Our Experience with Sevoflurane in Pediatric Dental Patients

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Nasibova This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6913547/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background. Pediatric oral surgery, especially removal of impacted teeth, is a common oral procedure and anesthesia management becomes a critical task to ensure a smooth surgery and minimize the child's discomfort. In recent years, with the development of anesthesiology and the emergence of new anesthetic drugs, the choice of anesthetics has become more diverse. Among them, sevoflurane, as an inhalation anesthetic with rapid onset and recovery, has attracted increasing attention for its safety and comfort in children. Sevoflurane can not only ensure a stable anesthetic condition, but also shorten the postoperative recovery time and reduce the risk of postoperative aspiration and vomiting and other adverse reactions, which helps improve anesthetic care in children. The aim of the study was to compare the effects of the traditional technique of inhalation induction and maintenance of anesthesia VIMA (Volatile Induction and Maintenance Anesthesia) and the new technique VIMA with double bolus induction with sevoflurane on the incidence of complications such as bradycardia and agitation in pediatric dental patients. Material and methods The study included 160 children aged 3 to 14 years who underwent dental treatment (treatment of multiple caries and tooth extraction) under sevoflurane inhalation anesthesia (traditional VIMA technique). The patients were divided into 2 groups depending on the anesthesia technique: in group 1 (n=80), treatment/tooth extraction was performed using the standard VIMA technique, and in group 2 (n=80), using a new method of inhalation anesthesia, with double block induction of sevoflurane. Research results During the study, we also identified the economic effect of using double bolus induction of sevoflurane by assessing the induction time before intubation and transfer of the patient to mechanical ventilation. Thus, when using the traditional VIMA technique, this time was 4.0-5.5 minutes, and with double bolus induction, 2.0-2.5 minutes (the first bolus was performed in 30 seconds and the second bolus in 1.5-2.0 minutes). Conclusions The VIMA technique with sevoflurane double bolus induction of anesthesia is cost-effective in children undergoing dental procedures. The VIMA technique with sevoflurane and double bolus induction of anesthesia provides a preconditioning effect and reduces the incidence of complications such as bradycardia, agitation and excitation in children. sevoflurane general anesthesia agitation Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Pediatric oral surgery, especially removal of impacted teeth, is a common oral procedure and anesthesia management becomes a critical task to ensure a smooth surgery and minimize the child's discomfort. However, children have different physiological characteristics and drug metabolism mechanisms compared with adults, and optimizing pediatric anesthesia management to achieve the best clinical outcomes is still one of the challenges facing anesthesiology research. In addition, oral surgery in children is often performed in a confined space, requiring more delicate anesthetic procedures, especially to maintain airway patency, which is critical to surgical success. In recent years, with the development of anesthesiology and the emergence of new anesthetic drugs, the choice of anesthetics has become more diverse. Among them, sevoflurane, as an inhalation anesthetic with rapid onset and recovery, has attracted increasing attention for its safety and comfort in children. Sevoflurane can not only provide a stable anesthetic condition, but also shorten the postoperative recovery time and reduce the risk of postoperative aspiration and vomiting and other adverse reactions, which helps to improve anesthetic care in children. Sevoflurane is currently the “gold standard” in pediatric dental practice, as it does not irritate the upper respiratory tract, has a cardioprotective effect, is easily controlled due to a dose-dependent effect, is low-toxic, and provides rapid induction and awakening after anesthesia [1]. Along with this, sevoflurane also has side effects. Of greatest interest from the standpoint of assessing the negative impact of sevoflurane on children is the postanesthetic agitation syndrome (PAAS) [2], characterized by severe anxiety, motor agitation, pronounced negativism, and lack of contact. To date, there is no definitive opinion on the etiology and pathogenesis of PAAS. The frequency of its development in young children, according to different authors, ranges from 6 to 80% [2–4]. The reasons for its occurrence include rapid recovery of consciousness against the background of insufficient analgesia, restless behavior of the child before anesthesia, his age, the nature of the surgical intervention, the absence of premedication with benzodiazepines, and pathology of the central nervous system [3, 5, 6]. Currently, there is a significant amount of work devoted to the prevention of PAAS during sevoflurane anesthesia. For this purpose, it is recommended to use opioid analgesics, ketamine, nitrous oxide, clonidine, benzodiazepines, propofol, dexmedetomidine [3, 6–11]. However, for a number of reasons, many of these drugs cannot be used in pediatric dentistry for short-term procedures under sevoflurane anesthesia with preserved spontaneous breathing. However, for a number of reasons, many of these drugs cannot be used in pediatric dentistry for short-term procedures under sevoflurane anesthesia with preserved spontaneous breathing. The absence of a strong odor and rapid induction of anesthesia, without additional injections, makes sevoflurane an ideal drug for mask induction of anesthesia in children [3]. The new inhalation anesthetic sevoflurane was discovered in 1971. Clinical use of sevoflurane began only in 1990 in Japan. In the USA and European countries, this inhalation anesthetic began to be used in 1995. Currently, sevoflurane is one of the most popular inhalation anesthetics in the world, primarily due to its low blood/gas distribution coefficient and lack of irritating effect on the respiratory tract [1]. Sevoflurane appears to be an ideal anesthetic for induction and maintenance of anesthesia in children due to its rapid action and lack of unpleasant odor [2]. In recent years, the VIMA (Volatile Induction and Maintenance Anesthesia) technique has become the most common in pediatric anesthesiology [3]. Currently, two methods of induction of anesthesia using sevoflurane are used [4]. The first method is stepwise induction, which involves gradually increasing the concentration of sevoflurane in the breathing circuit. This technique is accompanied by an increase in the time of induction of anesthesia, which requires additional assistance