European Journal of Cardiovascular Medicine

Postoperative delirium (POD) is a transient neurocognitive disturbance that often occurs in pediatric patients following general anesthesia. It is characterized by confusion, agitation, inconsolable crying, and disorientation, typically within the first hour of recovery (1). Although usually self-limiting, POD can lead to self-injury, delayed discharge, parental anxiety, and increased use of sedatives or analgesics (2,3).

Among the various factors influencing the development of POD, the method of anesthetic emergence has gained attention in recent years. Awake extubation, although commonly practiced, is often associated with airway irritation, coughing, and emergence agitation in children (4). Conversely, deep extubation, performed while the patient is still under adequate anesthesia depth, has been suggested to offer smoother emergence and potentially reduce the incidence of POD (5,6). However, concerns regarding airway obstruction and aspiration during deep extubation continue to limit its widespread use (7).

ENT surgeries in pediatric patients often require general anesthesia due to their invasive nature and the need for absolute immobility. These procedures are particularly associated with a higher risk of emergence delirium due to short duration, rapid recovery, and stimulation of sensitive airway structures (8). Despite this, limited studies have focused on the correlation between extubation techniques and POD in this population.

This study aims to compare the effects of awake versus deep extubation on the incidence of postoperative delirium in pediatric patients undergoing elective ENT surgeries. Understanding these differences can help refine anesthetic practices to enhance postoperative outcomes in children.

This prospective, randomized study was conducted in the Department of Anesthesiology at a tertiary care hospital after obtaining written informed consent from parents or legal guardians.

Study Population
A total of 60 pediatric patients, aged between 3 and 10 years, scheduled for elective ENT surgeries under general anesthesia, were enrolled. Inclusion criteria included American Society of Anesthesiologists (ASA) physical status I or II and no history of developmental delay or neurological disorders. Children with recent upper respiratory tract infections or airway abnormalities were excluded.

Study Design
Participants were randomly divided into two equal groups (n=30 each) using a computer-generated randomization list:

• Group A: Underwent awake extubation
• Group B: Underwent deep extubation

Anesthetic Protocol
All patients were kept nil per oral as per ASA guidelines and received standard premedication with oral midazolam (0.5 mg/kg) 30 minutes before surgery. Anesthesia was induced using sevoflurane in oxygen, followed by intravenous administration of propofol (2 mg/kg) and fentanyl (1 µg/kg). Muscle relaxation was achieved with atracurium (0.5 mg/kg), and patients were intubated with an appropriately sized endotracheal tube.

Anesthesia was maintained with a mixture of oxygen, air, and sevoflurane (1–2%). All patients received intravenous paracetamol for analgesia and ondansetron for antiemesis intraoperatively.

Emergence Technique
In Group A, extubation was performed once the child was fully awake, responsive to verbal commands, and exhibited adequate spontaneous ventilation.

In Group B, extubation was carried out while the child was still under a deep plane of anesthesia, maintaining spontaneous breathing without protective airway reflexes.

Assessment of Delirium
Postoperative delirium was evaluated using the Pediatric Anesthesia Emergence Delirium (PAED) scale at 10, 30, and 60 minutes following extubation in the recovery room. A PAED score ≥10 was considered indicative of emergence delirium.

Monitoring and Data Collection
Vital signs including heart rate, oxygen saturation, and respiratory rate were continuously monitored. Any adverse events such as laryngospasm, desaturation, or need for airway support were documented.

Statistical Analysis
Data were analyzed using SPSS software version 26. Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables were presented as percentages. Chi-square test was used for comparing categorical variables, and the Student’s t-test was applied for continuous data. A p-value <0.05 was considered statistically significant.

A total of 60 pediatric patients were included, with 30 in each group. The demographic characteristics, including age, gender, weight, and duration of surgery, were comparable between the two groups and showed no statistically significant difference (p>0.05) (Table 1).

Postoperative delirium, as assessed by the PAED scale, was significantly more frequent and severe in the awake extubation group (Group A) compared to the deep extubation group (Group B) at all observed time intervals (Table 2). At 10 minutes post-extubation, 18 children (60%) in Group A had PAED scores ≥10, whereas only 9 children (30%) in Group B showed similar scores. By 30 minutes, the incidence reduced to 12 (40%) in Group A and 5 (16.6%) in Group B. At 60 minutes, the symptoms had largely resolved, with only 3 (10%) in Group A and 1 (3.3%) in Group B showing signs of delirium.

The mean PAED scores also followed a similar trend, being consistently higher in Group A compared to Group B across all time points. The differences were statistically significant at 10 and 30 minutes (p<0.05), as shown in Table 3.

No major adverse events such as laryngospasm, desaturation, or need for reintubation were observed in either group. Minor complications such as coughing during extubation were more frequently noted in Group A (Table 4).

Table 1. Demographic and Clinical Characteristics of Patients

Table 2. Incidence of Postoperative Delirium (PAED Score ≥10)

Table 3. Mean PAED Scores at Different Time Intervals

Table 4. Intraoperative and Emergence-Related Complications

Postoperative delirium (POD) remains a frequently encountered complication in pediatric anesthesia, particularly following short and stimulating procedures such as ENT surgeries. In our study, deep extubation significantly reduced the incidence and severity of POD compared to awake extubation, especially during the early recovery period. These findings align with earlier research suggesting that smooth emergence techniques can minimize agitation and delirium in children (1,2).

The mechanism behind emergence delirium is multifactorial, involving rapid emergence from volatile anesthetics, pain, anxiety, and environmental stimuli (3,4). Sevoflurane, although commonly used for its favorable pharmacokinetics, has been associated with a higher incidence of POD (5,6). In our study, despite both groups receiving sevoflurane, those who underwent deep extubation demonstrated lower PAED scores, indicating that the technique of emergence plays a crucial role irrespective of the anesthetic agent used.

Awake extubation often leads to airway stimulation, coughing, and distress, which may trigger agitation during the transition from anesthesia to consciousness (7). In contrast, deep extubation helps maintain a more stable hemodynamic and psychological transition, contributing to a smoother recovery (8,9). Our results support this view, with significantly fewer children in the deep extubation group showing signs of delirium at 10 and 30 minutes postoperatively.

Previous studies have noted that preoperative anxiety and young age are strong predictors of POD (10,11). While age distribution was similar between our groups, the uniform administration of midazolam likely reduced baseline anxiety levels across both groups. Despite this, the variation in delirium incidence highlights that anesthetic emergence technique remains an independent factor influencing recovery quality.

The safety of deep extubation is often debated due to potential risks such as airway obstruction and hypoxia (12). However, in our study, no major adverse events were recorded in either group. Minor complications such as coughing were more prevalent in the awake extubation group, which is consistent with earlier observations (13).

Our findings are supported by a growing body of evidence recommending tailored anesthetic strategies to reduce POD (14,15). Implementation of deep extubation, when performed by experienced clinicians and with proper patient selection, may serve as an effective approach to improving postoperative outcomes in pediatric ENT cases.

Limitations

Of this study include a modest sample size and limited follow-up period. Longer observation may be needed to assess delayed neurocognitive effects, and multicentre trials could help validate these findings further.

Deep extubation significantly reduces the incidence and severity of emergence agitation in pediatric patients undergoing ENT surgeries compared to awake extubation. Incorporating this technique into anesthetic practice, with appropriate patient selection and monitoring, can enhance postoperative recovery and patient comfort.

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