Little Tykes Terror: - PowerPoint Presentation

Slide1

Little Tykes Terror:

Managing Pediatric Emergence DeliriumLeianne O. Knoll Krajewski, CRNA, DNPSlide2

Pediatric Emergence DeliriumSlide3

Pediatric Emergence DeliriumSlide4

Pediatric Emergence DeliriumSlide5

Pediatric Emergence DeliriumSlide6

Outline

DefinitionIncidenceRisk FactorsEtiologyPreventionIdentificationManagementSlide7

Emergence Delirium: Definition

Delirium is a complex psychiatric syndrome that includes perceptual disturbances, hallucinations and psychomotor agitation. “A disturbance in a child’s awareness of and attention to his or her environment with disorientation and perceptual alterations including hypersensitivity to stimuli and hyperactive motor behavior in the immediate post-anesthesia period.”

American Psychiatric

Association

(2000

)

Sikich

and

Lerman

, Anesthesiology (2004)Slide8

Definition? Clear as MUD

The term “delirium” is often replaced with the descriptive terms “agitation” or “excitation” as it is not feasible to fully evaluate a young child’s psycho- logical state during emergence EA (Emergence agitation) is a state of mild restlessness and mental distress that, unlike delirium, does not always suggest a significant change in behavior

Choen

, et al (2001)

Galford

(1992)Slide9

More Mud….

Agitation can indicate any number of sources, including pain, physiological compromise or anxiety.Delirium may be confused with agitation, but it may also be a cause of agitation.

Voepel

-Lewis, et al (2004)Slide10

Emergence Delirium

Usually within the first 30 minutes of recovery from general anesthesiaBrief (10-15 minutes)Self-limited and resolves spontaneouslyHowever, agitation and regressive behavior that lasted up to 2 days were also described in the literature. Slide11

How often does this happen?Incidence

The incidence of EA/ED largely depends on definition, age, anesthetic technique, surgical procedure and application of adjunct medication. First described by

Eckenhoff

,

et al in 1961

Pediatric:

G

enerally

ranged 10-50% but may be as high as 80%

Adult

:

3-4

%

Vlaikovic

, et al (2007)

Lepouse

, et al (2006)Slide12

Does it matter?

Risk of harming surgical repairRisk of harming selfRisk of harming caregivers (nurse, parent)Risk of pulling out IV’s, drains, tubes, catheters, dressingsIT’S STRESSFUL, NOT IDEAL AND IT MATTERS! WE CAN DO BETTER! Slide13

What’s the big deal?

More nursing resources requiredMay require physical or pharmacological restraint (with potential side effects)May prolong recovery room stayMay delay hospital dischargeParents/nurses/providers less satisfied with quality of surgical/anesthetic experience Slide14

RISK FACTORS

Patient relatedSurgery relatedAnesthesia relatedSlide15

Risk Factors:

Patient relatedAgeAnxietyPreoperativePostoperative

Patient

Parent

TemperamentSlide16

Risk Factors: Age

Generally, younger children are more likely to show altered behavior upon recovery from anesthesia More common in younger children (preschool vs. school age)2-5 year-olds

thought to be most vulnerable to

becoming easily

confused and frightened by unfamiliar experiences/

surroundings

Voepel

-Lewis, et al (2003)

Vlaikovic

, et al (2007)Slide17

Risk Factors: Patient

Multiple studies show the likelihood of patient preoperative anxiety increasing the risk of postoperative emergence deliriumPre-op anxiety in children may depend primarily on their stages of development.Previous hospital experience

Aono

, et al (

1999)

Kain

, et al (2004

)

Banchs

, et al (2014)Slide18

Risk Factors: Age

Infants: less likely to experience separation anxiety1-3 y/o: experience separation anxiety but respond positively to distraction and comforting measures4-5 y/o

: seek explanations and desire control of their

enviornment

Older children 7-12

y/o

: desire more independence and want to be involved in decision making processes.

Adolescents fear losing face and are concerned with their inability to cope

McGraw, (1994)Slide19

Risk Factors: Parent Anxiety

Pre-op PARENT anxiety also increases risk of post-op emergence deliriumThe higher the level of maternal salivary amylase, the more severe the child’s pre-op anxiety AND the more severe the post-op emergence delirium

Kain

, et al (2004)

Arai , et al (2008)Slide20

Risk Factors: Parent Anxiety

Maternal heart variability just before surgery significantly correlated with emergence behavior of children undergoing general anesthesiaIntense preoperative anxiety in children

AND their parents has been associated with increased likelihood of restless recovery from

anesthesia

Arai, et al (2008)

Aono

, et al (1999)

Kain

, et al (2004)Slide21

Risk Factors: Temperament

Children who are more emotional, impulsive, less social and less adaptable to environmental changes are at higher risk for emergence deliriumIt is likely that there is some substrate innate to each child that will elicit, to a larger or lesser extent, a fearful response to outside stimuli, depending on the interaction between the child and the

environment

Voepel

-Lewis, et al (2003)

Kain

, et al (2004)Slide22

Risk Factors: Temperament

This reactivity, which describes the “excitability, responsivity, or arousability” of the child, might be the underlying substrate from which both preoperative anxiety and ED arise.Patient related factors are an important source of variability for ED and are the most difficult to control.

