Updated May 2019 Valerie Au MD Andrew Infosino MD Department of Anesthesia and Perioperative Care University of California San Francisco Disclosures No relevant financial relationships ID: 1039896
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1. Emergence Delirium in Pediatric PatientsUpdated May 2019Valerie Au, M.D. Andrew Infosino, M.D.Department of Anesthesia and Perioperative CareUniversity of California, San Francisco
2. DisclosuresNo relevant financial relationships
3. Learning ObjectivesRecognize emergence delirium in pediatric patients in the recovery room and differentiate it from agitation due to pain.Compare and contrast the PAED, Cravero and Watcha numerical scales for rating emergence deliriumIdentify the risk factors for emergence delirium in pediatric patientsDescribe approaches for reducing the incidence of emergence deliriumDevelop an algorithm for treating emergence delirium in the recovery room
4. Emergence Delirium: What is it?Dissociated state of consciousness after anesthesiaCrying, thrashing, kicking, uncooperativeIncoherent, inconsolable and combative No eye contact, no recognition of familiar objects, parents or caregivers
5. Occurs in 10 – 20% of children who have anesthetics1Most common from age 2 – 5 years1Emergence delirium usually lasts from 3 – 45 minutes with a mean duration of 14 minutes290 – 95% of cases resolve by themselves in less than 30 minutes3Emergence Delirium: What is it?Cote C, A Practice of Anesthesia for Infants and Children 6eVoepel-Lewis et al., Anesth Analg 2003; 96:1625-30Lee CJ et al., Korean J Anesthesiol 2010; 59:75-81
6. Emergence Delirium: Why is it a problem?Can harm parents or caregiversCan harm themselvesCan pull out IVs, pull off monitors and remove dressings
7. Requires increased nursing resourcesAdditional medication administration Longer recovery room stays and increased costsFrightening to parentsDecreased parental satisfaction scoresPost-operative behavioral changesEmergence Delirium: What is the impact?
8. Post-operative behavioral changesIncreased general anxietyProblems with separationSleep disturbancesBedwettingTemper tantrumsEating disturbancesEmergence Delirium: What is the impact?
9. Both can be difficult to assess in preverbal children and preschoolersBoth present similarly with crying, thrashing and inconsolabilityED can occur after non-painful procedures such as MRIsDifferentiating Emergence Delirium (ED) from post-operative pain
10. Simple screening tools for PACU nursing, but with low specificity for distinguishing delirium from agitation/painWatcha ScaleCravero ScaleMore complex validated scale with higher specificity for deliriumPAED ScaleHow Do You Measure Emergence Delirium?
11. BehaviorScoreCalm1Crying, can be consoled2Crying, cannot be consoled3Agitated, thrashing around4ED Assessment Tools: WATCHA SCALEScores ≥ 3 indicative of emergence delirium
12. ED Assessment Tools: CRAVERO SCALEScores ≥ 4 indicative of emergence deliriumBehaviorScoreObtunded, no response to stimulation1Asleep, responds to stimulation2Awake and responsive3Crying for > 3 minutes4Thrashing behavior requiring restraints5
13. ED Assessment Tools:PAED SCALEBehaviorNot at allJust a littleQuite a bitVery muchExtremelyEye contact43210Purposeful actions43210Aware of surroundings43210Restless01234Inconsolable01234Scores > 12: very sensitive and specific for EDBajwa SA et al., Ped Anesth 2010; 20:704-711
