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ORIGINAL ARTICLE
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A Prospective Randomized Study to Compare Sevoflurane and Desflurane for Emergence and Recovery Characteristics in Pediatric Patients


 Department of Anaesthesiology, JLN Medical College and Hospital, Ajmer, Rajasthan, India

Date of Submission01-Jul-2020
Date of Decision28-Dec-2020
Date of Acceptance03-Jun-2021
Date of Web Publication06-Sep-2021

Correspondence Address:
Surendra Kumar Sethi,
Flat No. 202, Shiv Enclave, Civil Lines, Ajmer, Rajasthan
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mamcjms.mamcjms_57_21

  Abstract 


Background: Emergence and recovery have been found to be common problems after general anesthesia, especially in children. Both sevoflurane and desflurane have fast emergence and recovery from anesthesia which results in emergence delirium (ED). This study aims to compare the incidence of ED and rate of recovery in pediatric patients under sevoflurane and desflurane anesthesia. Materials and Methods: Seventy children aged 1 to 10 years belonging to American Society of Anesthesiologists physical status I or II were enrolled and randomly allocated into two groups. Group D (n = 35) received inhalational desflurane, whereas Group S (n = 35) received inhalational sevoflurane at 1.3 minimum alveolar concentration with oxygen and nitrous oxide for maintenance of anesthesia in both the groups. Rate of recovery from anesthesia (emergence time and recovery time) and incidence of ED were assessed in both the groups. Postanesthesia care unit (PACU) discharge time, hemodynamic changes, and side effects were also noted. Results: Emergence and recovery times were significantly shorter in Group D than Group S: (4.50 ± 1.53 minutes versus 6.25 ± 1.64 minutes) and (6.79 ± 1.52 minutes versus 9.12 ± 2.32 minutes), respectively (P < 0.001). No significant difference was observed in the incidence of ED in the two groups (P = 0.782). Mean PACU discharge time was significantly shorter in Group D than Group S (P < 0.001). No significant hemodynamic changes and side effects were noted in both the groups (P > 0.05). Conclusion: The incidence of ED was found to be similar with both sevoflurane and desflurane. Although the rate of recovery was significantly faster with desflurane, it was clinically insignificant. Hence, we inferred that both agents can be used safely in children, but sevoflurane should be preferred owing to its properties and cost-effectiveness particularly in our setup.

Keywords: Desflurane, emergence delirium, emergence time, recovery time, sevoflurane



How to cite this URL:
Jain N, Pareek P, Sethi SK, Patodi V, Mathur V, Meena D. A Prospective Randomized Study to Compare Sevoflurane and Desflurane for Emergence and Recovery Characteristics in Pediatric Patients. MAMC J Med Sci [Epub ahead of print] [cited 2021 Dec 3]. Available from: https://www.mamcjms.in/preprintarticle.asp?id=325600




  Introduction Top


Pediatric surgeries are commonly performed under general anesthesia with or without regional anesthesia (spinal or caudal). The induction and maintenance agents used for pediatric surgeries have a broad spectrum. However, an ideal inhalational anesthetic agent for pediatric age group should be nonirritant, sweet smelling and should have lower emergence delirium (ED) and faster recovery.[1]

Emergence and recovery have been found to be common problems after general anesthesia, especially in the children. Rapid emergence from anesthesia may result in an awake child with a dissociative state described as ED, which is manifested on recovery of consciousness.[2] The child becomes typically irritable, uncooperative, and inconsolable, with crying, moaning, writhing, kicking, and exhibiting generally inappropriate behavior.[3] This phenomenon is self-limiting and usually lasts for 5 to 25 minutes and occurs in 20% to 30% of children receiving general anesthesia.[4]

The two low-solubility inhalational anesthetic agents, that is, sevoflurane and desflurane, have increased the prevalence of ED due to their increasing use in children during anesthesia, which promotes early postanesthetic arousal leading to ED.[5] Both sevoflurane and desflurane are halogenated ethers having rapid induction and recovery due to their specific property of low blood–gas partition coefficient and fat–blood solubility. The faster emergence from anesthesia is expected due to these characteristic features of both sevoflurane and desflurane compared to other traditional inhalational agents.

