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Methods We enrolled 400 children, ages 1–12 years old, scheduled for dental procedures under general anesthesia. All children were induced with high concentration sevoflurane and BIS monitoring was continuous from induction through recovery in the PACU. A BIS reading. INTRODUCTION Emergence agitation (EA) in pediatric patients is a clinical entity generally defined by behaviors including combativeness, excitation, disorientation and inconsolability (). The incidence of EA is wide ranging in the literature from 10–80% (–). It is usually a self-limited phenomenon, but can be severe and present dangers to both patients and caregivers. Additionally, the severity and duration of EA may demand additional postoperative care personnel, delay parental presence in the Post Anesthesia Care Unit (PACU), and increase time to discharge.

Several factors have been associated with an increased risk of EA including the child’s baseline temperament and anxiety levels (, ), sevoflurane anesthesia (,,, ), young age (,, ) and ENT procedures (). Pain has also been implicated as a factor in EA, but it can be especially difficult to distinguish between pain and EA in the PACU (,, ).

While a multitude of studies have described the incidence and factors associated with EA, its etiology remains unclear. Following discharge to home, another perioperative complication which has been seen in up to 50% of children postoperatively is the development of negative postoperative behavioral changes (NPOBC) (). These behaviors include generalized anxiety, nighttime crying, enuresis, separation anxiety and temper tantrums. The incidence of these maladaptive behaviors was also seen in one study to be linked to the incidence of EA seen in the PACU (). As with EA, several factors have been associated with NPOBC including young age, preoperative anxiety in children and parents, and anesthetic agents such as sevoflurane (–).

As with EA, the etiology remains unclear. While the pathogenesis of postoperative behavioral disturbances such as EA and NPOBC remains undefined, we know that ENT procedures such as myringotomy and tympanostomy are associated with a higher incidence of EA (). This is usually an ultra-short procedure, but is performed using very deep levels of anesthesia. Within adults, titration of BIS levels improves postoperative () recovery while longer duration of anesthesia has been seen to be related to early postoperative cognitive dysfunction (, ). To our knowledge, no studies have looked at the relationship between hypnotic depth or duration of anesthesia and the incidence of EA or NPOBC in children. We wished to perform an observational study to investigate whether the length of time under deep hypnosis as measured by a BIS monitor reading of.

METHODS Following IRB approval, informed consent/assent was obtained for enrollment of 400 ASA I–III children between the ages of 1 and 12 years old. All patients were scheduled for outpatient dental procedures under general anesthesia. Exclusion criteria included pre-existing neurological disorders (e.g.

Seizure history, developmental delay, psychiatric diagnosis), planned use of ketamine and use of total intravenous anesthesia (TIVA). We also excluded non-English speaking patients to prevent difficulty in obtaining follow up results for NPOBC. All patients scheduled for outpatient dental procedures meeting inclusion/exclusion criteria during the study period were considered for participation. Following enrollment, a designated study nurse administered the modified Yale Preoperative Anxiety Scale (m-YPAS) () prior to the administration of pre-medication. A BIS monitoring strip was then placed on the child’s forehead in the preoperative holding area and data collection was begun. BIS data collection was continuous from the pre-operative period through recovery in the PACU. A BIS range from 40–60 is considered general anesthesia.

Studies in children have found BIS to correlate with clinical indicators of anesthesia and with the concentration of inhalational agents similar to that seen in adults (, ). For this study, we considered a BIS reading of less than 45 to be deep hypnosis ().

All children were induced with high concentration sevoflurane (6–8%) and nitrous oxide, and maintained on inhalational agent for the case. The choice of maintenance inhalational agent, as well as adjunctive medications given during the case, was determined by the anesthesiologist responsible for care. The anesthesiologist caring for the patient was blinded to the BIS.

The presence of EA was assessed in the PACU by recovery nurses using the Post Anesthesia Emergence Delirium scale (PAED) () (). EA was assessed continuously in the PACU from arrival through 10 minutes after the patient had awakened and remained awake.

The final score was determined to be the point at which the greatest agitation had occurred. Possible scores ranged from 0–25, with a higher score indicating greater symptoms of EA. Developers of this scale determined a score of 10 to be a reliable cutoff in assessing EA (). We therefore considered a score of 10 or greater to indicate the presence of EA, and dichotomized results into “yes” or “no” classifications. If EA was present, the type and amount of medication used to treat the patient was recorded, as well as the time required for assistance from additional personnel. Times in the PACU, including time to discharge to phase 2 and time to discharge to home were also documented.

