In the same issue of Paediatric Anaesthesia, Lapin et al compared 80 children anesthetized with either halothane or sevoflurane, with or without midazolam premedication, all having myringotomy tube insertion [7]. They used a unique method of evaluating emergence excitement. Nurses were asked a simple yes/no question: "Did this patient become uncontrollable to the point that you had to restrain him or her and could not perform other functions?" They also recorded accumulated crying times. The sevoflurane unpremedicated patients were discharged from PACU nearly twice as quickly, but 67% were described as agitated and 71% had prolonged crying compared with 29%and 33%, respectively, for halothane unpremedicated children. Premedication with midazolam reduced the incidence of emergence excitement, but it was still higher than halothane. These observations are consistent with studies currently being conducted in my institution.

The bottom line is that we still do not know if sevoflurane offers significant safety and efficacy advantages compared with halothane. We do not know if the markedly increased cost of the former agent justifies substantial changes in practice. We do not know if maintenance of anesthesia with sevoflurane is any safer than halothane from the patient�s standpoint, especially since there have been cases reports of acute hepatic dysfunction reported with sevoflurane [8-12]. Finally, it is still unclear if the purported safety of sevoflurane during induction is simply a "systems issue" since we are able to administer nearly twice the MAC multiples of halothane compared with sevoflurane. It may be that the cardiac depression observed simply reflects hitting the heart with a higher concentration of drug. My inclination is to accept sevoflurane as a wonderful induction agent that without doubt results in a more rapid induction and perhaps a smoother induction compared with halothane. However after induction, I change to halothane because I do not see any benefits beyond that time. Since most cardiac arrests occur during induction, the limited MAC multiples one can deliver with a sevoflurane vaporizer may be protective to the patient! I am concerned with the emergence phenomena that occur with all anesthetized children but we don�t need to double the rate of this complication for the as yet unproven benefits of the new drugs over the old. I am also concerned about the apparent prolonged changes in behavior occasionally observed. If good science bears this out, then again there is even less an indication to change to the new drug. I suspect some of my comments will be met with an outcry of "foul play" and the comments of an older generation but those of you that know me understand that I am very open minded but also very skeptical. I need to be convinced with good science which I can then confirm myself. Then this old dinosaur will change.