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The effect of small dose sufentanil on emergence agitation in preschool children undergoing sevoflurane anesthesia for repair of inguinal hernia Xiuze Li;Yonghong Zhang;Meijun Zhou;Qing Xia;Wei Li;Qing Lu. Objective: Emergence agitation is one of the most common complication in children with sevoflurane anaesthesia.In this study,we investigates sufentanil on emergence agitation in paediatric patients undergoing sevoflurane anesthesia,and compare it with fentanyl. Methods:80 children admitted at the Pediatric surgery of Mianyang Central Hospital between March 2011 and April 2012 were selected into this study. The patients were allocated randomly into one of the two groups receiving sufentanil(GrouS,n = 40) or fentanyl(Group F,n = 40).Emergence agitation scale was measured.Number of patients who required additional fentanyl during surgery and postoperative rescue fentanyl at the PACU were recorded. Recovery time as well as adverse events were also assessed. Results:Two groups were comparable with regard to demographic data.The mean emergence agitation scores were significantly lower in the sufentanil group compared with the fentanyl group(P = 0.001).The frequency of severe emergence agitation was 27.5% in group sufentanil 1 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] and 50% in group fentanyl respectively(P = 0.039).Significantly fewer children in the sufentanil group received additional fentanyl during surgery compared to the fentanyl group(P = 0.043)and significantly fewer children in the sufentanil group received 1 dose of postoperative rescue fentanyl at the PACU compared to the fentanyl group(P = 0.015).The incidence of vomiting was significantly higher in the fentanyl group than in the sufentanil group (p = 0.023). Conslusion In children with sevoflurane anaesthesia,compared with fentanyl,sufentanil decrease significantly the incidence of emergence agitation without delaying the recovery time. Keywords: emergence agitation,sufentanil,fentanyl,sevoflurane,children Introduction On the current application of the anesthetics,sevoflurane come closest to the ideal inhaled anesthetic(1),sevoflurane has become one of the most widely used inhalational agents in paediatric patients,but postoperative emergence agitation(EA)is a very frequent problem in children recovering from sevoflurane anesthesia.So far,the exact etiology of EA is not clear,but it is often observed in preschool children,and postoperative pain has been regarded as an important precipitating factor(2,3). 2 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] It was found that a protective effect of fentanyl on EA(4-6),but there is rarely reported literature about the effect of sufentanil on EA,sufentanil is a potent opioid receptor agonist,and is even stronger than fentanyl.we assumed that sevoflurane anesthesia assisting with sufentanil reduces the occurrence of EA while not delaying patient awakening and recovery after undergoing inguinal hernia repair in children. The purpose of this prospective,randomized,doubled-blined study was to evaluate the effect of intraoperative i.v. administration a small dose of sufentanil on EA in preschool patients undergoing sevoflurane anesthesia for elective unilateral inguinal hernia repair,and compare it with fentanyl. Approval for this study was obtained from the ethics committee of our hospital(Mianyang Central Hospital,Sichuan,China),informed and written consent was obtained from parents/guardians. Materials and methods From March 2011 to April 2012,there were a total of 80 preschool children (2-6 years old,classified as American Society of Anesthesiologists [ASA] physical status I-Ⅱ) undergoing elective repair of unilateral inguinal hernia during sevoflurane general 3 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] anaesthesia were enrolled in the study in Mianyang Central Hospital.Patients were excluded if with known allergy to any of the medications used,serious cardiovascular system disease,liver or kidney dysfunction,neurologic disease,a history of long-term therapeutic administration of analgesics,peptic ulceration,bleeding disorders,body weight less than 10 kg or greater than 30 kg were also excluded. All children fasted for 6h,forbidden to drink 4h preoperatively.before surgery,cream was was used to the back of the hand to alleviate the pain of the insertion of an i.v.cannula.Each child received an intraverous midazolam 0.1 mg/kg 5 minutes before entering into the operating room.The monitoring system include pulse oximetry,noninvasive arterial pressure and electrocardiography.Subjects were randomly allocated to one of two groups using a computer-generated random number assignment,sufentanil group(S,n = 40)and fentanyl group(F,n = 40). Anaesthesia was induced with 8 vol% sevoflurane in 100% oxygen via face mask without neuromuscular blocking agents.After achieving