Sevoflurane is one of the most commonly used inhalational anesthetic agents for pediatric anesthesia because of its nonpungent odor, faster induction, and emergence with insignificant airway irritation and better cardiovascular stability. However, it has also been associated with varying degree of incidence (10–80%) of ED in children which is unrelated to duration of exposure and dose.[6]

Desflurane has been used for maintenance of general anesthesia in adults. However, it has not been widely used in children during both induction and maintenance because of its pungent odor and irritant nature leading to possibility of airway complications and occurrence of ED.[7] Owing to its pharmacologic properties, desflurane provides faster or early to intermediate recovery compared to sevoflurane; however, the various studies have showed conflicting results. In addition, desflurane is a newly available anesthetic agent in India and is yet to be studied in the Indian population for surgeries of longer duration.

Hence, we designed a prospective randomized study to compare the efficacy of these two inhalational agents in terms of emergence and recovery characteristics in pediatric patients.


  Materials and Methods Top


This clinical trial was registered with Clinical Trial Registry of India (CTRI/2019/02/017805). The patients were enrolled for this trial after CTRI registration and study was conducted from March 2019 to September 2019. This has been depicted in a consort flow diagram [Figure 1].
Figure 1 Consort flow diagram

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This hospital-based prospective randomized double-blind comparative study was conducted at our institute after approval from local institutional ethical committee. Seventy pediatric patients aged 1 to 10 years of either sex, with American Society of Anesthesiologists (ASA) physical status I or II, scheduled to undergo various surgeries such as lower abdominal, urogenital, plastic, orthopedic corrective surgeries, etc. [Table 1], under general anesthesia were included and enrolled for this study. The patients whose parents refused to take part in the study, aged <1 year and >10 years, duration of surgery >2 hours, allergic to any drug used in the study with any neuropsychiatric illness, bronchial asthma, and upper respiratory infections were excluded from the study.
Table 1 Demographic profile, duration, and type of surgery in two groups

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The enrolled patients were randomly allocated into two groups;:Group S and Group D with 35 patients in each group using computer-generated tables of random numbers. Group D (n = 35) received desflurane as inhalational agent with oxygen and nitrous oxide for maintenance (at 1.3 minimum alveolar concentration [MAC])[8] of anesthesia and Group S (n = 35) received sevoflurane as inhalational agent with oxygen and nitrous oxide for maintenance (at 1.3 MAC) of anesthesia. The observer in postanesthesia care unit (PACU) was blinded for the inhalational agent used in maintenance of anesthesia to eliminate the observer bias. The primary outcome measure was the rate of recovery (emergence and recovery time), whereas secondary outcome measures were incidence of ED, PACU discharge time, hemodynamic changes, and adverse effects.