from medical personnel to physically hold the child during this anesthesia technique. And this technique is usually not welcomed by the children's parents. The second method is bolus induction of anesthesia. It should be noted that bolus induction with sevoflurane using the VIMA (Volatile Induction and Maintenance Anesthesia) method is more common and popular in pediatric anesthesiology [5]. The essence of this technique is to administer sevoflurane to the patient in a high concentration (6-8%), which ensures rapid falling asleep within 30-50 seconds. However, the VIMA technique also has its drawbacks, such as patient agitation during induction of anesthesia, the development of bradycardia, and the occurrence of post-anesthesia agitation upon awakening. The stage of excitation is characterized by the appearance of motor reactions after loss of consciousness, requiring the patient to be held, and occurs in 60–90% of children during induction of anesthesia with sevoflurane [6]. During the excitation stage, pulmonary ventilation may decrease due to the simultaneous contraction of the trunk muscles and neck muscles, which increases the risk of developing hypoxia and hypercapnia. A number of authors [7, 8] believe that the cause of tonic-clonic motor activity during induction of anesthesia is epileptiform cortical activity that develops when using sevoflurane. The development of bradycardia is associated with the specific effect of sevoflurane on the autonomic nervous system, namely, with the suppression of its parasympathetic link at the beginning of induction, which leads to a temporary increase in the influence of the sympathetic component on the heart. The consequence of this is short-term tachycardia; subsequently, as anesthesia deepens, sympathetic-adrenal activity decreases, which leads to the development of bradycardia [9]. In addition to its effect on the autonomic nervous system, sevoflurane also has a direct depressant effect on the sinus node [10, 11]. Severe bradycardia can be life-threatening [12]. Post-anesthesia agitation is a specific phenomenon that occurs in children and is accompanied by motor agitation, lack of contact with the child, disorientation and crying [13-16]. This condition can last from several minutes to 1 hour and goes away on its own, but requires observation of the child, prolongs the child’s recovery time after anesthesia and leads to parental concern, which is undesirable for dental patients [17]. The incidence of agitation varies from 10 to 67% [18]. Research data from recent years show that the incidence of post-anesthetic agitation in children using sevoflurane and desflurane is approximately the same and amounts to 25% [19]. These above mentioned conditions observed after sevoflurane anesthesia are undesirable in pediatric dental practice. The aim of our study was to use the preconditioning phenomenon during the induction of anesthesia to prevent adverse effects of sevoflurane anesthesia. In recent years, the phenomenon of sevoflurane preconditioning has been widely studied, and its cardioprotective and neuroprotective effects have been discussed [5, 20]. We decided that to achieve a preconditioning effect, induction of sevoflurane anesthesia should consist of two boluses. The first inhalation induction bolus with sevoflurane at a high concentration (6%) should ensure not only rapid loss of consciousness, but also preconditioning of the child's body. The second bolus of induction with sevoflurane is performed to achieve the required sufficient depth of anesthesia, to establish venous access, a nasotracheal tube, and to transfer to mechanical ventilation of the lungs. The aim of the study was to compare the effects of the traditional technique of inhalation induction and maintenance of anesthesia VIMA (Volatile Induction and Maintenance Anesthesia) and the new technique VIMA with double bolus induction with sevoflurane on the incidence of complications such as bradycardia and agitation in pediatric dental patients. Material and methods The study was conducted at the MediClub dental clinic in Baku and the surgical clinic of AMU. The study included 160 children aged 3 to 14 years, classified as ASA class I-II, who underwent dental treatment (treatment of multiple caries and tooth extraction) under inhalation anesthesia with sevoflurane (traditional VIMA technique). The patients were divided into 2 groups depending on the anesthesia technique: in group 1 (n = 80), treatment/tooth extraction was performed using the standard VIMA technique, and in group 2 (n = 80), using a new method of inhalation anesthesia, with double block induction of sevoflurane. The groups also did not differ in gender composition, average age, and body weight of children. The weight of children in the groups ranged from 12 to 46 kg. Children were anesthetized in the morning, on an empty stomach. Drinking clear liquids was stopped 2 hours before anesthesia. One hour before the appointment, parents applied a mixture of lidocaine and prilocaine (EMLA® cream) to the back of both palms of each child to provide venous access. Premedication was not used in children. Induction of anesthesia was performed in the presence of one of the parents, with the child sitting on the parent's lap. After falling asleep, the child was picked up, while the parent vacated the dental chair. The chair was brought to a horizontal position, and the child was placed on it. Parents were asked to be present with the child in the procedure room only during the induction of anesthesia. A pulse oximeter sensor was attached and a baseline Eva test was performed. The Eva test is a simple spatial perception control test in which the child touches the tip of his or her nose with the index finger while the eyes are closed. The standard VIMA technique involved delivering 8% sevoflurane at 5 L/min O2 via a face mask. After falling asleep (eyes closed), the sevoflurane flow was reduced from 8–5%. The child breathed this concentration of sevoflurane for an average of 5 minutes until the level of anesthesia required for establishing venous access was achieved. Then fentanyl was administered at a rate of 2 mcg/kg intravenously, a nasotracheal tube was installed, and the patient was transferred to mechanical ventilation. In patients of group II, we used a new method of inhalation anesthesia with sevoflurane (VIMA) in children, which is based on double induction [14]. In contrast to the standard VIMA technique, with the new technique, after an initial bolus (8% sevoflurane + 5 L/min O2) resulting in loss of consciousness as determined by eye closure, sevoflurane was discontinued while oxygen remained the same. The anesthesia machine circuit was flushed with 100% oxygen, while the breathing bag was actively emptied 3 to 5 times. During this time (3–4 minutes), the patient breathed a mixture of oxygen at the same flows. The anesthesia machine circuit was flushed with 100% oxygen, while the breathing bag