adequate depth of anesthesia,as evidenced by the tolerance of laryngoscopy,a laryngeal mask airway(LMA) was inserted under direct laryngoscopy for airway maintenance,pressure-controlled ventilation was adapted to maintain 4 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] end-tidal CO2 levels between 35 and 45 mmHg.Intraverous ketorolac 0.5 mg/kg was administered to each child immediately after induction of anesthesia for the control of postoperative pain.Just before skin incision the patients received sufentanil 0.15 ug/kg in group S and fentanyl 1.5 ug/kg in group F intravenously,anaesthesia was maintained with 3-5 vol% sevoflurane in oxygen without N2O.The sevoflurane concentration during surgery was controlled according to the haemodynamics of each children maintaining systolic arterial pressure,heart rate,or both changes within 30% of baseline,fentanyl 1 ug/kg was given to children in both groups for an increase in heart rate or systolic blood pressure 30% above preincision values that continued for 5 minutes.At the end of surgery the anesthetic was discontinued and the children were ventilated with 100% O2.When the patients were in a state of deep level of anesthesia,but recovering adequate spontaneous ventilation(VT›8 ml/kg,respiratory rate›16 breaths /min),the LMA was removed and the oropharynx was gently suctioned under direct laryngoscopy,the children were transferred to post-anaesthetic care unit(PACU). Postoperative agitation scores were evaluated by the same PACU nurse who was unaware of the group into which the child was divided until 5 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] all children were quiet.The paediatric anaesthesia emergence delirium (PAED)scale(table 1) was used to evaluate EA(7),and the highest scores were recorded.A four-point scale was also used to investigate the incidence of EA:agitation score was graded 1 if the child was calm;2 if the child was not calm but could be easily consoled;3 if the child was moderately agitated or restless and not easily calmed;and 4 if the child was combative,excited,or disoriented(8).Scores 1 and 2 were regarded as non-behavioral change,and scores 3 and 4 to indicate EA and the children received an intravenous rescue fentanyl 1 ug/kg.Number of patients who received additional fentanyl during surgery and postoperative rescue fentanyl at the PACU were recorded.The duration of surgery,time of anesthesia (from the start of induction till removal of LMA),emergence time(time to the first response to a verbal command following discontinuation of sevoflurane)and total time in the PACU were recorded.Heart rate and blood pressure ,as well as the incidence of adverse events such as vomiting,laryngospasm,oxygen desaturation (peripheral oxygen saturation on pulse oximetry less than 95%) and pruritus during PACU were also noted.Children were discharged from the PACU to general ward when hemodynamic stability,full awake and no pain or vomiting. 6 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] Assuming an incidence of postoperative agitation of 50% or more supplementing sevoflurane with fentanyl was previously reported(2), and a 50% reduction in EA was considered to be clinically significant,we calculated that 40 patients were required in each group (for a level of significance of 0.05 and a power of 0.80).Quantitative variables were described as mean and SD,qualitative variables were described as number and percentage,chi-square test was used to compare qualitative variables between groups,fisher exact test was used instead of chi-square when one expected cell or more less than or equal to 5.Independent-Samples t-test was used to compare two groups as regards to quantitative variables.A P-value less than 0.05 was considered to be statistically significant. Results A total of 80 children were enrolled in this study(n = 40 in the sufentanil group and n = 40 in the fentanyl group).There were no significant differences between the two groups with respect to age,weight,gender,ASA physical status,duration of surgery or duration of anesthesia.(table 2). The mean scores of the PAED scale and the incidence of emergence agitation were significantly lower in the sufentanil group as compared 7 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] with those in the fentanyl group(P = 0.001 and P = 0.039 respectively),There were no significant differences between the two groups in terms of emergence time and during stay in PACU(table 3). Number of children who received additional fentanyl during surgery were significantly lower in sufentanil group compared to fentanyl group(p = 0.043) and significantly fewer patients in the sufentanil group received 1 dose of postoperative rescue fentanyl at the PACU compared to the fentanyl group(p = 0.015) as shown in Table 4. A comparison of postoperative adverse events between the two groups is presented in table 5.The incidence of vomiting was