Acupuncture for the Prevention of Emergence Delirium in Children Undergoing Myringotomy Tube Placement
| Status: | Recruiting |
|---|---|
| Conditions: | Neurology, Psychiatric |
| Therapuetic Areas: | Neurology, Psychiatry / Psychology |
| Healthy: | No |
| Age Range: | 1 - 6 |
| Updated: | 4/21/2016 |
| Start Date: | February 2015 |
| End Date: | May 2016 |
| Contact: | Christine S Martin, MD |
| Email: | martich@ohsu.edu |
| Phone: | 5034946736 |
Myringotomy tube placement is one of the most commonly performed operations in children.
Emergence delirium after such procedures is common. During emergence delirium children can
become both a danger to themselves and others around them, including family members and
hospital staff.
The primary objective of this study is to determine if acupuncture, when used in combination
with standard anesthetic management, decreases the incidence of emergence delirium in
pediatric patients following myringotomy tube placement. Patients with and without
premedication of midazolam will be included. A secondary objective of this study is to
determine our institution's actual incidence of emergence delirium for this operation using
a validated scale, the Pediatric Anesthesia Emergence Delirium (PAED) scale. We will also
compare rates of emergence delirium in patients that received a premedication of midazolam
versus (V) those that did not (NV).
This is a randomized double-blinded trial. We will enroll 100 children aged 1-6 years old.
Premedication with midazolam will be decided by the anesthesiologist. If needed, the patient
will receive a standard does of oral midazolam plus acetaminophen (V). If the patient does
not require premedication with midazolam, oral acetaminophen will be given alone (NV).
Patients will then be randomized to receive either acupuncture with standard general
anesthesia care (A) or to receive standard anesthetic care alone (S). Patients, their family
members and recovery registered nurses (RNs) will not know if acupuncture was performed.
Intraoperative anesthetic techniques will be standardized and include inhaled inductions
with nitrous oxide and sevoflurane. Anesthesia maintenance will be inhaled sevoflurane and
the usual pain medication ketorolac will be given intramuscularly prior to emergence.
Acupuncture needles will be placed after anesthesia induction and removed prior to leaving
the operating room. A total of 4 needles will be placed, one in each wrist at the Heart 7
(HT7) point and one in each ear at the Shen Men point. The needles will be inserted
bilaterally to a depth of 1.8 mm.
In the PACU, a blinded study observer will evaluate the patient at four time points using
the PAED scale: time of awakening and 5, 10 & 15 minutes after awakening. Follow up phone
calls will be made one day and one week after surgery. Families will be asked about behavior
after discharge, sleep and bed-wetting.
Emergence delirium after such procedures is common. During emergence delirium children can
become both a danger to themselves and others around them, including family members and
hospital staff.
The primary objective of this study is to determine if acupuncture, when used in combination
with standard anesthetic management, decreases the incidence of emergence delirium in
pediatric patients following myringotomy tube placement. Patients with and without
premedication of midazolam will be included. A secondary objective of this study is to
determine our institution's actual incidence of emergence delirium for this operation using
a validated scale, the Pediatric Anesthesia Emergence Delirium (PAED) scale. We will also
compare rates of emergence delirium in patients that received a premedication of midazolam
versus (V) those that did not (NV).
This is a randomized double-blinded trial. We will enroll 100 children aged 1-6 years old.
Premedication with midazolam will be decided by the anesthesiologist. If needed, the patient
will receive a standard does of oral midazolam plus acetaminophen (V). If the patient does
not require premedication with midazolam, oral acetaminophen will be given alone (NV).
Patients will then be randomized to receive either acupuncture with standard general
anesthesia care (A) or to receive standard anesthetic care alone (S). Patients, their family
members and recovery registered nurses (RNs) will not know if acupuncture was performed.
Intraoperative anesthetic techniques will be standardized and include inhaled inductions
with nitrous oxide and sevoflurane. Anesthesia maintenance will be inhaled sevoflurane and
the usual pain medication ketorolac will be given intramuscularly prior to emergence.
Acupuncture needles will be placed after anesthesia induction and removed prior to leaving
the operating room. A total of 4 needles will be placed, one in each wrist at the Heart 7
(HT7) point and one in each ear at the Shen Men point. The needles will be inserted
bilaterally to a depth of 1.8 mm.