Kain

, et al (2004)

Rothbart

, et al (2000)Slide23

Risk Factors: Temperament

Recent evidence suggests that cultural differences including:LanguageEthnicity …Contribute to changes in behavior especially behavior during the recovery period.

Fortier, et al (2013)Slide24

Risk Factors: Surgery

Types of SurgerySpeculation that surgery involving the head leads patients into feelings of suffocation thus increased incidence of ED- Not clinically provenENTTonsils, adenoids, thyroid, middle ear

Ophthalmology

Strabismus

Voepel

-Lewis, et al (2003)Slide25

Etiology

PainIntrinsic characteristics of anesthesiaRapid awakeningAnxietySurgery typePsychologically immatureTemperamentUnfamiliar environment

Genetic predispositionSlide26

Etiology (continued)

PainMost confounding variable secondary to overlapping clinical picture with EDDifficult to distinguish between pain and ED Inadequate pain relief may cause agitation especially in short procedures where peak effect of analgesics may be delayed until after wake upSlide27

Etiology (continued)

Intrinsic characteristics of anesthesiaPostanesthesia agitation has been described not only with sevoflurane and desflurane, but also with

isoflu

-

rane

and lesser with halothane (no longer used)

Children who received

sevoflurane/isoflurane

for the induction/maintenance of anesthesia were twice as likely to develop EA when compared with children who had any other anesthetic regimen

Children who received total intravenous anesthesia (TIVA)- no documented cases of ED

Voepel

-Lewis et al (2003)Slide28

Etiology (continued)

Rapid awakeningpostulated that rapid awakening after the use of the insoluble anesthetics may initiate EA/ED by worsening a child’s underlying sense of apprehension when finding them self in an unfamiliar environment however……Delaying emergence by a slow, stepwise decrease in the concentration of inspired sevoflurane

at the end of surgery did

NOT

reduce the incidence of EA

Picard,

et

al

(

2000)

Oh,

et

al

(

2005)Slide29

Etiology (continued)

Temperament/unfamiliar environmentOlder children and adults usually become oriented rapidly P

reschool

-aged children, who are less able to cope with environmental stresses, tend to become agitated and

delirious

Vlajkovic

et al (2007) Slide30

Prevention

Given that the EA/ED etiology is still unknown, a clear-cut strategy for its prevention has not been developed Many conflicting studies on preventative pharmacological measuresDifficult to study considering confounding variables and inability to do randomized double blind study accuratelySlide31

Prevention

All aimed at decreasing preoperative anxiety.Preoperative Preparation ProgramsParental Presence Induction of Anesthesia (PPIA)Sedative premedication

Distraction techniquesSlide32

Prevention

Preoperative Preparation ProgramsPreoperative booklets or DVD sent to home prior to surgeryChild Life Specialist or Child Educator being present during admission to educate parents and child in age appropriate manner Use of anesthesia maskPractice “blowing up the balloon” or anesthesia ventilation bagSlide33

Prevention: Preparation

A novel preoperative preparation program is the ADVANCE family centered behavioral preparation program which is an acronym for Anxiety-reductionDistractionV

ideo modeling and education

A

dding parents

N

o excessive reassurance,

C

oaching

E

xposure shaping

Kain

, et al (2007)Slide34

Prevention: Preparation

ADVANCE ProgramEffectiveness on pre-op anxiety and post-op was compared with PPIA alone, oral midazolam and control groups Findings: Pre-op Anxiety in the ADVANCE group significantly

less than

all other groups

Less anxiety during induction in ADVANCE group than PPIA and control group

Incidence of ED and analgesic requirement less in ADVANCE group

Discharge times for children in the ADVANCE group were

less

Obstacle: large operational costs

Kain

, et al (2007)Slide35

Prevention

Parental Presence Induction of Anesthesia (PPIA)Very common practice in Europe, less common in USWhile 58% of US anesthesia providers agreed with PPIA only 5% of cases where parents allowed in OR84% of British anesthesia providers allowed PPIA in more than 75% of casesTheir belief that PPIA decreased children's anxiety, increased their cooperation and benefited both the parent and anesthesia provider

Bowie (1993)

Johnson (2012)Slide36

Prevention PPIA cont

Prospective randomized study, N=88, 2-7y/o, GA for MRIParents present group: reunited before emergence vs. Parents absent group: reunited per routing practiceParental presence at emergence did NOT decrease incidence or duration of agitation

Significant psychosocial benefits to the parents: present at the “right time” and felt “helpful” to their child

One study N=60, 1-3y/o, minor plastic surgery

PPIA

vs

Midazolam 0.5 mg/kg vs. Midazolam AND PPIA

Less ED seen with combination midazolam AND PPIA

Arai (2007)

Burke (2009)Slide37

If I can’t prevent, then what?