was actively emptied 3 to 5 times. When ventilation was reduced, assisted ventilation was applied through a face mask. During this time, sevoflurane was eliminated from the body, which was monitored using gas analyzer data. Repeated administration of sevoflurane with the evaporator fully open began at the moment the heart rate decreased to increase by 1–2 beats per minute. This heart rate dynamics is recorded when 0.3–0.5% sevoflurane is reached in exhaled air. The second bolus lasted on average 1.5–2.0 minutes. During this time, the required depth of anesthesia was achieved, fentanyl was administered intravenously at a rate of 2 mcg/kg, after which a nasotracheal tube was installed and mechanical ventilation began. In the study groups, anesthesia was maintained equally and was carried out using a semi-closed circuit (3% sevoflurane + O2 0.6 l/min). The average duration of inhalation anesthesia in the groups was the same and ranged from 50 to 150 minutes (105 ± 10 minutes). All children received mechanical ventilation with volume control and maintenance of exhaled carbon dioxide within 35–40 mm Hg. "Agitation" during induction of anesthesia was defined as movements of the limbs, trunk, and neck that required holding the child. The maximum values ​​of the Pediatric Anesthesia Emergence Delirium scales were used to diagnose agitation, i.e. signs of agitation were the lack of visual contact, screaming, crying of the child, and the need for physical holding. For inhalation anesthesia, a Fabius Plus (Dräger) anesthesia machine with a Scio Four Oxi plus gas analyzer and a Dräger monitor were used. Monitoring during anesthesia included determining: ECG, HR, BP, SpO2, etCO2, O2 sevoflurane concentration on inspiration and expiration, Vt, body temperature. Statistical processing was performed using IBM SPSS Statistics software, data are presented as M ± m (M is the mean value, m is the standard error of the mean), 95% confidence interval (CI). The statistical significance of the difference between groups was assessed using the t-test for independent samples; statistical significance was determined at a value of p < 0.05. Research results The excitation stage during induction of anesthesia in children of group I was observed 3.8 times more often (with 95% CI from 0.18 to 0.41) than in children of group II. Tonic-clonic movements of varying severity were recorded in 57 (71%) children of group I and in 15 (19%) of group II; p < 0.001 (Fig. 1 ). The average heart rate in children of group II at the stage of induction of anesthesia was 102 ± 14 beats/min, which is 21.5% higher than in children of group I, for whom this indicator was 80 ± 6 beats/min; p < 0.05 (Fig. 2 ). Bradycardia (HR less than 72 bpm) at the stage of induction of anesthesia in patients of group I was observed 9 times more often than in patients of group II (at 95% CI 0.05–0.35) and was recorded in 27 (33.75%) patients of group I and in 3 (3.75%) of group II (p < 0.001). Severe bradycardia (HR 60 bpm), which required intravenous administration of atropine, was recorded in 13 (16.25%) children of group I. This degree of bradycardia was not observed in patients of group II (Fig. 3 ). Postanesthetic agitation in patients of group I occurred more than 8 times more often than in patients of group II (at 95% CI 0.05–0.55). This type of complication of inhalation anesthesia was recorded in 23 (28.75%) patients of group I and in 3 (3.75%) of group II; p < 0.006 (Fig. 4 ). During the study, we also identified the economic effect of using double bolus induction of sevoflurane by assessing the induction time before intubation and transfer of the patient to mechanical ventilation. Thus, when using the traditional VIMA technique, this time was 4.0-5.5 minutes, and with double bolus induction, 2.0-2.5 minutes (the first bolus was performed in 30 seconds and the second bolus in 1.5-2.0 minutes). Discussion Our experience with the use and analysis of recent publications studying the phenomenon of sevoflurane preconditioning have shown that the use of sevoflurane preconditioning at the stage of anesthesia induction helps to reduce the complications of inhalation anesthesia. Preconditioning is a term that arose to describe the phenomenon of metabolic adaptation of the body or its individual organs (myocardium, brain, etc.) to a damaging factor, preliminary short-term exposure to which can increase the resistance of the body's cells to subsequent stress effects. Preconditioning is a kind of "training" of the body, triggering endogenous mechanisms of adaptation to the action of a damaging factor [21]. In studies examining epileptiform activity of the brain during induction of anesthesia with sevoflurane, which is associated with the development of the excitation stage [8], it was shown that the first peaks of epileptiform activity on the electroencephalogram appear 70 seconds after the start of bolus induction. The concentration of sevoflurane during induction of anesthesia is 3.0-3.5%. Therefore, it can be concluded that the concentration of sevoflurane in the brain did not reach the threshold level necessary for the development of its epileptiform activity. Perhaps, this led to a statistically significantly lower frequency of the excitation stage in patients of group II. The phenomenon of myocardial preconditioning can also explain the almost 9 times lower frequency of bradycardia development during induction of anesthesia in children of group II. It was the first short-term bolus of sevoflurane that provided preconditioning of the myocardium during induction, since the second bolus and the observed increase in the concentration of the anesthetic during exhalation from 0.2–0.3 to 2.5% no longer led to a decrease in heart rate. On the contrary, the heart rate increased by an average of 10–15 beats/min and remained at this level throughout the anesthesia. Our experience with double bolus sevoflurane induction has shown that bradycardia can be completely avoided using this technique of induction into anesthesia. However, the disadvantage and inconvenience of double bolus sevoflurane induction is that bradycardia prevention requires the fastest possible decrease in sevoflurane concentration in the body after the first bolus (from 3 to 0.3% in exhaled air), and this requires hyperventilation by means of auxiliary mechanical ventilation. The minimal frequency of development of post-anesthetic agitation in children of group II, which has much in common with the stage of excitement [15], can be explained by the effect of preconditioning and, as a consequence, possible neuroprotection of the brain. The technique of double bolus induction of anesthesia in pediatric dental patients that we use is more cost-effective, since the supply of sevoflurane at high flows before installing venous access and a nasotracheal tube and transferring to artificial ventilation continues for 1.5-2 min (the first bolus is 30 sec, the second is 1.5-2.0 