A routine preanesthetic examination along with all the routine investigations of the patients was performed. All patients included in the study were kept nil per oral for 6 hours. The patient’s parents were explained about the procedure and informed written consent was taken. All children were given oral midazolam syrup (0.5 mg/kg) 30 minutes prior to surgery to alleviate parent separation anxiety. After arrival of patients in operation theater, all standard ASA monitoring including electrocardiography, noninvasive blood pressure (NIBP), and pulse oximetry (SpO2) were applied. Forty-two patients were received with an intravenous (IV) cannula in situ from the ward. In the remaining 28 patients, a 22 or 24 gauge IV cannula chosen accordingly was secured under proper asepsis and analgesia using local application of Eutectic Mixture of Local Anesthetics cream. An infusion of ringer lactate was started. Baseline pulse rate (PR), NIBP, and arterial oxygen saturation (SpO2) were recorded. IV midazolam 0.03 mg/kg, and IV glycopyrrolate 4 µg/kg were administered as premedication. All patients were preoxygenated for 3 minutes with 100% O2. Induction of anesthesia was performed with IV propofol 2 mg/kg, and airway was secured after adequate muscle relaxation with a loading dose of IV atracurium 0.5 mg/kg using an adequate-sized cuffed endotracheal tube. Patients were ventilated with closed circuit and were maintained either on oxygen, nitrous oxide, and sevoflurane (1–3%) (Group S) or oxygen, nitrous oxide, and desflurane (3–8%) (Group D). The concentration of inhalational agent was maintained around a value of 1.3 MAC (by adjusting the concentration of both inhalational agents) throughout the surgery. The adequate depth of anesthesia was ensured on the basis of observing the clinical parameters (hemodynamic variations and movement in response to surgical stimulus). Analgesia was maintained perioperatively with IV paracetamol 15 mg/kg, whereas adequate muscle relaxation was maintained with IV atracurium 0.1 mg/kg.

All anesthetic agents were discontinued when spontaneous recovery of neuromuscular function was confirmed toward the end of surgery and neuromuscular blockade was reversed with IV glycopyrrolate 0.01 mg/kg and IV neostigmine 0.05 mg/kg. Ventilation was continued at the same fresh gas flow until the return of cough reflex. Each patient’s trachea was extubated ensuring cough and gag reflex, grimace, and purposeful movements. Emergence time (the time from discontinuation of anesthetics to extubation) was noted.[4],[8] Recovery time (the time from discontinuation of anesthetics to achieve the Steward recovery score of 6) was noted.[8],[9] [Table 2]. The three parameters of Steward recovery score, that is, consciousness, airway, and movement were constantly monitored till a score of 6 was achieved, and at the moment when Steward recovery score of 6 was achieved after the discontinuation of inhalational agent, recovery time was noted. Rate of recovery was determined by the emergence and recovery times in both the study groups. Incidence of postoperative nausea and vomiting, if any, was recorded. Patients who complained of nausea or vomiting were treated with IV ondansetron 0.1 mg/kg. After extubation, at 0, 5, 15, 30, 45, and 60 minutes, ED was monitored using the Pediatric Anesthesia Emergence Delirium (PAED)[10] score. Its range is from 0 to 20; score ≥10 shows the presence of ED[11] [Table 3]. PACU discharge time (time from receiving patient in PACU from the operation theater till transferring them from PACU to the ward after achieving modified Aldrete score[12] of ≥9) was noted [Table 4]. Duration of surgery and anesthesia was also noted.
Table 2 Steward simplified postanesthesia recovery score

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Table 3 Pediatric anesthesia emergence delirium score*

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Table 4 Modified Aldrete score*

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Statistical analysis

Based on previous study of Kotwani and Malde,[13] sample size was calculated to be 31 patients randomly included in each group with 80% power and type 1 error of 0.05. To allow for study error and attrition, 35 patients were included in each group. Chi-squared test was used to analyze nominal or categorical variables such as gender expressed as frequency and percentage. Fischer exact test was used if more than 20% of the expected values were below five. Student t test was used to compare continuous variables such as PR, blood pressure, etc., between two groups and expressed as mean and standard deviation. Mann–Whitney U test was used to analyze ordinal variables such as various scores and which were expressed as median with interquartile range. All statistical analyses were carried out using Epi info version 7.2.1.0; CDC Atlanta, GA, USA (2018). P < 0.05 was considered as statistically significant.


  Results Top


There were no statistically significant differences in the demographic data such as mean age, gender, weight, and ASA physical status of the patients with duration of surgery and anesthesia between the two groups; P > 0.05 [Table 1].