The presence of NPOBC was assessed using the Post Hospital Behavior Questionnaire (PHBQ) (). This instrument was developed in 1966 to evaluate negative behavioral changes in children following surgery, and has been widely used to assess behavioral changes following hospitalization and procedures, with good test-retest reliability. It is a parent-rated scale, including 27 items in 6 categories of symptoms, that children have been observed to experience post-operatively. The PHBQ was administered by the parents on post-operative day 3–5 and the data was collected via a follow-up phone call. Scoring of the PHBQ occurs on a Likert scale, with a response of 4 or 5 for an item considered to be a negative behavioral change (). The presence of 7 or more negative behavioral changes on the PHBQ was considered positive for NPOBC and the occurrence of NPOBC was dichotomized into the classifications of “yes” or “no” (). The primary outcome measure was assessing the relationship between length of time under deep hypnosis and the incidence of EA in the PACU.

Secondary outcome measures included assessing the relationship between length of time under deep hypnosis and the incidence of NPOBC following discharge to home, as well as the influence of age, gender, preoperative anxiety and the type of maintenance inhalational agent used on the incidence of EA or NPOBC. We also assessed the relationship between EA and NPOBC, whether length of time in the PACU until discharge to home was increased with the presence of EA, and whether an increased level of care was necessary if EA was present. To measure the length of time under deep hypnosis, average BIS data points were acquired every minute and were recorded continuously during the study. The data was then downloaded to a secure laptop computer and imported into an excel file for data manipulation. To calculate the length of time with BIS.

EA and NPOBC are not associated with length of time under deep anesthesia In our secondary analyses, patients with EA were found to be an average of 0.3 years younger than those who did not experience EA. This difference, however, was not statistically significant (p = 0.11). Likewise, logistic regression analysis revealed no significant effect of gender (p = 0.14) or preoperative anxiety as assessed by the m-YPAS (p = 0.31) on the incidence of EA.

There was, however a statistically significant difference in the incidence of EA when examining the inhalational agents used for maintenance of anesthesia. The incidence of EA was significantly greater in those patients maintained on desflurane as compared to those maintained on isoflurane (p = 0.006). We found no significant difference in the incidence of EA between patients maintained on desflurane versus sevoflurane, or isoflurane versus sevoflurane (). EA vs Maintenance Anesthetic Agents.

Chi square analyses revealed the incidence of EA was significantly greater when desflurane was used as the maintenance inhalational agent as opposed to isoflurane (*p=0.006). There was no significant difference in. In terms of the impact of EA in the PACU, there was an increase in care requirements for children who experienced EA. In addition to the primary nurse caregiver, extra PACU personnel were required for care in 49% of patients with EA as opposed to only 15% of those not experiencing EA (p. Negative Post Operative Behavioral Changes After the presence of NPOBC was dichotomized into yes/no categories, analyses revealed the incidence of NPOBC in our study populations to be 8.8% (28/318) (95%CI 5.9%–12.5%). As with EA, logistic regression revealed no significant difference in the incidence of NPOBC with respect to length of time under deep hypnosis (p = 0.29) (). Secondary analyses included assessing the impact of age, gender, preoperative anxiety, and type of maintenance inhalational agent on the incidence of NPOBC.

While patients with NPOBC were, on average, 0.3 years younger than those without NPOBC, there was no statistically significant difference when considering age (p = 0.48). Likewise, gender (p = 0.33) and preoperative anxiety levels (p = 0.37) revealed no significant difference on the incidence of NPOBC. There was an observed increase of about 10% in the incidence of NPOBC when sevoflurane as opposed to desflurane or isoflurane was used for maintenance of anesthesia.

This difference was not statistically significant by chi square analysis (p = 0.21). In addition, while we found patients with EA were 3% more likely to have NPOBC, there was not a statistically significant correlation between these two phenomena. DISCUSSION We conducted this observational study to determine whether length of time under a deep hypnotic state, as assessed by a BIS monitor reading of less than 45, was associated with the presence of EA in the PACU or NPOBC upon discharge to home.

We hypothesized longer times under deep hypnosis would correlate with the occurrence of these postoperative maladaptive behaviors. Within this population of pediatric dental patients, our results found no association between length of time under deep hypnosis and either the incidence of EA in the PACU, or NPOBC upon discharge. Emergence Agitation The reported incidence of EA in the literature is variable (–). This is likely due to factors including different study populations, confounding factors such as pain, and importantly, the use of various subjective tools to assess the presence of EA. For this study, we used a recently developed and validated scale, the PAED, to assess EA.

Using this tool, we found no association between length of time under deep hypnosis and the incidence of EA within this population of pediatric dental patients. Additionally, we found no difference in the incidence of EA when length of time under deep hypnosis was stratified (e.g.

