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Comparison of the Effect of Thiopental Sodium with Midazolam-Ketamine on Post-Tonsillectomy Agitation in Children

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Comparison of the Effect of Thiopental Sodium with Midazolam-Ketamine on Post-Tonsillectomy Agitation in Children ORIGINAL ARTICLE Comparison of the Effect of Thiopental Sodium with Midazolam-ketamine on Post-tonsillectomy Agitation in Children Maryam Toliyat1, Maliheh Zangoee2, Shahnaz Ahrari3, and Reza Zangoee4 1 Department of Paramedicine, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran 2 School of Medicine, Birjand University of Medical Sciences, Birjand, Iran 3 Department of Paramedicine, School of Nursing and Midwifery, Gonabad University of Medical Sciences, Gonabad, Iran 4 Islamic Azad University, Birjand Branch, Birjand, Iran Received: 11 Jul. 2014; Accepted: 25 Dec. 2014 Abstract- The aim of this study was to determine the effect of thiopental sodium with that of midazolam- ketamine on relieving agitation after tonsillectomy in children. In a clinical trial, 50 children aged 5-10 years, candidates for tonsillectomy, were randomly divided into two 25-member groups. In the first group, thiopental sodium 5mg/kg/IV, and in the second group combination of midazolam 0.01 mg/kg/IV and ketamine 1 mg/kg/IV were used to induce anesthesia. The level of sedation was assessed after surgery with the Ramsay scale. There were no significant differences between the two groups in terms of heart rate, arterial oxygen pressure (PO2), and duration of anesthesia. The Ramsay sedation score was significantly higher in the thiopental sodium group than in the midazolam-ketamine group (P=0.01). Thiopental sodium can be more effective than the combination of midazolam-ketamine for controlling agitation after tonsillectomy in children. © 2015 Tehran University of Medical Sciences. All rights reserved. Acta Med Iran 2015;53(10):637-642. Keywords: Ketamine; Midazolam; Thiopental sodium; Sedation; Agitation Introduction known, different factors have been mentioned in this regard: pre-school age, nervousness, previous surgery, Tonsillectomy is one of the most common surgeries the adaptability of the patient, pain in eye and ENT in children (1). Agitation is a common complication surgeries, using inhalation agents, particularly, after surgery in children, particularly, those who receive sevoflurane and isoflurane for anesthesia, and the Sevoflurane for anesthesia (2-4). Initial epidemiological duration of anesthesia (5,9,10). Among these, pain and studies report the incidence rate of tonsillectomy in nervousness are known as the most common causes different ages at 5.3%, but later studies estimated it at (11). Although agitation will be resolved on its own, it 18%-80% in children (5). Generally, agitation is defined leads to the dissatisfaction of the parents, nurses, and as a series of physical symptoms or emotional distress caregivers (12). Premedication is needed in children to with some or all of the following sings: crying, alleviate anger, induce anesthesia, and prevent restlessness, grabbing, verbal presentations, kicking, aspiration, preventing bradycardia and psychological purposeful or unintentional behavior, which might have effects after surgery. logical connections with each other (5). This Different medicines are used to sedate children, such complication can be severe and chronic, expose the as a benzodiazepine, midazolam and ketamine (13,14). patient to physical harm, pain or bleeding, and prolong The properties of a good medicine lie in its rapid onset, the recovery time (6). The widespread use of short-term effect, and it’s significantly fewer sevoflurane and desflurane in developing countries has complications (15). Midazolam is a benzodiazepine with increased agitation after surgery in children (7). Another anxiolytic and sedative properties, which is commonly problem of agitation after surgery is nursing problems in used in both children and adults in different diagnostic delivering care for the agitated child (8). and therapeutic procedures due to its short-term effects Although the etiology of this complication is not and rapid onset. Corresponding Author: Sh. Ahrari Department of Paramedicine, School of Nursing and Midwifery, Gonabad University of Medical Sciences, Gonabad, Iran Tel: +98 51 57225027, Fax: +98 51 57223815, E-mail address: [email protected] Comparison of the effect of thiopental sodium with midazolam-ketamine This medicine prevents the formation of an tonsillectomy in children. undesirable memory of the painful procedure by creating anterograde amnesia However, It needs to be used with Materials and Methods an analgesic in painful procedures due to its lack of an analgesic property (16,17). Although midazolam causes This clinical trial was conducted on children aged 5- respiratory depression, it is used as a sedative before 15 years after briefing their