Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia

Background: Many children are restless, disoriented, and inconsolable immed iately after bilateral myringotomy and tympanosotomy tube placement (BMT). Rapid emergence from sevoflurane anesthesia and postoperative pain may incr ease emergence agitation. The authors first determined serum fentanyl conce ntrations in a two-phase study of intranasal fentanyl, The second phase was a prospective, placebo-controlled, double-blind study to determine the eff icacy of intranasal fentanyl in reducing emergence agitation after sevoflur ane or halothane anesthesia. Methods: In phase 1, 26 children with American Society of Anesthesiologists (ASA) physical status I or II who were scheduled for BMT received intranas al fentanyl, 2 mug/kg, during a standardized anesthetic. Serum fentanyl con centrations in blood samples drawn at emergence and at postanesthesia care unit (PACU) discharge were determined by radioimmunoassay, In phase 2, 265 children with ASA physical status I or II were randomized to receive sevofl urane or halothane anesthesia along with either intranasal fentanyl (2 mug/ kg) or saline. Postoperative agitation, Children's Hospital of Eastern Onta rio Pain Scale (CHEOPS) scores, and satisfaction of PACU nurses and parents with the anesthetic technique were evaluated. Results: In phase 1, the mean fentanyl concentrations at to +/- 4 min (mean +/- SD) and 34 +/- 9 min after administering intranasal fentanyl were 0.80 +/- 0.28 and 0.64 +/- 0.25 ng/ml, respectively. In phase 2, the incidence of severe agitation, highest CHEOPS scores, and heart rate in the PACU were decreased with intranasal fentanyl. There were no differences between sevo flurane and halothane in these measures and in times to hospital discharge. The incidence of postoperative vomiting, hypoxemia, and slow respiratory r ates were not increased with fentanyl. Conclusions Serum fentanyl concentrations after intranasal administration e xceed the minimum effective steady state concentration for analgesia in adu lts. The use of intranasal fentanyl during halothane or sevoflurane anesthe sia for BMT is associated with diminished postoperative agitation without a n increase in vomiting, hypoxemia, or discharge times.