significantly higher in the fentanyl group than in the sufentanil group (p = 0.023).There were no differences between the two groups in terms of the incidence of laryngospasm,oxygen desaturation or pruritus. Discussion All children completed the present experiment,and all the patients get good ventilation,its possible reason is that we place LMA into the correct position under direct laryngoscopy. In recent years,sevoflurane has been widely used in children for general anesthesia induction and maintenance because of its low bloodgas solubility and blood-tissue solubility,but EA is a common and 8 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] difficult to deal with problems faced by the pediatric anesthesiologists,with a incidence up to 80%(9),and it is potentially dangerous to the child,such as falling out of bed,the removal of the surgical dressings,intravenous catheters and so on.Additional care may need when children are excited.Their parents are often worried when seeing their children restlessness.The otorhinolaryngologic surgeries,post-operative pain,young age,pre-operative anxiety,and adjustment disorder of patients are risk factors for EA(10). The present study demonstrated that administration of IV a single dose of 0.15 ug/kg sufentanil compared with 1.5 ug/kg fentanyl just before skin incision significantly reduced postoperative agitation after sevoflurane anesthesia in preschool children undergoing elective repair of unilateral inguinal hernia,We also found that significantly fewer children in the sufentanil group received additional fentanyl during surgery and significantly fewer children in the sufentanil group received 1 dose of postoperative rescue fentanyl at the PACU compared to the fentanyl group,thus may reduce the injure to children caused by EA and decrease the adverse effects brought by supplemental fentanyl. Many studies have shown that EA in pediatric anesthesia is related 9 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] to preoperative anxiety of the children(11-13),in order to relieve the emotional stress in children before surgery,premedication with an intraverous midazolam 0.1 mg/kg was given before separating from their parents in this study,rather than oral midazolam in the majority of studies,because the former is rapid onset of action.Type of surgery is also a predisposing factor of EA(14),all children receiving the same type surgery and all surgery was performed by the same surgeon in the present study so as to get rid of the effect of surgery on EA.Airway irritation reactions caused by tracheal intubation may lead to emergence behavior change,including EA(15).The present study used LMA for control ventilation and pull out it while in a deeply anaesthetized state to avoid the effect of airway irritation on EA. Study has suggested that rapid recovery of sevoflurane from general anesthesia may trigger EA(9),However,compared with continuing sevoflurane for maintenance,recovery from maintenance of anesthesia with propofol after sevoflurane induction,which is also rapid,is smoother than recovery from sevoflurane(16).Therefore, Sevofluranerelated emergence agitation is maybe an intrinsic characteristic of the anaesthetic itself,having different central nervous functions compared with other inhaled anaesthetics. 10 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] Many drugs can reduce the occurrence of postoperative agitation,propofol,pain prevention,ketamine,and a2-AR agonists are effective against EA(4). Postoperative pain is one of the most important factors leading to EA,there were many studies that had confirmed a decrease of EA with the use of fentanyl(4,6,17,18).The frequency of severe agitation of the present study is inconsistent with the results of another study investigating the prophylactic effects of fentanyl on EA(2),however LMA was used for airway maintenance and removed it while in a deeply anaesthetized state in this study,but tracheal intubation was performed in that study.Also, intraverous ketorolac was administered to child for the control of postoperative pain in the present study,but there was no analgesic for the control of postoperative pain. Just as fentanyl,sufentanil is also a pure µ agonist,but it is approximately ten times as potent as fentanyl in human(19)and produce less and shorter-lasting respiratory depression than fentanyl(20),so we studied the effect of 0.15 ug/kg sufentanil on EA and compared it with 1.5 ug/kg fentanyl.The mean PAED scores and the incidence of severe agitation were significantly lower in the sufentanil group 11 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] compared with the fentanyl group,this is probably because it can produce longer lasting analgesia(19) and is more lipophilic than fentanyl(21),will allow the drug to penetrate the blood-brain barrier rapidly,resulting in sufficient sedation effect with low-dose(22).We speculate that the