14. Question:What can we do as anesthesiologists to reduce the incidence of emergence delirium?
15. Answers:Identify risk factorsDetermine best anesthetic approach to decrease the incidence of ED in high risk cases
16. Age – highest incidence in 2-5 year-olds1 Anxiety – higher incidence in preexisting anxiety of patients and/or parents2Surgical factors – associated with ENT/ophthalmological procedures3Volatile anesthetics3Prior history of emergence deliriumEmergence Delirium: Risk FactorsCote, A Practice of Anesthesia for Infants and Children 6eKain et al. Anesth Analg 2004; 99:1648–1654Voepel-Lewis et al., Anesth Analg 2003; 96:1625-30
17. Preoperative counseling and educationChild Life servicesParental presence during inductionDistraction techniques: videos, music, video games, virtual reality headsetsAllowing the child to bring a favorite stuffed animal or blanket into the operating room Pharmacologic preoperative anxiolysisTreating Preoperative Anxiety
18. Effective PropofolDexmedetomidineClonidineKetamineFentanylIV Midazolam at endPeri-op analgesiaIneffectivePreop oral midazolamPreop gabapentinMelatoninMagnesium5-HT3 antagonistsParental presence at emergencePharmacological Approaches
19. Propofol based anesthetic (induction and maintenance infusion) decreases the incidence of ED compared to either desflurane or sevoflurane 1,2Propofol bolus at induction alone does not decrease the incidence of ED1Propofol bolus (1mg/kg) at the end of a sevoflurane based anesthetic decreases the incidence of ED vs placebo without lengthening recovery time3Reducing ED: PropofolDahmani et al, BJA, 2010; 104:216-23Kanaya et al, J Anesth 2014; 28:4-11Van Hoff et al, Pediatric Anesthesia, 2015; 25:668-76
20. Dexmedetomidine IV bolus prior to end of a sevoflurane based anesthetic decreases the incidence of ED1,2,3,4Both IV bolus and infusions are effective1May increase emergence, extubation and PACU times3,4Clonidine also decreases the incidence of ED2Reducing ED: Alpha-2 AgonistsPickard et al, BJA, 2014; 112:982-90Dahmani et al, BJA, 2010; 104:216-23Zhu et al, PLoS ONE 2015; 10(4): e0123728Zhang et al., PLoS ONE 2014; 16:e99718
21. Ketamine 6 mg/kg PO preoperatively decreases the incidence of ED1Ketamine 0.25 mg/kg IV 10 minutes prior to the end of surgery decreases the incidence of ED2Does not lengthen recovery time2Reducing ED: KetamineKararmaz A et al., Paediatr Anesth 2004; 14:477-482Abu-Shawan I and Chowdary K. Pediatric Anesthesia 2007; 14:846-50
22. Fentanyl prior to end of surgery decreases the incidence of ED1,2,3Fentanyl 1 mcg/kg bolus at end of surgery effective1 IV and intranasal found to be effective3Increase in PONV1,3Can increase in emergence time and recovery time1,3Reducing ED: FentanylKim et al., Ped Anesth 2017; 27:885-892Dahmani et al., BJA 2010; 104:216-223Shi et al., Plos One 2015 10:e0135244
23. Meta-analysis by Dahmani et al. of 4 studies demonstrated that oral midazolam does NOT decrease the incidence of ED1Study by Cho et al2 and a study by Kim et al3 both demonstrated that IV midazolam given prior to emergence DOES decrease the incidence of EDReducing ED: MidazolamDahmani et al., BJA 2010; 104:216-223Cho et al., Anesthesiology 2014; 2010:1354-61Kim et al., Ped Anesth 2017; 27:885-892
24. Gabapentin MagnesiumMelatonin5-HT3 AntagonistsAcupunctureKetorolacReducing ED:What Doesn’t Work?Dahmani et al., BJA 2010; 104:216-223
25. A 4 year old with history of emergence delirium after a previous anesthetic presents for T & A.What should I do to decrease this patient’s risk of emergence delirium?A Case…
26. Recommendations For High Risk CasesMinimize preoperative anxiety in parents and patient including nonpharmacologic techniquesPropofol based anesthetic, rather than sevofluraneDexmedetomidine 0.3 – 0.5 mcg/kg IV prior to emergence