Preoperative (baseline), intraoperative, and postoperative PR, systolic blood pressure (SBP), diastolic blood pressure (DBP), and SpO2 were found to be comparable in both the groups (P > 0.05). The mean emergence time in Group D (4.50 ± 1.53 minutes) was significantly shorter than Group S (6.25 ± 1.64 minutes); P < 0.001. Similarly, mean recovery time in Group D (6.79 ± 1.52 minutes) was significantly shorter than Group S (9.12 ± 2.32 minutes), P < 0.001; and PACU discharge time was also significantly shorter in Group D (12.21 ± 1.91 minutes) than Group S (14.90 ± 2.54 minutes), P < 0.001, showing that desflurane had faster emergence and recovery with an early PACU discharge than sevoflurane [Table 5].
Table 5 Comparison of recovery rate and PACU discharge time in the two groups

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The median and interquartile range of PAED score were found comparable between the two groups at all the time intervals (P > 0.05). The overall PAED score of Group S (10[8],[9],[10]) and Group D (10[8],[9],[10]) was also found statistically insignificant using Mann–Whitney U test, P = 0.782. Hence, we found the incidence of ED comparable between sevoflurane and desflurane [Table 6].
Table 6 Comparison of pediatric anesthesia emergence delirium score (median [interquartile range]) in the two groups

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  Discussion Top


Although there are studies comparing sevoflurane and desflurane anesthesia in children, the results are varying and lack uniformity.[4],[14] Most of them have either compared the rate of recovery and emergence or the incidence of ED or both. We have also taken into consideration both these factors in our study. But in our study, the primary outcome measure was to compare the rate of recovery between sevoflurane and desflurane to conclude about the better agent.

Oofuvong et al.[15] had noticed that after adjusting for other risk factors, hazard ratio of intraoperative respiratory adverse events was higher with assisted ventilation through face mask and laryngeal mask airway when compared with endotracheal tube and they concluded that anesthesiologists should be more careful, especially when certain airway devices or desflurane are used. Hence, we have intubated the patients with appropriate-sized endotracheal tube after adequate muscle relaxation to avoid such respiratory complications.[4]

In the present study, anesthesia was maintained with both sevoflurane and desflurane at 1.3 MAC similar to Agrawal et al.,[8] along with oxygen (O2) and nitrous oxide (N2O) in a 50:50 ratio. During maintenance of anesthesia, nitrous oxide reduces the MAC of sevoflurane thereby lowering the concentration of inhalational agent required to maintain anesthesia with faster rate of recovery and reduced incidence of postoperative agitation.[16]

The emergence time was significantly shorter in desflurane group (4.5 ± 1.53 minutes) than sevoflurane (6.25 ± 1.64 minutes), P < 0.001. Hence our results were supported by Kotwani and Malde,[13] who reported that time to awakening and time to removal of supraglottic airway were significantly shorter with desflurane (5.3 ± 1.4 minutes and 5.8 ± 1.3 minutes, respectively) than sevoflurane (9.1 ± 2.4 minutes and 10.0 ± 1.6 minutes, respectively), (P < 0.001). A faster emergence with desflurane showed its rapid washout due to a low blood–gas solubility.

In our study, recovery time was significantly shorter in Group D (6.79 ± 1.52 minutes) than Group S (9.12 ± 2.32 minutes). This was cognate with previous studies by Agrawal et al., who found significantly shorter recovery time in desflurane group (11.7 ± 2.08 minutes) when compared with sevoflurane group (20 ± 3.06 minutes). Similarly, Kotwani and Malde,[13] also found significantly shorter recovery time in desflurane group than sevoflurane group (18 ± 8.4 minutes versus 45.3 ± 9.7 minutes). A faster recovery in desflurane is corroborated by the fact that it has lower blood gas partition coefficient than sevoflurane. As interpreted by both emergence time and recovery time, rate of recovery was found to be faster in Group D than Group S owing to the lower blood gas partition coefficient of desflurane. However, both emergence and recovery times were found to be clinically insignificant between the two groups.

