Oral clonidine vs midazolam in the prevention of sevoflurane-induced agitation in children
Sheffield, UK
* E-mail: ianwrench{at}blueyonder.co.uk
Editor—I was interested to read the study1 concerning the use of midazolam or clonidine premedication for children undergoing sevoflurane anaesthesia. This clearly showed that clonidine effectively reduced the incidence of postoperative agitation in comparison with the benzodiazepine group. A key finding of the study was that this beneficial effect was achieved ‘without increasing postoperative side-effects’. On reviewing the paper, it can be seen that there is a higher incidence of hypotension in the two clonidine groups (25%) when compared with the midazolam group (10%). It is also the case that postoperative bradycardia only occurred in the groups receiving clonidine (four out of 40 patients). These differences may not have reached statistical significance, but it is quite possible that this would have been the case in a larger study. I believe that it would have been more appropriate to state that there was an increased incidence of postoperative hypotension and bradycardia for patients receiving clonidine, but that this did not reach statistical significance. Although it is compelling to believe that an intervention may be made without negative effects, sadly this is seldom the case. The evidence presented in the paper does not support the author's assertion.
Brussels, Belgium
* E-mail: philippe.vanderlinden{at}chu-brugmann.be
Editor—We read with interest the comment of Dr Wrench concerning the incidence of side-effects associated with the preoperative use of clonidine to reduce sevoflurane-induced emergence agitation. However, we do not agree with his statement that there was an increased incidence of postoperative hypotension and bradycardia. First, the incidence of postoperative hypotension and bradycardia was not significantly different between the clonidine 4 µg kg–1 and the midazolam groups. Suggesting that this difference might become significant in a more powerful study is speculative, in particular in relation to bradycardia which was 1/20 patients in the clonidine 4 µg kg–1 group and 0/20 patients in the midazolam group. Secondly, only the 4 µg kg–1 dose of clonidine was effective in reducing sevoflurane-induced emergence agitation. In comparison with the 2 µg kg–1 dose, the incidence of postoperative hypotension (5/20 in each group) or bradycardia (3/20 in the 2 µg kg–1 dose and 1/20 in the 4 µg kg–1 dose) was not increased. Thirdly, episodes of hypotension or bradycardia did not require treatment in any of the children. After leaving the recovery room, all the children had an uneventful postoperative course. We therefore believe that in comparison with midazolam, clonidine 4 µg kg–1 reduced sevoflurane emergence agitation without increasing clinically relevant postoperative side-effects.
References
1 Tazeroualti N, De Groote F, De Hert S, et al. Oral clonidine vs midazolam in the prevention of sevoflurane-induced agitation in children. A prospective, randomized, controlled trial. Br J Anaesth (2007) 98:667–71.
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