Emergence Delirium

Educational Objectives

The goal of this program is to improve management of emergence delirium. After hearing and assimilating this program, the clinician will be better able to:

1. Select anesthetic regimens to minimize risk for emergence delirium.

Summary

Emergence delirium (ED): a disturbance in a child's awareness and attention to his or her environment with disorientation and perceptual alteration, including hypersensitivity to stimuli and hyperactive motor behavior in the immediate postoperative period; typically occurs ≤30 min of anesthesia emergence and is self-limited to 5 to 20 min; self-resolving; a diagnosis of exclusion; the physician must check the factors that could be causing this in the postoperative period

Incidence: 1% to 2% to ≤22% in adults; some studies show the incidence decreases further after testing post-emergence in the operating room (OR) and again in the post-anesthesia care unit; risk in teenagers can be ≤80% depending on the study; ED found to be more prevalent in children

Risk factors: similar in children and adults; patients with post-traumatic stress disorder and anxiety have been found to have higher incidence (in adults)

Data: for preoperative treatment, midazolam is commonly cited with mixed data (some studies suggest it helps, while others suggest it worsens the condition); melatonin, in different doses, may help with anxiolysis, but there is limited data for its association with ED; Yuen et al (2008) — found a significant difference with a decreased risk for ED in group given intranasal dexmedetomidine (DEX) vs oral midazolam group; meta-analysis (Petre et al [2021]) — found sevoflurane alone had a 40% risk for ED, sevoflurane plus DEX had a 12% risk, and total intravenous anesthesia (TIVA) had a 9% risk; other studies show TIVA with propofol and remifentanil decreased the risk further; rapid wake-ups may have caused ED in the sevoflurane group; slow deescalation in the sevoflurane group did not decrease ED risk; studies show that DEX boluses after induction can decrease the ED risk; a survey among Canadian pediatric anesthesiologists revealed that 42% considered ED an issue in their patients, with 45% providing treatment in anticipation or prophylaxis; treatment for active ED included propofol (42%), midazolam (31%), fentanyl (10%), morphine (7%), and DEX (5%); Han et al (2022) — randomized patients with severe ED to receive propofol (l mg/kg) or DEX (0.5 μg/kg); 19 out of 26 patients in the propofol group experienced ED recurrence (some requiring a second dose), while 100% of those receiving DEX showed no significant ED symptoms; some children in the propofol group experienced self-resolving apnea, and one patient in the DEX group had bradycardia

Associated risks: propofol — a gamma-aminobutyric acid type A receptor agonist and can cause hypotension and respiratory depression (in a dose-dependent manner); DEXA — anα2 agonist (more selective than clonidine); commonly used for ED, with hypotension and bradycardia being common adverse effects; assessing the safety profile and patient's medical history can guide decision-making

Tips: evaluate patients in the preoperative area who seem to have high risk factors for ED; consider remifentanil and propofol rather than sevoflurane to decrease their risk; DEX has been shown to help through various means of administration, eg, bolus or infusion during the anesthetic; the speaker suggests a combination of DEX and propofol for the treatment of patients who require quicker sedation

Readings

Han X, Sun X, Liu X, et al. Single bolus dexmedetomidine versus propofol for treatment of pediatric emergence delirium following general anesthesia. Paediatr Anaesth. 2022 Mar;32(3):446-451. doi: 10.1111/pan.14381; Klabusayova E, Musilova T, Fabian D, et al. Incidence of Emergence Delirium in the Pediatric PACU: Prospective observational trial. Children (Basel). 2022 Oct;9(10):1591. doi: 10.3390/children9101591; Petre MA, Levin DN, Englesakis M, et al. Dexmedetomidine vs. total intravenous anaesthesia in paediatric emergence delirium: A network meta-analysis. European Journal of Anaesthesiology. 2021 November;38(11):p1111-1123. DOI: 10.1097/EJA.0000000000001490; Yuen VM, Hui TW, Irwin MG, et al. A comparison of intranasal dexmedetomidine and oral midazolam for premedication in pediatric anesthesia: a double-blinded randomized controlled trial. Anesth Analg. 2008 Jun;106(6):1715-21. doi: 10.1213/ane.0b013e31816c8929; Zhang X, Bai Y, Shi M, et al. Effect of different administration and dosage of dexmedetomidine in the reduction of emergence agitation in children: a meta-analysis of randomized controlled trials with sequential trial analysis. Transl Pediatr. 2021;10(4):929-957. doi: 10.21037/tp-21-105.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Van Tienderen was recorded at the 62nd Clinical Conference in Pediatric Anesthesiology, held February 16-18, 2024, in Anaheim, CA, and presented by the Pediatric Anesthesiology Foundation, Children’s Hospital Los Angeles. For information about upcoming CME activities from this presenter, please visit www.peds-gas.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

AN664303

Qualifies for:

ABA MOCA, Clinical Pharmacology

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.