Peritonsillar bupivacaine infiltration reduces emergence delirium after tonsillectomy in children: a randomized, double-blind, controlled study

Background: The study aimed to evaluate the effect of peritonsillar bupivacaine infiltration on the development of postoperative emergence delirium (ED) in pediatric patients undergoing tonsillectomy or adenotonsillectomy. Methods: This prospective, randomized, controlled clinical trial included 80 pediatric patients aged 3 to 7 years, classified as American Society of Anesthesiologists (ASA) Physical Status I. Patients were randomly divided into 2 groups of 40 patients each: Group A (peritonsillar bupivacaine injection) and Group B (control). In the recovery unit, delirium was assessed with the Pediatric Emergence Delirium Scale (PAEDS) and pain was assessed with the Face, Legs, Activity, Cry and Consolability (FLACC) scale at baseline and at 5, 10, 20, 30 and 60 minutes after surgery. A PAEDS score of ≥10 was considered indicative of postoperative delirium, and 0.5 µg/kg fentanyl was administered intravenously (IV). The FLACC scores ≥4 were considered indicative of pain, and 10 mg/kg paracetamol IV was administered as rescue analgesic. Results: The rate of rescue analgesic use, rescue fentanyl, and the incidence of delirium were significantly lower in group A compared to group B (p = 0.001, p = 0.001 and p = 0.001, respectively). The 20th, 30th and 60th minute FLACC measurements of group A were found to be significantly lower than those in group B (p = 0.002, p = 0.001 and p = 0.001). No significant differences were observed in PAEDS scores between the groups. The group assignment and PAEDS scores at the 5th minute were found as independent risk factors for the development of ED. In comparison to Group A (infiltration), the risk of delirium was higher in Group B (adjusted Odd Ratio (aOR): 14.533, 95% Confidence Interval (CI): 1.766–119.620). Additionally, a one-unit increase in PAEDS score at the 5th minute was associated with a 2.362-fold increased risk of delirium (95% CI: 1.44–3.87). Conclusions: Peritonsillar bupivacaine infiltration significantly reduces the risk of postoperative ED in pediatric patients undergoing tonsillectomy or adenotonsillectomy. Clinical Trial Registration: The study was registered with ClinicalTrials.gov as NCT06863714.

Emergence delirium; Tonsillectomy; Bupivacaine; Infiltration analgesia; Postoperative pain

[1] Liu K, Liu C, Ulualp SO. Prevalence of emergence delirium in children undergoing tonsillectomy and adenoidectomy. Anesthesiology Research and Practice. 2022; 2022: 1465999.

[2] Mason KP. Paediatric emergence delirium: a comprehensive review and interpretation of literature. British Journal of Anaesthesia. 2017; 118: 335–343.

[3] Liao Y, Xie S, Zhuo Y, Chen S, Luo Y, Wei Y, et al. Intranasal dexmedetomidine-esketamine combination premedication versus monotherapy for reducing emergence delirium and postoperative behavioral changes in pediatric tonsillectomy and/or adenoidectomy: a randomized controlled trial. Drug Design, Development and Therapy. 2024; 18: 4693–4703.

[4] Kapoor D, Tweddle EA, Baitch L. The effect of deep versus awake removal of the laryngeal mask airway on the incidence of emergence delirium in paediatric tonsillectomy: a randomised controlled trial. Anaesthesia and Intensive Care. 2025; 53: 55–62.

[5] Biricik E, Karacaer F, Tunay DL, Ilgınel M, Küçükbingöz Ç. The effect of different propofol-ketamine combinations on emergence delirium in children undergoing adenoidectomy and tonsillectomy surgery. Journal of PeriAnesthesia Nursing. 2024; 39: 1012–1018.

[6] Wei B, Yu C, Xiao J, Xu H, Zheng P, Wang W. The median effective dose of dexmedetomidine for the inhibition of emergence delirium in preschool children undergoing tonsillectomy and/or adenoidectomy: a retrospective dose-response trial. Dose-Response. 2024; 22: 15593258241248919.

[7] Zhang YZ, Wei XL, Tang B, Qin YY, Ou M, Jiang XH, et al. The effects of different doses of alfentanil and dexmedetomidine on prevention of emergence agitation in pediatric tonsillectomy and adenoidectomy surgery. Frontiers in Pharmacology. 2022; 13: 648802.

[8] Sousa-Júnior FA, Souza ASR, Lima LC, Santos ÍGM, Menezes LAP, Ratis PAPL, et al. Intraoperative clonidine to prevent postoperative emergence delirium following sevoflurane anesthesia in pediatric patients: a randomized clinical trial. Brazilian Journal of Anesthesiology. 2021; 71: 5–10.

[9] Opperman JB, Tshifularo MI. The application of xylocaine 10% pump-spray to improve immediate post-adenotonsillectomy pain in children: a randomized controlled trial. International Journal of Pediatric Otorhinolaryngology. 2022; 161: 111260.

[10] Somaini M, Sahillioğlu E, Marzorati C, Lovisari F, Engelhardt T, Ingelmo PM. Emergence delirium, pain or both? A challenge for clinicians. Pediatric Anesthesia. 2015; 25: 524–529.

[11] Naja Z, Kanawati S, Al Khatib R, Ziade F, Naja ZZ, Naja AS, et al. The effect of IV dexamethasone versus local anesthetic infiltration technique in postoperative nausea and vomiting after tonsillectomy in children: a randomized double-blind clinical trial. International Journal of Pediatric Otorhinolaryngology. 2017; 92: 21–26.

[12] Kim JS, Kim GW, Park DH, Ahn HE, Chang MY, Kim JY. Effects of scalp nerve block on pain and emergence agitation after paediatric nevus surgery: a clinical trial. Acta Anaesthesiologica Scandinavica. 2017; 61: 935–941.

[13] Ohashi N, Denda S, Furutani K, Yoshida T, Kamiya Y, Komura R, et al. Ultrasound-guided ilioinguinal/iliohypogastric block did not reduce emergence delirium after ambulatory pediatric inguinal hernia repair: a prospective randomized double-blind study. Surgery Today. 2016; 46: 963–969.

[14] Wang H, Liu G, Fu W, Li ST. The effect of infraorbital nerve block on emergence agitation in children undergoing cleft lip surgery under general anesthesia with sevoflurane. Pediatric Anesthesia. 2015; 25: 906–910.

[15] Kilinc L, Türk B, Türk HS, Cinar S, Turgut S, İslamoğlu S. Peritonsillar dexamethasone-bupivacaine vs. bupivacaine infiltration for post-tonsillectomy pain relief in children: a randomized, double-blind, controlled study. European Archives of Oto-Rhino-Laryngology. 2019; 276: 2081–2089.

[16] Somaini M, Engelhardt T, Fumagalli R, Ingelmo PM. Emergence delirium or pain after anaesthesia—how to distinguish between the two in young children: a retrospective analysis of observational studies. British Journal of Anaesthesia. 2016; 116: 377–383.