Negative Post Operative Behavioral Changes As with EA, the length of time under deep hypnosis, as measured by a BIS value of. Criticisms of Study Several criticisms of this study may be raised.

Amedeo Minghi Discografia Completa De Cesar Dario on this page. First, as an observational study, we did not attempt to control the anesthetic regimen. Though induction with high dose sevoflurane was universal, the choice of maintenance and adjunctive agents used was at the discretion of the anesthesiologist responsible for the care of the patient. Three dental anesthesiologists at TCH were responsible for the care of the majority of patients in this study (72%).

By self reports prior to beginning the study, their techniques were very similar. However, variation did exist which may impact the results of this study. Specifically, bias may have been introduced if the anesthesiologist was anticipating EA in their patient and designed their anesthetic regimen to minimize the occurrence of this phenomenon.

To address the issue of maintenance agents being chosen non-randomly by the anesthesiologists in our study, we performed subgroup analyses stratifying by the type of maintenance agent used. We found no significant difference between length of time under deep hypnosis and the occurrence of either EA or NPOBC (). Maintenance agent and the Occurrence EA and NPOBC Second, the constraints of our system led to multiple assessors of EA in the PACU which may affect the incidence of EA and confound results. To minimize the effects of multiple scorers, we tested for inter-rater reliability quarterly during the study by having the individual responsible for training the PACU nurses administer the PAED scale to patients independently of the nursing staff. Scores were compared and seen to fall within 10% of one another. Third, a variety of dental procedures were performed including cleanings, crowns, pulpotomies and extractions.

Some of these procedures may have produced more pain than others. Pain has been implicated as a factor in EA and can be especially difficult to distinguish from EA in the PACU (). We attempted to minimize the potentially confounding effects of pain on the assessment of EA by using the PAED scale to evaluate children in the PACU. This scale was developed and validated, including items which assess disturbances in consciousness and cognition to help differentiate pain from EA. Our aim in using this scale was to minimize the effect of pain on behavioral disturbances in the PACU that may affect the incidence of EA in our study. Finally, another factor that might affect outcomes was the use of midazolam pre-medication. Eighty nine percent of our study participants received a midazolam premedication.

The incidence of EA was 27% in those patients receiving midazolam and 23% in those who did not receive a premedication (p = 0.5). For NPOBC, the incidence of behavioral changes was seen in 9% versus 6%, respectively, of those patients receiving or not receiving midazolam preoperatively (p = 0.49).

Subgroup analyses were performed and found no significant association between the length of time under deep hypnosis and the occurrence of either EA or NPOBC, regardless of premedication (). While we observed no correlation between the use of preoperative midazolam and the occurrence of EA or NPOBC with respect to duration of deep hypnosis, this may still be a confounding factor as previously discussed.

When it was first published in 1947, The Age of Anxiety--W. Auden's last, longest, and most ambitious book-length poem--immediately struck a powerful chord, capturing the imagination of the cultural moment that it diagnosed and named. Beginning as a conversation among four strangers in a barroom on New York's Third Avenue, Auden's analysis of Western culture during the Second World War won the Pulitzer Prize and inspired a symphony by Leonard Bernstein as well as a ballet by Jerome Robbins. Yet reviews of the poem were sharply divided, and today, despite its continuing fame, it is unjustly neglected by readers. This volume--the first annotated, critical edition of the poem--introduces this important work to a new generation of readers by putting it in historical and biographical context and elucidating its difficulties.

Alan Jacobs's introduction and thorough annotations help today's readers understand and appreciate the full richness of a poem that contains some of Auden's most powerful and beautiful verse, and that still deserves a central place in the canon of twentieth-century poetry. First published in 2011. Alan Jacobs is the Clyde S. Kilby Professor of English at Wheaton College in Illinois.

His books include Original Sin: A Cultural History, The Narnian: The Life and Imagination of C. Lewis, and What Became of Wystan: Change and Continuity in Auden's Poetry. 'Princeton University Press's new critical, annotated edition of The Age of Anxiety seeks to repair and renew contemporary readers' relationship with the poem.

That it should triumphantly succeed in this task, however, has less to do with unraveling the poem's intricacies than with clearly showing how its many knots are tied. In an expansive preface and through rigorous textual notes, editor and Auden scholar Alan Jacobs outlines the circumstances of the poem's composition, traces the relations between psychology and religious belief as they play out in the text, and firmly situates the work in its historical moment.... It can only be hoped that this handsome new edition brings The Age of Anxiety to a new 'pitiful handful'. Those lucky few will discover in its pages one of the last century's great, and greatly neglected, poems.' --Geordie Williamson, Australian.