parents and obtaining their surgery (18). written consent. The inclusion criteria for the study were Ketamine is a derivative of phencyclidine and a children aged 5-15 years with grades 1 and 2 of the sedative and analgesic, which can be used alone or with health criteria of the American Society of other medicines for analgesia during diagnostic and Anesthesiologists, who were applicants for therapeutic procedures in children. This medicine can be tonsillectomy. prescribed orally, intravenously, intramuscularly or Patients with a history of consuming barbiturates, a intrathecally for inducing anesthesia and relieving history of acute respiratory failure or severe renal failure agitation in different diagnostic and therapeutic and mental retardation, or a history of anesthetic activities (19,20). The kind of medicine used for complications such as bleeding or complications during anesthesia depends on anesthesiologist’s choice after surgery, including the impossibility or difficulty of considering the patient’s condition and the length of the intubation, were excluded. The qualified patients were surgery. assigned to two groups using block randomization Despite the widespread use of ketamine in adults as a method to receive anesthetic. After selecting and suitable sedative and analgesic, its use in children is preparing the patients for anesthesia, thiopental sodium 5 questioned due to its hallucinating and agitating mg/kg/IV was used for the thiopental sodium group, and complications (21). Thiopental sodium is barbiturate used the combination of midazolam 0.01 mg/kg/IV and for inducing anesthesia. The major complications of this ketamine 1 mg/kg/IV was used in the other group to medicine include spasm and respiratory depression (22). induce anesthesia (26). Its cardiovascular effects are the decreased mean arterial The heart rate, respiratory rate, and oxygen pressure and reduced cardiac output. A study by Darabi saturation were controlled by the anesthesiologist during et al., showed that both combinations of propofol- anesthesia. Apnea, arterial oxygen saturation fall, alfentanil and midazolam-ketamine are safely and bradycardia or tachycardia, and agitation were recorded effectively used for sedation and analgesia in children on a questionnaire. The same hydration therapy was during bone marrow aspiration (23). used in both groups. After surgery, the anesthetics were A study by Khalili et al., showed that midazolam can discontinued, and the residual effects of the muscle reduce agitation and its mean duration after surgery relaxants were reversed with neostigmine and atropine, significantly better than does ketamine (24). Kaviani et and the patient’s endotracheal tube was preserved until al., conducted a study to examine the sedative effect of his or her full consciousness. the combination of oral midazolam and ketamine The duration of anesthesia (from the injection of combined with inhalational nitrous oxide in controlling anesthetic until discontinuation), the extubation time the movement of children during dentistry operations. (from discontinuing anesthetics until extubation), and Their study did not show a significant statistical the recovery period (from the beginning of recovery difference between the two groups. Consciousness until the patient’s discharge) were recorded on the during the operation was higher in the midazolam group questionnaire. In case of pain during recovery, patients than in the ketamine group; also, the recovery period were injected with meperidine 1mg/kg/IV. The patients was shorter in the former (25). were studied by a co-researcher who was not aware of A review of previous studies on the effectiveness of the kind of anesthesia induction during recovery after midazolam-ketamine combination, compared with anesthesia in terms of symptoms, the degree and thiopental sodium for inducing anesthesia confirms that duration of agitation, the extubation time, and the no study has been performed about their effect on hospitalization length. controlling agitation. However, due to the advantages The agitation degree was examined with the Ramsay and disadvantages of ketamine, midazolam, and scale; then, the data were analyzed with the SPSS thiopental sodium for pediatric anesthesia, the researchers software version 16 and a statistical test with the compared midazolam-ketamine with thiopental sodium confidence level of 95%. After collecting and encoding used intravenously in controlling agitation after the data, they were entered into the computer, analyzed 638 Acta Medica Iranica, Vol. 53, No. 10 (2015) M. Toliyat, et al. with the SPSS software with the following statistical being 6.4 ± 2.64 in the thiopental sodium and 7.1 ± 2.7 in methods. the midazolam-ketamine group. The t-test did not show To describe the characteristics of the research units, a significant difference between the two groups. The descriptive statistics
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