Agrawal et al. have not used nitrous oxide in their study along with inhalational agent and oxygen. Nitrous oxide reduces the concentration of any inhalational agent required to achieve a required MAC and hence hastens the recovery by early removal of inhalational agent from the body. We have used a mixture of inhalational agent with nitrous oxide and oxygen, which seems to have reduced our emergence and recovery time. Although Kotwani and Malde have used N2O in their study to maintain adequate depth of anesthesia, they have used both higher dose of propofol during induction and additional doses during maintenance of anesthesia, which might have caused longer emergence and recovery times when compared with our study.

We compared ED between sevoflurane and desflurane using PAED scale similar to Driscoll et al.[17] Following the work of Sikich and Lerman,[11] a PAED scale of ≥10 was used as a cutoff value to define the presence or absence of ED. We found no significant difference in PAED scores between Group S and Group D (10[8],[9],[10] versus 10[8],[9],[10]; P = 0.782). Our results were supported by Driscoll et al. in which PAED scores between sevoflurane and desflurane were 12[0],[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18] and 12[0],[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20], respectively, which showed that the incidence of ED was similar in both sevoflurane and desflurane.

We compared modified Aldrete score ≥9 as the criteria for PACU discharge time, similar to the study by Mayer et al.[18] and found desflurane offering a faster discharge from PACU when compared with sevoflurane (12.21 ± 1.91 minutes versus 14.90 ± 2.54 minutes; P < 0.001). Driscoll et al.,[17] also concluded that time to discharge from PACU initially demonstrated significant advantage for desflurane (31.0 ± 10.8 minutes versus 39.3 ± 14.9 minutes; P < 0.05) using the standardized postanesthesia recovery score and a self-maintained airway. Although the discharge times were significantly earlier in the desflurane group but the delayed discharge times noted in comparison with our study might be due to higher MAC (2.0 MAC) of inhalational agents used in the study carried out by Driscoll et al. A faster PACU discharge with desflurane when compared with sevoflurane is justified by the lower blood–gas solubility of desflurane. This property is of greater advantage in cases of day-care surgeries.

In our study, we found all hemodynamic parameters (intraoperative and postoperative), including PR, SBP, DBP, and SpO2 comparable in both the groups (P > 0.005). Similarly, Locatelli et al.[19] and Gupta et al.[20] also found no significant hemodynamic changes in their studies. We found no major respiratory and hemodynamic adverse effects in both the study groups similar to the observations of Kotwani and Malde.

There have been certain limitations to our study. We sensed that sample size was not sufficient enough to assess a subjective variable such as ED. An increase in sample size would have increased the precision of our results. Few studies, such as Kotwani and Malde, Driscoll et al., took into account the pain factor by using face, legs, activity, cry, consolability score[13],[18] to differentiate agitation due to pain from ED. Although we made sure to keep our patients pain free by providing adequate analgesia, still, “pain” being a confounding factor should have been taken into consideration. The type of surgery and degree of postoperative pain might also affect our results. The depth of anesthesia was monitored clinically only. The anesthesiologist, who had administered the inhalational agent, was not blinded particularly during emergence phase might lead to observer bias.


  Conclusion Top


We concluded that although desflurane has a statistically faster rate of recovery when compared with sevoflurane, the difference was clinically insignificant. In addition, the incidence of ED is similar with both the inhalational agents. Hence, either of these can be used safely in pediatric patients. However, in cases of day-care surgeries, desflurane may provide an early discharge, but its pungency, higher cost, and limited availability in India are a hindrance to its use in pediatric population. Sevoflurane, therefore, being pleasant smelling, less costly, easily available, and having a similar incidence of ED to that of desflurane should be preferred for pediatric surgeries particularly in our setup.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Dahmani S, Brasher C, Stany I et al. Premedication with clonidine is superior to benzodiazepines. A meta-analysis of published studies. Acta Anaesthesiol Scand 2010;54:397-402.  Back to cited text no. 1
    
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Wong DD, Bailey CR. Emergence delirium in children. Anesthesia 2015;70:383-7.  Back to cited text no. 3
    