likely reason of significantly fewer children in the sufentanil group received additional fentanyl during surgery is that the duration of the analgesic effect of sufentanil is longer than that of fentanyl.Opioids can lead to postoperative nausea and vomiting, the incidence of vomiting was significantly higher in the fentanyl group than that in the sufentanil group,this is probably due to a reduction in children exposure to postoperative rescue fentanyl. EA may also occur in the case of adequate treatment of pain or even no pain (23,24).In addition,according to a meta-analysis,there are no correlation of the efficacy of ketamine,a2-agonists,or fentanyl in postoperative pain relief and EA decreasing(4).These results suggest that the analgesic properties are not alone involved in their prevention of EA,other properties such as sedation effect may play a role against EA,because sufentanil is more lipophilic than fentanyl,will allow the drug to penetrate the blood-brain barrier rapidly,resulting in sufficient sedation effect,and the incidence of 12 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] agitation were significantly lower in the sufentanil group compared with the fentanyl group.The protective effect of fentanyl on EA may be through the hypocretin system,because opioids can directly or indirectly inhibit the hypocretin system(25). As we worry about additional sufentanil may resulted in delayed recovery,additional fentanyl was given to children during surgery or at the PACU,instead of giving sufentanil. In the present study we did not compare the pain score between the two groups because we focused on the effects of sufentanil on EA in preschool patients undergoing sevoflurane anesthesia.Another limitation of our study is the absence of a placebo-controlled group because of the rejection by our Hospital Ethics Committee.Futher studies are needed to find the optimal dose of sufentanil for prevention of EA in inguinal hernia repair pediatric sevoflurane anesthesia and the extent to which reducing postoperative agitation when additional sufentanil rather than fentanyl was given to children or sufentanil was given to children at the end of surgery,instead of skin incision. Conclusion In summary,this study demonstrateds that the intravenous 13 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] administration of a single dose of 0.15 ug/kg sufentanil just before skin incision decrease significantly the incidence of EA and does not lengthen discharge time from the PACU in children undergoing inguinal hernia repair under sevoflurane anesthesia compared with a single dose of 1.5 ug/kg fentanyl. References 1. Delgado-Herrera L,Ostroff RD,Rogers SA.Sevoflurance:approaching the ideal inhalational anesthetic.a pharmacologic,pharmacoeconomic,and clinical review.CNS Drug Rev 2001;7(1):48-120 2. Aouad MT,Kanazi GE,Siddik-Sayyid SM et al.Preoperative caudal block prevents emergence agitation in children following sevoflurane anesthesia.Acta Anaesthesiol Scand 2005;49:300-4. 3. Davis PG,Greenberg A,Gendelman M et al.Recovery characteristics of sevoflurane and halothane in preschool-aged children undergoing bilateral myringotomy and pressure equalization tube insertion.Anesth Analg 1999;88:34—8. 4. Dahmani1 S,Stany1 C,Brasher1 C et al.Pharmacological prevention of sevoflurane-and desflurane-related emergence agitation in children:a meta-analysis of published studies. 14 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] Br J Anaesth 2010;104:216-23. 5. Inomata S,Maeda T,Shimizu T et al.Effects of fentanyl infusion on tracheal intubation and emergence agitation in preschool children anaesthetized with sevoflurane.Br J Anesth 2010;105:361-7. 6. Erdil F,Demirbilek S,Begec Z et al.The effects of dexmedetomidine and fentanyl on emergence characteristics after adenoidectomy in children.Anaesth intensive care 2009;37:571-6. 7. Sikich N,Lerman J.Development and psychometric evaluation of the paediatric emergence delirium scale.Anesthesiology 2004;100:1138– 45. 8. Welborn LG,Hannallah RS,Norden JM et al.Comparison of emergence and recovery characteristics of sevoflurane,desflurane,and halothane in pediatric ambulatory patients.Anesth Analg 1996;83: 917-20. 9. Kuratani N, Oi Y. Greater incidence of emergence agitation in children after sevoflurane anesthesia as compared with halothane.A meta-analysis of randomized controlled trials. Anesthesiology 2008;109:225–32. 10. Veyckemans F.Excitation phenomena during sevoflurane anaesthesia in children.Curr Opin Anaesthesiol 2001;14:339-343. 11. Kim YH,Yoon SZ,Lim HJ,et al.Prophylactic use of midazolam or 15 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] propofol at the end of surgery may reduce the incidence of emergence agitation after sevoflurane anaesthesia.Anaesth Intensive Care 2011;39:904-8. 12. Aono J,Mamiya K,Manabe M.Preoperative anxiety is associated with a high incidence of problematic behavior on emergence after halothane anesthesia in boys.Acta Anaesthesiol Scand 1999;43:542-4. 