Professor
Oregon Health and Science University