In the PACU, a blinded study observer will evaluate the patient at four time points using
the PAED scale: time of awakening and 5, 10 & 15 minutes after awakening. Follow up phone
calls will be made one day and one week after surgery. Families will be asked about behavior
after discharge, sleep and bed-wetting.
Myringotomy tube placement is one of the most commonly performed operations in children,
with almost 700,000 completed in the United States each year 1. Common anesthetic management
of these cases includes inhalational anesthesia and no intravenous line placement.
Sevoflurane is the inhalational agent used most commonly for induction and maintenance of
these patients. Emergence delirium after sevoflurane maintenance is common. In a study of
children receiving sevoflurane-based anesthetic for MRIs, 47.6% of participants had
emergence agitation 2. In a comparison of different emergence delirium scales, Bajwa and
colleagues detected emergence delirium in 32% of subjects using the Pediatric Anesthesia
Emergence Delirium (PAED) scale 3. Emergence delirium can be distressing for both children
and their caregivers. During emergence delirium children can become both a danger to
themselves and others around them, including family members and hospital staff. Emergence
delirium can also delay discharge from the post-operative care unit (PACU).
There has been some published evidence that intraoperative acupuncture can decrease the
incidence of post-operative delirium. One study enrolled 60 children undergoing bilateral
ear tube placement and randomized half of the patients to receive acupuncture at points LI-4
(he gu) and HT-7 (shen men). The acupuncture group had a lower incidence of emergence
agitation than the control group at time of arrival in the PACU and during the following 30
minutes 4. This study did not include patients that had received pre-medication with
midazolam. It also did not use a validated assessment for emergence delirium in children.
A small retrospective review of 12 children that received acupuncture found that 83% did not
show signs of emergence delirium. These patients had needling at 3 locations (SP 6, HT 7,
Liv 3) and magnets placed at the ear shen men area. The anesthetic technique used for these
patients was not standardized and there was no comparison group.
The primary objective of this study is to determine if acupuncture, when used in combination
with standard anesthetic management, decreases the incidence of emergence delirium in
pediatric patients following myringotomy tube placement. Patients with and without
premedication of midazolam will be included as it is common that children receive sedating
medications to facilitate separation from their caregivers.
A secondary objective of this study is to determine our institution's actual incidence of
emergence delirium after this operation. We can also compare rates of emergence delirium
with or without premedication of midazolam. Emergence delirium will be evaluated using a
validated pediatric delirium scale. The Pediatric Anesthesia Emergence Delirium (PAED) scale
has been tested for reliability and validity in 50 children 5.
Study Design We plan to explore this question with a randomized double blinded trial of
acupuncture in children who are undergoing myringotomy tube placement. Patients will be
randomized to receive either acupuncture immediately after anesthesia induction (A) or to
receive standard anesthetic care only (S). Patients, their family members and recovery
registered nurses (RNs) will not know if acupuncture was performed. The researchers
observing the patients in the PACU will also be blinded to whether or not the subject
received acupuncture. Intraoperative anesthetic techniques will be standardized, including
administering the usual pain medication of ketorolac 0.5mg/kg given intramuscularly to each
patient prior to emergence. Needles will be placed after anesthesia induction and removed
prior to leaving the operating room. A total of 4 needles will be placed, one in each wrist
at the HT7 point and one in each ear at the shen men point. Emergence delirium will be
assessed with the Pediatric Anesthesia Emergence Delirium (PAED) scale. A follow up phone
call will be made on the first post-operative day (POD #1). We will assess continued
emergence delirium after discharge from the PACU, as well as a brief assessment on sleeping
patterns the night after surgery. A second follow-up phone call will be made one week after
surgery. During that call, we will ask about the child's behavior and sleep patterns since
the time of surgery.
We do not know our institution's actual incidence of emergence delirium for this operation.
We will assume it to be 25% as suggested by the literature. We do not know the effects of
pre-medication with midazolam on the incidence of emergence delirium. We will assume a
standard deviation of 4, a value consistent with the current published literature. By
enrolling 100 subjects we can detect a difference of scores of at least 2.5 points. This
enrollment will give us 80% power with an alpha of 0.05. Since the distribution of scores
won't be normal, this enrollment target also includes a 15% increase to allow for a
non-parametric distribution of results. Group (A) and group (S) will each have 50 children.
with almost 700,000 completed in the United States each year 1. Common anesthetic management
of these cases includes inhalational anesthesia and no intravenous line placement.