min). With the traditional technique, the supply of sevoflurane at high flows lasts up to 4–6 min. Conclusions The VIMA technique with sevoflurane double bolus induction of anesthesia is cost-effective in children undergoing dental procedures. The VIMA technique with sevoflurane and double bolus induction of anesthesia provides a preconditioning effect and reduces the incidence of complications such as bradycardia, agitation and excitation in children. Declarations Ethics approval and consent to participate: The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Azerbaijan Medical University (Protocol No. AMU-2024-04). Written informed consent was obtained from the parents or legal guardians of all participants. The study was conducted in accordance with institutional ethical standards. No formal approval was required as only standard non-invasive procedures were used. Consent for publication: Written informed consent for publication of anonymized data was obtained from the parents or legal guardians of all participants. Not applicable. Availability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The author declares no competing interests. Funding: This study received no external funding. Authors' contributions: EN designed the study, collected the data, performed the analysis, and wrote the manuscript. Acknowledgements: The author thanks the staff of MediClub dental clinic and the surgical clinic of AMU for their support. References Eger El II. New inhaled anesthetics. Anesthesiology. 1994;80:906–922. doi: 10.1097/00000542-199404000-00024. De Hert S, Moerman A. Sevoflurane. F1000.Research. 2015;4:626. Carmel B, Patel K, Fox D, et al. An unexpected trial: Sevoflurane in status asthmaticus. Obstructive Lung Diseases, Chest J. 2021;160(4):A1769. Flood P, Rathmell JP, Urman RD. Stoelting’s Pharmacology & Physiology in Anaesthetic Practice, 5th Ed. Wolters Kluwer, 2015. 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Brain Res. 2005 Feb 9;1034(1-2):147–52. doi: 10.1016/j.brainres.2004.12.006. Ding Q, Wang Q, Deng J, Gu Q, Hu S, Li Y, et al. Sevoflurane preconditioning induces rapid ischemic tolerance against spinal cord ischemia/reperfusion through activation of extracellular signal-regulated kinase in rabbits. Anesthes Analges. 2009 Oct;109(4):1263–72. doi: 10.1213/ane.0b013e3181b2214c. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Nasibova","email":"data:image/png;base64,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","orcid":"","institution":"Azerbaijan Medical University","correspondingAuthor":true,"prefix":"","firstName":"Esmira","middleName":"M.","lastName":"Nasibova","suffix":""}],"badges":[],"createdAt":"2025-06-17 10:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6913547/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6913547/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90984169,"identity":"f2c69b3f-ecc2-474e-9b87-46348acee9b6","added_by":"auto","created_at":"2025-09-10 09:40:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":326762,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency of excitation during induction in Group I and Group II.\u003c/p\u003e","description":"","filename":"Figure1Excitation.png","url":"https://assets-eu.researchsquare.com/files/rs-6913547/v1/40591cee14cf2f0e8be08883.png"},{"id":90984881,"identity":"721f5c3e-8dda-40ac-b94d-b5c8bdc4c515","added_by":"auto","created_at":"2025-09-10 09:48:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":316231,"visible":true,"origin":"","legend":"\u003cp\u003eAverage heart rate during induction in Group I and Group II.\u003c/p\u003e","description":"","filename":"Figure2HeartRate.png","url":"https://assets-eu.researchsquare.com/files/rs-6913547/v1/d62c1d94b4bd0af540bd930f.png"},{"id":90984885,"identity":"0b5b16cc-51f7-430d-9fdf-fc0384d521eb","added_by":"auto","created_at":"2025-09-10 09:48:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":328652,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency of occurrence of bradycardia in Group I and Group II.\u003c/p\u003e","description":"","filename":"Figure3Bradycardia.png","url":"https://assets-eu.researchsquare.com/files/rs-6913547/v1/fa294bf7b2f3445482d431fc.png"},{"id":90985831,"identity":"1bbd6985-30b1-4c7e-b717-4e3368d10862","added_by":"auto","created_at":"2025-09-10 09:56:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":318980,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency of postanesthesia agitation in Group I and Group II.\u003c/p\u003e","description":"","filename":"Figure4Agitation.png","url":"https://assets-eu.researchsquare.com/files/rs-6913547/v1/8db2f1730ba7a31db1a77f32.png"},{"id":92375323,"identity":"8bdeff12-e2c3-4538-9236-e26c33eb7ed7","added_by":"auto","created_at":"2025-09-29 04:32:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1552569,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6913547/v1/3016ccf5-80a6-4793-806d-63d7126bb319.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Our Experience with Sevoflurane in Pediatric Dental Patients","fulltext":[{"header":"Background","content":"\u003cp\u003ePediatric oral surgery, especially removal of impacted teeth, is a common oral procedure and anesthesia management becomes a critical task to ensure a smooth surgery and minimize the child\u0026apos;s discomfort. However, children have different physiological characteristics and drug metabolism mechanisms compared with adults, and optimizing pediatric anesthesia management to achieve the best clinical outcomes is still one of the challenges facing anesthesiology research. In addition, oral surgery in children is often performed in a confined space, requiring more delicate anesthetic procedures, especially to maintain airway patency, which is critical to surgical success.\u003c/p\u003e\n\u003cp\u003eIn recent years, with the development of anesthesiology and the emergence of new anesthetic drugs, the choice of anesthetics has become more diverse. Among them, sevoflurane, as an inhalation anesthetic with rapid onset and recovery, has attracted increasing attention for its safety and comfort in children. Sevoflurane can not only provide a stable anesthetic condition, but also shorten the postoperative recovery time and reduce the risk of postoperative aspiration and vomiting and other adverse reactions, which helps to improve anesthetic care in children.