Emergence agitation (EA) occurs in up to 67% of patients undergoing Sevoflurane anesthesia for bilateral myringotomy tube placement (BMT). Often EA presents as inconsolable screaming, crying, thrashing, and kicking, and may require restraints. It can be dangerous for the patient because it may be difficult to monitor their vital signs during a critical phase of recovery (i.e. unable to detect hypoxemia), they may injure themselves as they thrash about, it usually requires the presence of extra staff, and it can be very distressing to the parents. Causes of EA are theoretical, but can be exacerbated by pain. 70% of patients undergoing BMT have pain requiring treatment. Since BMT is performed without IV placement the options for analgesia are limited to intranasal fentanyl, intramuscular ketorolac, rectal or oral acetaminophen, oral opioids (i.e. codeine, oxycodone). Intranasal Fentanyl has been shown to decrease EA, but results in post operative nausea and vomiting, as with any opioids. Intramuscular ketorolac is costly and can lead to hematomas. In previous studies (common practice), acetaminophen is given either 30 minutes before induction (PO route) or immediately after induction (PR route). Since the procedure is generally completed in 5-10 minutes, the therapeutic effect of acetaminophen can not be appreciated. The peak effect (for analgesia) of acetaminophen is 60-120 minutes. Our hypothesis: If acetaminophen is given 60-120 minutes prior to emergence, when it reaches therapeutic effect, it can decrease EA in patients undergoing BMT. The importance of mitigating EA not only involves patient safety and satisfaction, but will also impact hospital/surgery center efficiency (RN staffing and smoother and shorter recovery periods).
This study will be a randomized controlled trial. Potential subjects will be identified and recruited by study personnel and/or patient's surgeon. Children scheduled for BMT placement whose parents' consent to participate will be enrolled in the study. These patients will be consented on the day of surgery. Parents will be informed that whether they enroll their children in the study or not, they will be receiving standard clinical care. Only subjects meeting all inclusion criteria and requirements for continuation in the study will be consented.
Patients will be enrolled into one of three study groups. All patients meeting all inclusion criteria and requirements for the study (see below) will be identified, consented then computer randomized into either control, group 1 or 2.
Control - acetaminophen PR (20-40mg/kg) after induction of Anesthesia (acetaminophen is in suppository form and given rectally) Group 1 - acetaminophen PO (10mg/kg) 60-120min before start of BMT placement (acetaminophen is in syrup form and given by mouth) Group 2 - acetaminophen PO (20mg/kg) 60-120min before start of BMT placement (acetaminophen is in syrup form and given by mouth)
After randomization, treating physicians will be made aware of what treatment group the patient is assigned to. The data collection and behavior/pain assessments will be made by blinded study personnel in the operating room (only for induction) and PACU.
Data Collection: Data will be collected at the time points: Induction, Emergence (spontaneous extremity movement), and every 5 minutes after emergence until the patient is discharged. There will also be a follow-up questionnaire for the parent on satisfaction with the child's emergence, side effects, additional medications, and his/her PACU experience. This will be conducted on the phone within 36 hours after the parents have left the hospital.