Sevoflurane is the inhalational agent used most commonly for induction and maintenance of
these patients. Emergence delirium after sevoflurane maintenance is common. In a study of
children receiving sevoflurane-based anesthetic for MRIs, 47.6% of participants had
emergence agitation 2. In a comparison of different emergence delirium scales, Bajwa and
colleagues detected emergence delirium in 32% of subjects using the Pediatric Anesthesia
Emergence Delirium (PAED) scale 3. Emergence delirium can be distressing for both children
and their caregivers. During emergence delirium children can become both a danger to
themselves and others around them, including family members and hospital staff. Emergence
delirium can also delay discharge from the post-operative care unit (PACU).
There has been some published evidence that intraoperative acupuncture can decrease the
incidence of post-operative delirium. One study enrolled 60 children undergoing bilateral
ear tube placement and randomized half of the patients to receive acupuncture at points LI-4
(he gu) and HT-7 (shen men). The acupuncture group had a lower incidence of emergence
agitation than the control group at time of arrival in the PACU and during the following 30
minutes 4. This study did not include patients that had received pre-medication with
midazolam. It also did not use a validated assessment for emergence delirium in children.
A small retrospective review of 12 children that received acupuncture found that 83% did not
show signs of emergence delirium. These patients had needling at 3 locations (SP 6, HT 7,
Liv 3) and magnets placed at the ear shen men area. The anesthetic technique used for these
patients was not standardized and there was no comparison group.
The primary objective of this study is to determine if acupuncture, when used in combination
with standard anesthetic management, decreases the incidence of emergence delirium in
pediatric patients following myringotomy tube placement. Patients with and without
premedication of midazolam will be included as it is common that children receive sedating
medications to facilitate separation from their caregivers.
A secondary objective of this study is to determine our institution's actual incidence of
emergence delirium after this operation. We can also compare rates of emergence delirium
with or without premedication of midazolam. Emergence delirium will be evaluated using a
validated pediatric delirium scale. The Pediatric Anesthesia Emergence Delirium (PAED) scale
has been tested for reliability and validity in 50 children 5.
Study Design We plan to explore this question with a randomized double blinded trial of
acupuncture in children who are undergoing myringotomy tube placement. Patients will be
randomized to receive either acupuncture immediately after anesthesia induction (A) or to
receive standard anesthetic care only (S). Patients, their family members and recovery
registered nurses (RNs) will not know if acupuncture was performed. The researchers
observing the patients in the PACU will also be blinded to whether or not the subject
received acupuncture. Intraoperative anesthetic techniques will be standardized, including
administering the usual pain medication of ketorolac 0.5mg/kg given intramuscularly to each
patient prior to emergence. Needles will be placed after anesthesia induction and removed
prior to leaving the operating room. A total of 4 needles will be placed, one in each wrist
at the HT7 point and one in each ear at the shen men point. Emergence delirium will be
assessed with the Pediatric Anesthesia Emergence Delirium (PAED) scale. A follow up phone
call will be made on the first post-operative day (POD #1). We will assess continued
emergence delirium after discharge from the PACU, as well as a brief assessment on sleeping
patterns the night after surgery. A second follow-up phone call will be made one week after
surgery. During that call, we will ask about the child's behavior and sleep patterns since
the time of surgery.
We do not know our institution's actual incidence of emergence delirium for this operation.
We will assume it to be 25% as suggested by the literature. We do not know the effects of
pre-medication with midazolam on the incidence of emergence delirium. We will assume a
standard deviation of 4, a value consistent with the current published literature. By
enrolling 100 subjects we can detect a difference of scores of at least 2.5 points. This
enrollment will give us 80% power with an alpha of 0.05. Since the distribution of scores
won't be normal, this enrollment target also includes a 15% increase to allow for a
non-parametric distribution of results. Group (A) and group (S) will each have 50 children.
Inclusion Criteria:
- children ages 1 - 6 years old with ASA physical status of 1-3
- scheduled for unilateral or bilateral myringotomy tube placement only.
Exclusion Criteria:
- use of mood altering medications, including anti-epileptic medications.
- genetic abnormalities, including Trisomy 21 (Down syndrome).
- children scheduled for additional surgical procedures to be done in conjunction with
myringotomy tube placement.
- Patients scheduled for an overnight admission post operatively.
We found this trial at
1
site
Click here to add this to my saved trials