\u003c/p\u003e\n\u003cp\u003eSevoflurane is currently the \u0026ldquo;gold standard\u0026rdquo; in pediatric dental practice, as it does not irritate the upper respiratory tract, has a cardioprotective effect, is easily controlled due to a dose-dependent effect, is low-toxic, and provides rapid induction and awakening after anesthesia [1]. Along with this, sevoflurane also has side effects. Of greatest interest from the standpoint of assessing the negative impact of sevoflurane on children is the postanesthetic agitation syndrome (PAAS) [2], characterized by severe anxiety, motor agitation, pronounced negativism, and lack of contact. To date, there is no definitive opinion on the etiology and pathogenesis of PAAS. The frequency of its development in young children, according to different authors, ranges from 6 to 80% [2\u0026ndash;4]. The reasons for its occurrence include rapid recovery of consciousness against the background of insufficient analgesia, restless behavior of the child before anesthesia, his age, the nature of the surgical intervention, the absence of premedication with benzodiazepines, and pathology of the central nervous system [3, 5, 6]. Currently, there is a significant amount of work devoted to the prevention of PAAS during sevoflurane anesthesia. For this purpose, it is recommended to use opioid analgesics, ketamine, nitrous oxide, clonidine, benzodiazepines, propofol, dexmedetomidine [3, 6\u0026ndash;11]. However, for a number of reasons, many of these drugs cannot be used in pediatric dentistry for short-term procedures under sevoflurane anesthesia with preserved spontaneous breathing. However, for a number of reasons, many of these drugs cannot be used in pediatric dentistry for short-term procedures under sevoflurane anesthesia with preserved spontaneous breathing. The absence of a strong odor and rapid induction of anesthesia, without additional injections, makes sevoflurane an ideal drug for mask induction of anesthesia in children [3]. The new inhalation anesthetic sevoflurane was discovered in 1971. Clinical use of sevoflurane began only in 1990 in Japan. In the USA and European countries, this inhalation anesthetic began to be used in 1995. Currently, sevoflurane is one of the most popular inhalation anesthetics in the world, primarily due to its low blood/gas distribution coefficient and lack of irritating effect on the respiratory tract [1]. Sevoflurane appears to be an ideal anesthetic for induction and maintenance of anesthesia in children due to its rapid action and lack of unpleasant odor [2]. In recent years, the VIMA (Volatile Induction and Maintenance Anesthesia) technique has become the most common in pediatric anesthesiology [3]. Currently, two methods of induction of anesthesia using sevoflurane are used [4]. The first method is stepwise induction, which involves gradually increasing the concentration of sevoflurane in the breathing circuit. This technique is accompanied by an increase in the time of induction of anesthesia, which requires additional assistance from medical personnel to physically hold the child during this anesthesia technique. And this technique is usually not welcomed by the children\u0026apos;s parents. The second method is bolus induction of anesthesia. It should be noted that bolus induction with sevoflurane using the VIMA (Volatile Induction and Maintenance Anesthesia) method is more common and popular in pediatric anesthesiology [5]. The essence of this technique is to administer sevoflurane to the patient in a high concentration (6-8%), which ensures rapid falling asleep within 30-50 seconds. However, the VIMA technique also has its drawbacks, such as patient agitation during induction of anesthesia, the development of bradycardia, and the occurrence of post-anesthesia agitation upon awakening. The stage of excitation is characterized by the appearance of motor reactions after loss of consciousness, requiring the patient to be held, and occurs in 60\u0026ndash;90% of children during induction of anesthesia with sevoflurane [6]. During the excitation stage, pulmonary ventilation may decrease due to the simultaneous contraction of the trunk muscles and neck muscles, which increases the risk of developing hypoxia and hypercapnia. A number of authors [7, 8] believe that the cause of tonic-clonic motor activity during induction of anesthesia is epileptiform cortical activity that develops when using sevoflurane. The development of bradycardia is associated with the specific effect of sevoflurane on the autonomic nervous system, namely, with the suppression of its parasympathetic link at the beginning of induction, which leads to a temporary increase in the influence of the sympathetic component on the heart. The consequence of this is short-term tachycardia; subsequently, as anesthesia deepens, sympathetic-adrenal activity decreases, which leads to the development of bradycardia [9]. In addition to its effect on the autonomic nervous system, sevoflurane also has a direct depressant effect on the sinus node [10, 11]. Severe bradycardia can be life-threatening [12]. Post-anesthesia agitation is a specific phenomenon that occurs in children and is accompanied by motor agitation, lack of contact with the child, disorientation and crying [13-16]. This condition can last from several minutes to 1 hour and goes away on its own, but requires observation of the child, prolongs the child\u0026rsquo;s recovery time after anesthesia and leads to parental concern, which is undesirable for dental patients [17]. The incidence of agitation varies from 10 to 67% [18]. Research data from recent years show that the incidence of post-anesthetic agitation in children using sevoflurane and desflurane is approximately the same and amounts to 25% [19]. These above mentioned conditions observed after sevoflurane anesthesia are undesirable in pediatric dental practice.\u003c/p\u003e\n\u003cp\u003eThe aim of our study was to use the preconditioning phenomenon during the induction of anesthesia to prevent adverse effects of sevoflurane anesthesia. In recent years, the phenomenon of sevoflurane preconditioning has been widely studied, and its cardioprotective and neuroprotective effects have been discussed [5, 20]. We decided that to achieve a preconditioning effect, induction of sevoflurane anesthesia should consist of two boluses. The first inhalation induction bolus with sevoflurane at a high concentration (6%) should ensure not only rapid loss of consciousness, but also preconditioning of the child\u0026apos;s body. The second bolus of induction with sevoflurane is performed to achieve the required sufficient depth of anesthesia, to establish venous access, a nasotracheal tube, and to transfer to mechanical ventilation of the lungs.\u003c/p\u003e\n\u003cp\u003eThe aim of the study was to compare the effects of the traditional technique of inhalation induction and maintenance of anesthesia VIMA (Volatile Induction and Maintenance Anesthesia) and the new technique VIMA with double bolus induction with sevoflurane on the incidence of complications such as bradycardia and agitation in pediatric dental patients.