Diagnose or IdentifyAssessment toolsReliability and validity of toolsManagePharmacologicalEnvironmentalSlide38

Identification: Assessment Tools

16 rating scales and 2 visual analog scales that measure agitation have been used to measure ED in young children These scales are deficient in two main respectsScale contentPsychometric evaluation

These finding lead to the development

of Pediatric Anesthesia Emergence Delirium (PAED

)

Sikich

(2004)Slide39

Date of download: 9/9/2015

Copyright © 2015 American Society of Anesthesiologists. All rights reserved.

From: Development and Psychometric Evaluation of the Pediatric Anesthesia Emergence Delirium Scale

Anesthesiology. 2004;100(5):1138-1145. Slide40

Identify

2010 comparison of these 3 emergence delirium scales Findings include: All three scales correlate reasonably well with each otherEach have individual limitationsAll patients in this study assessed by the experienced pediatric anesthetist observer has having ED scored highly on all three scalesSlide41

PAED ScaleSlide42

PAED SCALE

Pros:PAED Scale strong evidence of measurement reliability and validity.Internal consistency of 0.89 with delirium characteristics of Diagnostic and Statistical Manual of Mental Disorders (DSM IV)High sensitivity and specificity when scores where equal or greater than 10Cons:

Possibly cumbersom

e to use in busy clinical settingSlide43

Cravero ScaleSlide44

Cravero Scale

Pros:Advantage of simplicityCons:Authors subsequently changed definition of items usedItem 4 (crying) is nonspecific to ED and shows distress that could be related to pain, hunger or parental separation

Not scientifically validated

Pro or Con:

Has “sleep” item

component

Argument is not necessary component for agitation/delirium Slide45

Watcha ScaleSlide46

Watcha Scale

Pro:Watcha scale has higher correlation than Cravero with respect to the PAED scalePAED score >12 and Watcha

scale have maximal sensitivity and high specificity in detecting ED

Ease of use

Cons:

No evidence of validation

Minimal research using just

Watcha

scale is effective for determining ED

Cannot rule out other causes for high ratings, pain, anxiety etc. Slide47

Diagnosis

Rule out other factors: begin with basicsHypoxemia: using adhesive sat probe vs. clip onDehydration: case dependent, fluid status, urine output, surgical blood lossHypotension: fluid status, medication related etc.Hypoglycemia: patient dependentAnxiety

Narcotic side effects: itching, urinary retention etc.

Pain: case dependent, procedure, VS, anesthetic technique, intra op medicationsSlide48

Diagnosis

Critical Thinking is a necessary component to diagnosing EDRuling out other causative factors in combinations with….Use of diagnostic toolsDIAGNOSIS IS ED……NOW WHAT?Slide49

MANAGEMENT

Decision to treat ED in PACU is often influenced by the severity and duration of symptoms.Likely to treat pharmacologically when concerns of safety of the child, disruption of surgical site or accidental removal of lines or drainsTwo strategies: Non Pharmacologic

PharmacologicSlide50

Management

Non-pharmacologicAllow child to wake up in their own time (preventative)Decrease stimulationConsider foregoing EKG lead (per anesthesia or department policy)Dark and quiet environmentSoothing verbal reassurance and orientation if appropriateSlide51

Management

Non-pharmacologic (continued)Allowing familiar objects (blanket, stuffed animal)Parental reuniting- if appropriate

Soothing

music or

iPad

cartoons

Physical

restraint- may “wrap” in warm blankets in lieu of restraintsSlide52

Management

Pharmacologic- used as preventative and for management.FentanylMorphineMidazolamDexmedetomidineClonidineKetorolac

PropofolSlide53

Prevention/Management

Vlajkovic et al (2007 )Slide54

Management

Large meta-analysis 201037 articles, 3172 patientsMidazolam, propofol, ketamine, A2 antagonists, fentanyl, 5HT3 inhibitorsPrimary outcomes: incidence of emergence agitationResults in brief:Midazolam, and 5HT3 inhibitors not found to have protective effect against EA/ED

Propofol,

ketamine

, A2 agonists, fentanyl and

preop

analgesia were all found to have a preventative effect.