13. Arai YC,Ueda W,Ito H et al.Maternal heart rate variability just before surgery significantly correlated with emergence behavior of children undergoing general anesthesia. Paediatr Anaesth 2008 ;18:167-71. 14. Voepel-Lewis T,Malviya S,Tait AR.A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit.Anesth Analg 2003;96:1625–1630. 15 .Lee YC,Kim JM,Ko HB et al.Use of laryngeal mask airway and its removal in a deeply anaesthetized state reduces emergence agitation after sevoflurane anaesthesia in children.J Int Med Res 2011;39:2385-92. 16. Cohen IT;Finkel JC;Hannallah RS et al.Rapid emergence does not explain agitation following sevoflurane anaesthesia in infants and children:a comparision with propofol.Paediatr Anaesth 2003;13:63-7. 16 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] 17. Cohen IT,Hannallah RS,Hummer KA.The incidence of emergence agitation associated with desflurane anesthesia in children is reduced by fentanyl.Anesth Analg 2001;93:88-91. 18. Hung WT, Chen CC, Liou CM et al.The effects of low-dose fentanyl on emergence agitation and quality of life in patients with moderate developmental disabilities.J Clin Anesth 2005;17: 494-8. 19. Rolly G,Kay B,Cockx F.A double-blined comparison of high doses of fentanyl and sufentanil in man.Acta Anaesthesiol Belg 1979;30:24756. 20. Peter L,Bailey MD,James B.Differences in Magnitude and Duration of Opioid-Induced Respiratory Depression and Analgesia with Fentanyl and Sufentanil.Anesth Analg 1990;70:8-15. 21. Bovill JG,SebeI PS,Blackburn CL et al.The pharmacokinetics of sufentanil in surgical patients. Anesthesiology 1984;61:502-6. 22. Prause A,Wappler F,Scholz J et al.Respiratory depression under long-term sedation with sufentanil,midazolam and clonidine has no clinical significance.Intensive Care Med 2000;26:1454-61. 23. Graero J,Surgenor S,Whalen K.Emergence agitation in paediatric patients after sevoflurane anaesthesia and no surgery:a comparison with halothane.Paediatr Anesth 2000;10:419-24. 17 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] 24. Cravero JP,Beach M,Thyr B et al.The effect of small dose fentanyl on the emergence characteristics of pediatric patients after sevoflurane anesthesia without surgery.Anesth Analg 2003;97:364-7. 25.Li Y,van den Pol AN.Mu-opioid receptor-mediated depression of the hypothalamic hypocretin/orexin arousal system.J Neurosci 2008;28:2814-9. Table 1 The paediatric anaesthesia emergence delirium (PAED)scale Score1 the child makes eye contact with the caregiver Score2 the child shows purposeful actions Score3 the child is aware of his or her surroundings 18 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] Score4 the child is restless Score5 the child is inconsolable Items1-3 are reversed scored as follows:4,not at all;3,just a little;2,quite a bit;1,very much;and 0,extremely.Items (4)and(5) are scored as follows:0,not at all;1,just a little;2,quite a bit;3,very much;and 4,extremely.The score for each item was summed to obtain a total PAED scale score. Table 2 Demographic data,surgical and anesthetic times group F group S Age(year) 3.5 ± 1.2 3.4 ± 1.3 Weight(kg) 15.1 ± 8.9 16.2 ± 9.7 Gender(male/female) 33/7 32/8 ASA Ⅰ/Ⅱ 35/5 36/4 surgery duration(min) 45.6 ± 13.3 43.9 ± 16.5 anesthesia duration(min) 61.2 ± 15.8 63.4 ± 17.1 Data are mean±SD or numbers of patients,there was no difference in variables between the two groups. Table 3 Postoperative agitation scores,recovery time 19 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] Group F group S p PAED scale score 12 ± 3.8 9.1 ± 3.5 0.001 Incidence of agitation 20(50%) 11(27.5%) 0.039 emergence time(min) 15.05 ± 3.19 16.13 ± 3.65 0.165 PACU time(min) 29.83 ± 6.43 27.9 ± 8.45 0.255 The mean scores of the PAED scale and the incidence of severe emergence agitation were significantly lower in the sufentanil group compared with the fentanyl group. Table 4 Number of patients(%) received fentanyl group F additional fentanyl during surgery: 8(20%) group S 2(5%) p 0.043 postoperative rescue fentanyl: 1dose More than 1 doses 17(42.5%) 3(7.5%) 7(17.5%) 4(10%) 0.015 1.0 Number of patients received additional fentanyl during surgery and 1 dose of postoperative rescue fentanyl at PACU were significantly lower in sufentanil group compared to fentanyl group. 20 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected] Table 5 Incidence of side effects No.group F (%) No.group S(%) p vomiting 9(22.5%) 2(5%) 0.023 laryngospasm 1(2.5%) 0 1.0 oxygen desaturation 3(7.5%) 1(2.5%) 0.608 pruritus 2(5%) 4(10%) 0.671 The incidence of vomiting was significantly higher in the fentanyl group than in the sufentanil group 21 Department of Anesthesiology and Health statistics,Mianyang Central Hospital,Sichuan,China. Correspondence: Xiu Ze LI,Department of Anesthesiology,Mianyang Central Hospital,Sichuan,China. e-mail:[email protected]