27. Question:What can we do as anesthesiologists to treat emergence delirium in the recovery room?
28. Answers:Rule out other causes of agitation in the recovery roomReassure parentsEducate PACU nurses Pharmacologic treatment
29. Hypoxemia – check O2 SatUrinary retention – evaluate IVFs given and last voidIrritation from foley catheterHypoglycemia – check blood glucose in at risk patientsPain – evaluate for pain and treat with appropriate medication (e.g. fentanyl)29Ruling Out Other Causes
30. Tincture of Time: Remember that the vast majority of cases of of emergence delirium resolve by themselves in less than 30 minutes Reassure parentsEducate PACU nurses and parents 30Emergence Delirium:Treatment
31. If emergence delirium persists in the PACU consider IV bolus of either:Dexmedetomidine (0.2-0.4 mcg/kg) Propofol (1-2 mg/kg) Remember to have emergency airway equipment available at the bedside31Emergence Delirium:Treatment
32. ED is a complex behavioral state that is poorly understood ED is difficult to distinguish from agitation/pain PAED is best current assessment tool for EDPropofol based anesthetic with Dexmedetomidine is best approach to decrease the incidence of ED in high risk casesConsider Dexmedetomidine or Propofol IV bolus to manage ED in PACUConclusions
33. References:References:Abu-Shahwan MD, Chowdary K. Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia. Pediatric Anesthesia 2007 17: 846–850Bajwa SA, Costi D, Cyna AM. A comparison of emergence delirium scales following general anesthesia in children. Pediatric Anesthesia 2010; 20:704-711Cho EJ, Yoo SZ, Cho JE, Lee HW. Comparison of effects of 0.03 and 0.05 mg/kg midazolam with placebo on prevention of emergence agitation in children having strabismus surgery. Anesthesiology 2014; 210: 1354-61Cote, C, Jerrold L, Anderson Brian (2013) A Practice of Anesthesia for Infants and Children 6e. Philadelphia, PA. SaundersDahmani S, Stany I, Brasher C, et al. Pharmacological prevention of sevoflurane and desflurane-related emergence agitation in children: a meta-analysis of published studies. Br J Anaesth 2010; 104: 216–23Dahmani S, Delivet H, Hilly J. Emergence delirium in children: an update. Curr Opin Anesthesiol 2014; 27: 309–315.Kararmaz A, Kaya S, Turhanoglu S, Ozyilmaz MA. Oral ketamine premedication can prevent emergence agitation in children after desflurane anaesthesia. Paediatr Anesth 2004; 14:477-482Kain ZN, Caldwell-Andrews AA, Maranets I, et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviours. Anesth Analg 2004; 99:1648–1654Kanaya A, Kuratani N, SatohD, Kurosawa S. Lower incidence of emergence agitation in children after propofol anesthesia compared with sevoflurane: a meta-analysis of randomized controlled trials. J Anesth 2014; 28:4–11Kim KM, Lee KH, Kim YH, Ko MJ, Jun J, Kang E. Comparison of effects of intravenous midazolam and ketamine on emergence agitation in children: randomized controlled trial. J International Med Res. 2016; 44:258–266Kim N, Park JH, Lee JS, Choi T, Kim M. Effects of intravenous fentanyl around the end of surgery on emergence agitation in children: systematic review and meta-analysis. Ped Anesth 2017; 27:885–892
34. References:References (cont.):Lee CJ et al. The effect of Propofol on emergence agitation in children receiving sevoflurane for adenotonsillectomy. Korean J Anesthesiol 2010:59:75-81Pickard A, Davies P, Birnie K, Beringer R. Systematic review and meta-analysis of the effect of intraoperative a2-adrenergic agonists on postoperative behavior in children. . Br J Anaesth 2014; Shi F, Xiao Y, Xiong W, Zhou Q, Yang P, Huang X. Effects of fentanyl on emergence agitation in children under sevoflurane anesthesia: Meta-analysis of Randomized Controlled Trials. Plos One 2015 10:e0135244 Van Hoff SL, O’Neill ES, Cohen LC, Collins BA. Does a prophylactic dose of Propofol reduce emergence agitation in children receiving anesthesia? A systematic review and meta-analysis. Paediatr Anaesth 2015; 25:668-76Vlajkovic G, Sindjelic R. Emergence delirium in children: many questions, few answers. Anesthesia & Analgesia 2007; 104:84-91 Voepel-Lewis T, Malviya S, Tait AR. A Prospective Cohort Study of Emergence Agitation in the Pediatric Postanesthesia Care Unit. Anesth Analg 2003; 96:1625-30Zhang C, Hu J, Liu X, Yan J. effects of intravenous dexmedetomidine on emergence agitation in children under sevoflurane anesthesia: a meta-analysis of randomized controlled trials. PLoS ONE 2014; 16:e99718Zhu M, Wang H, Zhu A, Niu K, Wang G. Meta-Analysis of Dexmdetomidine on Emergence Agitation and Recovery Profiles in Children after Sevoflurane Anesthesia: Different Administration and Different Dosage. PLoS ONE 2015; 10(4): e012372834