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eThe study was conducted at the MediClub dental clinic in Baku and the surgical clinic of AMU. The study included 160 children aged 3 to 14 years, classified as ASA class I-II, who underwent dental treatment (treatment of multiple caries and tooth extraction) under inhalation anesthesia with sevoflurane (traditional VIMA technique). The patients were divided into 2 groups depending on the anesthesia technique: in group 1 (n = 80), treatment/tooth extraction was performed using the standard VIMA technique, and in group 2 (n = 80), using a new method of inhalation anesthesia, with double block induction of sevoflurane. The groups also did not differ in gender composition, average age, and body weight of children. The weight of children in the groups ranged from 12 to 46 kg. Children were anesthetized in the morning, on an empty stomach. Drinking clear liquids was stopped 2 hours before anesthesia. One hour before the appointment, parents applied a mixture of lidocaine and prilocaine (EMLA® cream) to the back of both palms of each child to provide venous access. Premedication was not used in children. Induction of anesthesia was performed in the presence of one of the parents, with the child sitting on the parent's lap. After falling asleep, the child was picked up, while the parent vacated the dental chair. The chair was brought to a horizontal position, and the child was placed on it. Parents were asked to be present with the child in the procedure room only during the induction of anesthesia. A pulse oximeter sensor was attached and a baseline Eva test was performed. The Eva test is a simple spatial perception control test in which the child touches the tip of his or her nose with the index finger while the eyes are closed. The standard VIMA technique involved delivering 8% sevoflurane at 5 L/min O2 via a face mask. After falling asleep (eyes closed), the sevoflurane flow was reduced from 8–5%. The child breathed this concentration of sevoflurane for an average of 5 minutes until the level of anesthesia required for establishing venous access was achieved. Then fentanyl was administered at a rate of 2 mcg/kg intravenously, a nasotracheal tube was installed, and the patient was transferred to mechanical ventilation. In patients of group II, we used a new method of inhalation anesthesia with sevoflurane (VIMA) in children, which is based on double induction [14]. In contrast to the standard VIMA technique, with the new technique, after an initial bolus (8% sevoflurane + 5 L/min O2) resulting in loss of consciousness as determined by eye closure, sevoflurane was discontinued while oxygen remained the same. The anesthesia machine circuit was flushed with 100% oxygen, while the breathing bag was actively emptied 3 to 5 times. During this time (3–4 minutes), the patient breathed a mixture of oxygen at the same flows. The anesthesia machine circuit was flushed with 100% oxygen, while the breathing bag was actively emptied 3 to 5 times. When ventilation was reduced, assisted ventilation was applied through a face mask. During this time, sevoflurane was eliminated from the body, which was monitored using gas analyzer data. Repeated administration of sevoflurane with the evaporator fully open began at the moment the heart rate decreased to increase by 1–2 beats per minute. This heart rate dynamics is recorded when 0.3–0.5% sevoflurane is reached in exhaled air. The second bolus lasted on average 1.5–2.0 minutes. During this time, the required depth of anesthesia was achieved, fentanyl was administered intravenously at a rate of 2 mcg/kg, after which a nasotracheal tube was installed and mechanical ventilation began.\u003c/p\u003e\u003cp\u003eIn the study groups, anesthesia was maintained equally and was carried out using a semi-closed circuit (3% sevoflurane + O2 0.6 l/min). The average duration of inhalation anesthesia in the groups was the same and ranged from 50 to 150 minutes (105 ± 10 minutes). All children received mechanical ventilation with volume control and maintenance of exhaled carbon dioxide within 35–40 mm Hg.\u003c/p\u003e\u003cp\u003e\"Agitation\" during induction of anesthesia was defined as movements of the limbs, trunk, and neck that required holding the child. The maximum values ​​of the Pediatric Anesthesia Emergence Delirium scales were used to diagnose agitation, i.e. signs of agitation were the lack of visual contact, screaming, crying of the child, and the need for physical holding.\u003c/p\u003e\u003cp\u003eFor inhalation anesthesia, a Fabius Plus (Dräger) anesthesia machine with a Scio Four Oxi plus gas analyzer and a Dräger monitor were used. Monitoring during anesthesia included determining: ECG, HR, BP, SpO2, etCO2, O2 sevoflurane concentration on inspiration and expiration, Vt, body temperature.\u003c/p\u003e\u003cp\u003eStatistical processing was performed using IBM SPSS Statistics software, data are presented as M ± m (M is the mean value, m is the standard error of the mean), 95% confidence interval (CI). The statistical significance of the difference between groups was assessed using the t-test for independent samples; statistical significance was determined at a value of p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Research results","content":"\u003cp\u003eThe excitation stage during induction of anesthesia in children of group I was observed 3.8 times more often (with 95% CI from 0.18 to 0.41) than in children of group II. Tonic-clonic movements of varying severity were recorded in 57 (71%) children of group I and in 15 (19%) of group II; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe average heart rate in children of group II at the stage of induction of anesthesia was 102\u0026thinsp;\u0026plusmn;\u0026thinsp;14 beats/min, which is 21.5% higher than in children of group I, for whom this indicator was 80\u0026thinsp;\u0026plusmn;\u0026thinsp;6 beats/min; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eBradycardia (HR less than 72 bpm) at the stage of induction of anesthesia in patients of group I was observed 9 times more often than in patients of group II (at 95% CI 0.05\u0026ndash;0.35) and was recorded in 27 (33.75%) patients of group I and in 3 (3.75%) of group II (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Severe bradycardia (HR 60 bpm), which required intravenous administration of atropine, was recorded in 13 (16.25%) children of group I. This degree of bradycardia was not observed in patients of group II (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003ePostanesthetic agitation in patients of group I occurred more than 8 times more often than in patients of group II (at 95% CI 0.05\u0026ndash;0.55). This type of complication of inhalation anesthesia was recorded in 23 (28.75%) patients of group I and in 3 (3.75%) of group II; p\u0026thinsp;\u0026lt;\u0026thinsp;0.006 (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eDuring the study, we also identified the economic effect of using double bolus induction of sevoflurane by assessing the induction time before intubation and transfer of the patient to mechanical ventilation. Thus, when using the traditional VIMA technique, this time was 4.0-5.5 minutes, and with double bolus induction, 2.0-2.5 minutes (the first bolus was performed in 30 seconds and the second bolus in 1.5-2.0 minutes).