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Welborn LG, Hannallah RS, Norden JM, Ruttimann UE, Callan CM. Comparison of emergence and recovery characteristics of sevoflurane, desflurane, and halothane in pediatric ambulatory patients. Anesth Analg 1996;83:917-20.  Back to cited text no. 4
    
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Moore AD, Anghelescu DL. Emergence delirium in pediatric anesthesia. Paediatr Drugs 2017;19:11-20.  Back to cited text no. 5
    
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Behne M, Wilke HJ, Harder S. Clinical pharmacokinetics of sevoflurane. Clin Pharmacokinet 1999;36:13-26.  Back to cited text no. 6
    
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Patel SS, Goa KL. Desflurane. Drugs 1995;50:742-67.  Back to cited text no. 7
    
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Agrawal R, Desai P, Sarkar M. Comparison of emergence and recovery characteristics of sevoflurane and desflurane in pediatric patients undergoing ambulatory surgery. Indian J Clin Anaesth 2014;1:23-9.  Back to cited text no. 8
    
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Steward DJ. A simplified scoring system for the post-operative recovery room. Can Anaesth Soc J 1975;22:111-3.  Back to cited text no. 9
    
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Eckenhoff JE, Kneale DH, Dripps RD. The incidence and etiology of postanesthetic excitement. A clinical survey. Anesthesiology 1961;22:667-73.  Back to cited text no. 10
    
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Sikich N, Lerman J. Development and psychometric evaluation of the post anesthesia emergence delirium scale. Anesthesiology 2004;100:1138-45.  Back to cited text no. 11
    
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Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth 1995;7:89-91.  Back to cited text no. 12
    
13.
Kotwani MB, Malde AD. Comparison of maintenance, emergence and recovery characteristics of sevoflurane and desflurane in pediatric ambulatory surgery. J Anaesth Clin Pharmacol 2017;33:503-8.  Back to cited text no. 13
    
14.
Cohen IT, Finkel JC, Hannallah RS, Hummer KA, Patel KM. The effect of fentanyl on the emergence characteristics after desflurane or sevoflurane anesthesia in children. Anesth Analg 2002;94:1178-81.  Back to cited text no. 14
    
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Oofuvong M, Siripruekpong S, Naklongdee J, Hnookong R, Lakateb C. Comparison the incidence of emergence agitation between sevoflurane and desflurane after pediatric ambulatory urologic surgery. J Med Assoc Thai 2013;96:1470-5.  Back to cited text no. 15
    
16.
Shibata S, Shigeomi S, Sato W, Enzan K. Nitrous oxide administration during washout of sevoflurane improves postanesthetic agitation in children. J Anesth 2005;19:160-3.  Back to cited text no. 16
    
17.
Driscoll JN, Bender BM, Archilla CA, Klim CM, Hossain MJ, Mychaskiw G. Comparing incidence of emergence delirium between sevoflurane and desflurane in children following routine otolaryngology procedures. Minerva Anestesiol 2017;83:383-91.  Back to cited text no. 17
    
18.
Mayer J, Boldt J, Röhm KD, Scheuermann K, Suttner SW. Desflurane anesthesia after sevoflurane inhaled induction reduces severity of emergence agitation in children undergoing minor ear‑nose‑throat surgery compared with sevoflurane induction and maintenance. Anesth Analg 2006;102:400‑4.  Back to cited text no. 18
    
19.
Locatelli BG, Ingelmo PM, Emre S et al. Emergence delirium in children: a comparison of sevoflurane and desflurane anesthesia using the Pediatric Anesthesia Emergence Delirium scale. Paediatr Anaesth 2013;23:301-8.  Back to cited text no. 19
    
20.
Gupta P, Rath GP, Prabhakar H, Bithal PK. Comparison between sevoflurane and desflurane on emergence and recovery characteristics of children undergoing surgery for spinal dysraphism.Indian J Anaesth 2015;59:482-7.  Back to cited text no. 20
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