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      <P align="center"><B><font color="#0c2d83" size="+2">Literature Reviews</font></B> 

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      <P><b><font color="#0c2d83">Emergence behaviour in children: defining the 
        incidence of excitement and agitation following anaesthesia <br>
        </font></b>Cole JW, Murray DJ, McAllister JD, Hirshberg GE. Paediatric 
        Anaesthesia 2002 12:442-447. 
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      <p>This interesting article discusses the authors' experience in a prospective 
        trial documenting the incidence and covariables associated with emergence 
        agitation and excitement. Using a qualitative self designed scoring system 
        and a blinded observer (blinded to anesthetic management and premedication) 
        serial scores were obtained every ten minutes in the PACU. A 10% incidence 
        of severe restlessness was noted at emergence and an additional 30% of 
        children were found to be experiencing s significant period of distress 
        during their recovery room stay. 
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<P>The authors made a significant attempt to provide analgesia before emergence with caudal anesthesia 
in approximately 70% of the children and midazolam premedication was used in just over half of 
the children.  Midazolam premedication was not randomized and was not controlled in the trial. 
Anesthetic vapor included halothane for induction and either halothane or isoflurane for maintenance. The 
incidence noted is similar to previous reports, but what was novel was the description of `delayed' 
emergence phenomena  in 10% of children not noted until after 30 minutes in the PACU.  Whether this reflects 
a slowness to awaken from halothane is not known.  Although midazolam administration was 
statistically associated with an increased incidence of emergence issues in the older children, the authors 
carefully state that a cause and effect relationship is not shown.  They appropriately report the finding and 
discuss the observation as appropriate for another trial to examine the question directly.  I would really like 
to know the mechanism(s) responsible for this commonly noted problem and an effective prophylactic 
or therapeutic strategy!
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<P><B>Reviewed by </B>Joseph Tobin, MD


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