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur experience with the use and analysis of recent publications studying the phenomenon of sevoflurane preconditioning have shown that the use of sevoflurane preconditioning at the stage of anesthesia induction helps to reduce the complications of inhalation anesthesia. Preconditioning is a term that arose to describe the phenomenon of metabolic adaptation of the body or its individual organs (myocardium, brain, etc.) to a damaging factor, preliminary short-term exposure to which can increase the resistance of the body's cells to subsequent stress effects. Preconditioning is a kind of \"training\" of the body, triggering endogenous mechanisms of adaptation to the action of a damaging factor [21].\u003c/p\u003e\u003cp\u003eIn studies examining epileptiform activity of the brain during induction of anesthesia with sevoflurane, which is associated with the development of the excitation stage [8], it was shown that the first peaks of epileptiform activity on the electroencephalogram appear 70 seconds after the start of bolus induction. The concentration of sevoflurane during induction of anesthesia is 3.0-3.5%. Therefore, it can be concluded that the concentration of sevoflurane in the brain did not reach the threshold level necessary for the development of its epileptiform activity. Perhaps, this led to a statistically significantly lower frequency of the excitation stage in patients of group II. The phenomenon of myocardial preconditioning can also explain the almost 9 times lower frequency of bradycardia development during induction of anesthesia in children of group II. It was the first short-term bolus of sevoflurane that provided preconditioning of the myocardium during induction, since the second bolus and the observed increase in the concentration of the anesthetic during exhalation from 0.2\u0026ndash;0.3 to 2.5% no longer led to a decrease in heart rate. On the contrary, the heart rate increased by an average of 10\u0026ndash;15 beats/min and remained at this level throughout the anesthesia. Our experience with double bolus sevoflurane induction has shown that bradycardia can be completely avoided using this technique of induction into anesthesia. However, the disadvantage and inconvenience of double bolus sevoflurane induction is that bradycardia prevention requires the fastest possible decrease in sevoflurane concentration in the body after the first bolus (from 3 to 0.3% in exhaled air), and this requires hyperventilation by means of auxiliary mechanical ventilation. The minimal frequency of development of post-anesthetic agitation in children of group II, which has much in common with the stage of excitement [15], can be explained by the effect of preconditioning and, as a consequence, possible neuroprotection of the brain. The technique of double bolus induction of anesthesia in pediatric dental patients that we use is more cost-effective, since the supply of sevoflurane at high flows before installing venous access and a nasotracheal tube and transferring to artificial ventilation continues for 1.5-2 min (the first bolus is 30 sec, the second is 1.5-2.0 min). With the traditional technique, the supply of sevoflurane at high flows lasts up to 4\u0026ndash;6 min.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe VIMA technique with sevoflurane double bolus induction of anesthesia is cost-effective in children undergoing dental procedures.\u003c/p\u003e\u003cp\u003eThe VIMA technique with sevoflurane and double bolus induction of anesthesia provides a preconditioning effect and reduces the incidence of complications such as bradycardia, agitation and excitation in children.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u003cbr\u003e\u0026nbsp;The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Azerbaijan Medical University (Protocol No. AMU-2024-04). Written informed consent was obtained from the parents or legal guardians of all participants.\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with institutional ethical standards. No formal approval was required as only standard non-invasive procedures were used.\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u003cbr\u003e\u0026nbsp;Written informed consent for publication of anonymized data was obtained from the parents or legal guardians of all participants.\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials:\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u003c/p\u003e\n\u003cp\u003eThe author declares no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eThis study received no external funding.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions:\u003c/p\u003e\n\u003cp\u003eEN designed the study, collected the data, performed the analysis, and wrote the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements:\u003c/p\u003e\n\u003cp\u003eThe author thanks the staff of MediClub dental clinic and the surgical clinic of AMU for their support.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEger El II. New inhaled anesthetics. Anesthesiology. 1994;80:906\u0026ndash;922. doi: 10.1097/00000542-199404000-00024.\u003c/li\u003e\n\u003cli\u003eDe Hert S, Moerman A. Sevoflurane. F1000.Research. 2015;4:626.\u003c/li\u003e\n\u003cli\u003eCarmel B, Patel K, Fox D, et al. An unexpected trial: Sevoflurane in status asthmaticus. Obstructive Lung Diseases, Chest J. 2021;160(4):A1769.\u003c/li\u003e\n\u003cli\u003eFlood P, Rathmell JP, Urman RD. Stoelting\u0026rsquo;s Pharmacology \u0026amp; Physiology in Anaesthetic Practice, 5th Ed. Wolters Kluwer, 2015.\u003c/li\u003e\n\u003cli\u003eBrioni JD, Varughese S, Ahmed R, Bein B. A clinical review of inhalation anesthesia with sevoflurane: from early research to emerging topics. Journal of Anesthesia. 2017;31(5):764-778.\u003c/li\u003e\n\u003cli\u003eVeyckemans F. Excitation phenomena during sevoflurane anaesthesia in children. Current Opinion in Anaesthesiology. 2001;14:339-343.\u003c/li\u003e\n\u003cli\u003ePilge S, Jordan D, Kochs EF, Schneider G. Sevoflurane-induced epileptiform electroencephalographic activity and generalized tonic-clonic seizures in a volunteer study. Anesthesiology. 2013;119:447.\u003c/li\u003e\n\u003cli\u003eKreuzer I, Osthaus WA, Schultz A, Schultz B. Influence of the Sevoflurane Concentration on the Occurrence of Epileptiform EEG Patterns. PLoS One. 2014;9(2):e89191.\u003c/li\u003e\n\u003cli\u003eWodey E, Senhadji L, Pladys P, Carre F, Ecoffey C.The relationship between expired concentration of sevoflurane and sympathovagal tone in children. Anesthesia and Analgesia. 2003;97(2):377-382.\u003c/li\u003e\n\u003cli\u003eKojima A, Kitagawa H, Omatsu-Kanbe M, Matsuura H, Nosaka S. Inhibitory effects of sevoflurane on pacemaking activity of sinoatrial node cells in guinea-pig heart. British Journal of Pharmacology. 2012;166(7):2117-2135.\u003c/li\u003e\n\u003cli\u003eKundra P, Vinodhadevi V, Arimanickam G. Sevoflurane-induced arrhythmia in an adult and a child. Journal of Anaesthesiology, Clinical Pharmacology. 