BJA (2010)Slide55

Management

Research has found PACU nurses have first utilized pain management orders such as fentanylIf assertive treatment is necessary…Single bolus of propofol 0.5-1 mg/kg IVFentanyl 1-2.5 mcg/kg IVDexmedetomidine 0.5 mcg/kg IVHas been successful in decreasing the severity and duration of ED episode.

Banchs

(2014)Slide56

Emergence Delirium: Conclusion

ED is common and self limitingED is usually brief, but pharmacological management may be required Potentially harmful to patient and caregiversChallenging to manageGood post-op pain control is crucialSlide57

Emergence Delirium Conclusion

Pre-op sedation is probably helpful for anxious patientsNO evidence that if left untreated ED had long-term sequelae in childrenMore research is necessary to find better anesthetic agents, diagnostic tools and preventative measures. Slide58

We like Happy TykesSlide59

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Arlington, VA: American Psychiatric Publishing, 2000. 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.

Bajwa

S,

Costi

, D,

Cyna

, A, A comparison of emergence delirium scales following general anesthesia in children. Pediatric Anesthesia 2010;20:704-

11

Bowie, JR. Parents in the operating room? Anesthesiology 1993:78:1192-

3

Cohen IT,

Hannallah

RS, Hummer KA. The incidence of emergence agitation associated with

desflurane

anesthesia in children is reduced by

fentanil

.

Anesth

Analg

2001;93:88–91.

 Slide60

References

Cravero J, Surgenor S, Whalen K. Emergence agitation in paediatric patients after sevoflurane anesthesia

and no surgery: a comparison with halothane.

Paediatr

Anaesth

2000;10: 419 –24

.

Eckenhoff

JE,

Kneale

DH,

Dripps

RD. The incidence and

etiol

-

ogy

of

postanesthetic

excitement. A clinical survey. Anesthesiology 1961;22:667–73.

Fortier MA, Tan ET, Mayes LC, et al. Ethnicity and parental report of postoperative behavioral changes in children.

Paediatr

Anesthe

2013;23:422-

8

Galford

RE. Problems in anesthesiology: approach to diagnosis.

Boston

, MA: Little, Brown & Company, 1992:341–3.

 Slide61

References

Johnson, YJ, Nickerson M, Quezado ZM. An unforeseen peril of parental presence during induction of anesthesia. Anesth Analg 2012;115:1371-4

Kain

ZN, Caldwell-Andrews AA, Mayes LC, et al. Family-centered preparation for surgery improves

perioperative

outcomes in children. Anesthesiology 2007;106:65

74

Kain

ZN, Caldwell-Andrews AA,

Maranets

I, et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors.

Anesth

Analg

2004;99:1648–54.

Kulka

PJ,

Bressem

M,

Tryba

M.

Clonidine

prevents

sevoflurane

- induced agitation in children.

Anesth

Analg

2001;93:335–8.

 Slide62

References

Lepouse et al. BJA 2006: 96(6):747-753McGraw T. Preparing children for the operating room: psychological issues. Can J Anesth 1994;41:1094-103

Oh AY,

Seo

KS, Kim SD, et al. Delayed emergence process does not result in a lower incidence of emergence agitation after

sevoflurane

anesthesia in children.

Acta

Anaesthesiol

Scand 2005;49:297–9.

Picard V, Dumont L,

Pellegrini

M. Quality of recovery in children:

sevoflurane

versus propofol.

Acta

Anaesthesiol

Scand 2000;44:307–10.

Przybylo

HJ, Martini DR,

Mazurek

AJ, et al. Assessing

behaviour

in children emerging from

anesthesia:

can we apply psychiatric diagnostic techniques?

Paediatr

Anaesth

2003;13: 609 –16.

 Slide63

References

Rothbart MK, Ahadi SA, Evans DE. Temperament and personality: origins and outcomes. J Pers Soc Psychol

2000;78:122–35

Sikich

, N,

Lermann

J. Development and psychometric evaluation of the Pediatric Anesthesia Emergence Delirium Scale. Anesthesiology 2004; 11: 1138-

1145

Vlajkovic

&

Sindjelic

,

Anesth

Analg

2007: 104(1):84-

91

Voepel

-Lewis T, Burke C. Differentiating pain and delirium is only part of assessing the agitated child. J

Perianesth

Nurs

2004;19

:298 –9.

Voepel

-Lewis T,

Malviya

S,

Tait

AR. A prospective cohort study of emergence agitation in the pediatric

postanesthesia

care unit.

Anesth

Analg

2003;96:1625–30.