Allan M Cyna^1,2,3, Kate Stephens¹, Penny Strickland², Jessica N Larsson², Philippa Middleton³

¹Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
²Department of Paediatric Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
³Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia

Purpose of study: To compare sevoflurane with other general anaesthetic agents with or without pharmacological adjuncts with regards to paediatric postoperative behavioural disturbance in PACU.

Methods: We searched the Cochrane Library and other electronic databases in November 2007, for randomized or quasi-randomized controlled trials of children < 18 years presenting for general anaesthesia (GA). We included any sevoflurane anaesthetic +/- nitrous oxide compared with any other (GA). Types of GA included: other volatiles e.g. isoflurane, halothane, other GAs e.g. ketamine, propofol TIVA, and anaesthetic adjuncts such as opioids and benzodiazepines. The primary outcome was: the number of patients with postoperative behaviour disturbance as measured by the authors of the included studies. Two authors independently extracted data using standardized data collection forms. Revman 5 [1] was used for data synthesis and meta-analyses.

Results: 42 trials investigating > 4000 children met criteria for inclusion and 15 trials are awaiting assessment. Main comparisons were: General anaesthetics alone (e.g. TIVA, halothane) vs sevoflurane alone (13 trials); General anaesthetics with adjunct vs sevoflurane with the same adjunct (16 studies); Sevoflurane with an adjunct such as fentanyl or clonidine vs sevoflurane alone (13 studies). General anaesthetics alone resulted in fewer instances of postoperative behaviour disturbance than sevoflurane alone (RR 0.60 95% CI 0.42 to 0.86; 13 trials of 1509 children). For halothane compared with sevoflurane, the relative risk was 0.60 [95% CI 0.46 to 0.79] (7 trials of 825 children) and for the propofol subgroup the relative risk was 0.27 [95% CI 0.14 to 0.51] (2 trials of 222 children). Interim analyses indicate that other regimens also reduce the incidence of behavioural disturbance when compared with sevoflurane.

Conclusions: Postoperative behaviour disturbance is more common with sevoflurane when compared with other general anaesthetics such as halothane or propofol. Other regimens are also likely to show this effect.

References: [1] The Cochrane Collaboration. Review Manager (RevMan) 5.0 for
Windows. The Cochrane Collaboration, 2008. www.cochrane.org