2011;27(2):269-271.\u003c/li\u003e\n\u003cli\u003eTownsend P, Stokes MA. Bradycardia during rapid inhalation induction with sevoflurane in children. British Journal of Anaesthesia. 1998;80(3):410.\u003c/li\u003e\n\u003cli\u003eChoi EK, Lee S, Kim WJ, Park SJ. Effects of remifentanil maintenance during recovery on emergence delirium in children with sevoflurane anesthesia. Paediatr Anaesth. 2018;28(8):739\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003ePark JH, Lim BG, Kim HZ, Kong MH, Lim SH, Kim NS, Lee IO. Comparison of emergence agitation between sevoflurane/nitrous oxide administration and sevoflurane administration alone in children undergoing adenotonsillectomy with preemptive ketorolac. Korean J Anesthesiol. 2014;66(1):34\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eAouad MT, Yazbeck-Karam VG, Nasr VG, El-Khatib MF, Kanazi GE, Bleik JH. A single dose of propofol at the end of surgery for the prevention of emergence agitation in children undergoing strabismus surgery during sevoflurane anesthesia. Anesthesiology. 2007;107(5):733\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eVeyckemans F. Excitation and delirium during sevoflurane anesthesia in pediatric patients. Minerva Anestesiologica. 2002;68(5):402-405.\u003c/li\u003e\n\u003cli\u003eSikich N, Lerman J. Development and Psychometric Evaluation of the Pediatric Anesthesia Emergence Delirium Scale. Anesthesiology. 2004; 100:1138-1145.\u003c/li\u003e\n\u003cli\u003eda Silva LM, Braz LG, Modolo NS. Emergence agitation in pediatric anesthesia:current features. Jornal de Pediatria. 2008;84(2):107-113.\u003c/li\u003e\n\u003cli\u003eBortone L, Ingelmo P, Grossi S, Grattagliano C, Bricchi C, Barantani D, Sani E, Mergoni M. Emergence agitation in preschool children: doubleblind,randomized, controlled trial comparing sevoflurane and isoflurane anesthesia. Paediatric Anaesthesia. 2006;16(11):1138-1143.\u003c/li\u003e\n\u003cli\u003eLocatelli BG, Ingelmo PM, Emre S, Meroni V, Minardi C, Frawley G, Benigni A, Di Marco S, Spotti A, Busi I, Sonzogni V. Emergence delirium in children: a comparison of sevoflurane and desflurane anesthesia using the Paediatric Anesthesia Emergence Delirium scale. Paediatric Anaesthesia. 2013;23(4):301-308.\u003c/li\u003e\n\u003cli\u003eMcAuliffe JJ, Joseph B, Vorhees CV. Isoflurane-delayed preconditioning reduces immediate mortality and improves striatal function in adult mice after neonatal hypoxia-ischemia. Anesthes Analges. 2007 May;104(5):1066\u0026ndash;77. doi: 10.1213/01.ane.0000260321.62377.74.\u003c/li\u003e\n\u003cli\u003eKitano H, Kirsch JR, Hurn PD, Murphy SJ. Inhalational anesthetics as neuroprotectants or chemical preconditioning agents in ischemic brain. J Cereb Blood Flow Metab. 2007 Jun;27(6):1108\u0026ndash;28. doi: 10.1038/sj.jcbfm.9600410.\u003c/li\u003e\n\u003cli\u003ePayne RS, Akca O, Roewer N, Schurr A, Kehl F. Sevoflurane-induced preconditioning protects against cerebral ischemic neuronal damage in rats. Brain Res. 2005 Feb 9;1034(1-2):147\u0026ndash;52. doi: 10.1016/j.brainres.2004.12.006.\u003c/li\u003e\n\u003cli\u003eDing Q, Wang Q, Deng J, Gu Q, Hu S, Li Y, et al. Sevoflurane preconditioning induces rapid ischemic tolerance against spinal cord ischemia/reperfusion through activation of extracellular signal-regulated kinase in rabbits. Anesthes Analges. 2009 Oct;109(4):1263\u0026ndash;72. doi: 10.1213/ane.0b013e3181b2214c.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"sevoflurane, general anesthesia, agitation","lastPublishedDoi":"10.21203/rs.3.rs-6913547/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6913547/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground. Pediatric oral surgery, especially removal of impacted teeth, is a common oral procedure and anesthesia management becomes a critical task to ensure a smooth surgery and minimize the child's discomfort. In recent years, with the development of anesthesiology and the emergence of new anesthetic drugs, the choice of anesthetics has become more diverse. Among them, sevoflurane, as an inhalation anesthetic with rapid onset and recovery, has attracted increasing attention for its safety and comfort in children. Sevoflurane can not only ensure a stable anesthetic condition, but also shorten the postoperative recovery time and reduce the risk of postoperative aspiration and vomiting and other adverse reactions, which helps improve anesthetic care in children.\u003c/p\u003e\n\u003cp\u003eThe aim of the study was to compare the effects of the traditional technique of inhalation induction and maintenance of anesthesia VIMA (Volatile Induction and Maintenance Anesthesia) and the new technique VIMA with double bolus induction with sevoflurane on the incidence of complications such as bradycardia and agitation in pediatric dental patients.\u003c/p\u003e\n\u003cp\u003eMaterial and methods\u003c/p\u003e\n\u003cp\u003eThe study included 160 children aged 3 to 14 years who underwent dental treatment (treatment of multiple caries and tooth extraction) under sevoflurane inhalation anesthesia (traditional VIMA technique). The patients were divided into 2 groups depending on the anesthesia technique: in group 1 (n=80), treatment/tooth extraction was performed using the standard VIMA technique, and in group 2 (n=80), using a new method of inhalation anesthesia, with double block induction of sevoflurane.\u003c/p\u003e\n\u003cp\u003eResearch results\u003c/p\u003e\n\u003cp\u003eDuring the study, we also identified the economic effect of using double bolus induction of sevoflurane by assessing the induction time before intubation and transfer of the patient to mechanical ventilation. Thus, when using the traditional VIMA technique, this time was 4.0-5.5 minutes, and with double bolus induction, 2.0-2.5 minutes (the first bolus was performed in 30 seconds and the second bolus in 1.5-2.0 minutes).\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eThe VIMA technique with sevoflurane double bolus induction of anesthesia is cost-effective in children undergoing dental procedures.\u003c/p\u003e\n\u003cp\u003eThe VIMA technique with sevoflurane and double bolus induction of anesthesia provides a preconditioning effect and reduces the incidence of complications such as bradycardia, agitation and excitation in children.\u003c/p\u003e","manuscriptTitle":"Our Experience with Sevoflurane in Pediatric Dental Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-10 09:40:24","doi":"10.21203/rs.3.rs-6913547/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a7364ec-7975-4fa4-ad10-7d7449125676","owner":[],"postedDate":"September 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T04:23:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-10 09:40:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6913547","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6913547","identity":"rs-6913547","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}