Emergence Delirium

Question 1

You are asked to review 3-year-old male patient in recovery following insertion of grommets under a general anaesthetic. He is agitated and restless, and his mother is becoming increasingly upset by his behaviour.

What are the potential causes of agitation in this patient?

Answer 1

• Pain.
• Hypoxia.
• Hypoglycaemia.
• Residual anaesthetic agent.
• Hunger/thirst.
• Hypothermia.
• Sepsis.
• Need for micturition or defaecation.
• Emergence delirium.

Question 2

What is your initial management?

Answer 2

• Review the patient in recovery with their anaesthetic chart and a full set of bedside observations including a blood glucose level and temperature to identify or rule out treatable causes.
• Reassure the mother and encourage her to try and soothe the child by holding him on the bed if appropriate.
• Consider location – quiet corner in recovery, familiar faces.
• Ensure adequate analgesia has been given and prescribed perioperatively.
• Escalate to senior paediatric anaesthetist and/or surgeons if any specific concerns.

Question 3

What is emergence delirium?

Answer 3

• A collection of symptoms that may be displayed in children in the immediate postoperative period.
• This includes disturbances in awareness and interaction with their environment, increased motor responses and hypersensitivity to light and sound.
• Behaviours displayed include confusion, thrashing, screaming, avoiding eye contact and inconsolability.

Question 4

What are the risk factors for the development of emergence delirium?

Answer 4

Patient factors:
* Pre-school age.
* Male.
* Anxiety preoperatively.
* Anxious parent.

Surgical factors:
* Ear, nose and throat surgery.
* Eye surgery.

Anaesthetic factors:
* Use of short-acting volatile anaesthetic agents e.g. desflurane and sevoflurane.

Question 5

How can the risk of developing emergence delirium be decreased?

Answer 5

• Parental and child education preoperatively, including play therapy, preoperative assessment and familiarisation with anaesthetic techniques e.g. facemask.
• Consider a total intravenous anaesthetic technique.
• Single dose of propofol (1 mg/kg) at the end of the procedure, prior to emergence.
• Consider the use of intraoperative pharmacological agents e.g.
  midazolam, clonidine, dexmedetomidine, ketamine, fentanyl.

Question 6

What are the options for reducing preoperative anxiety in children?

Answer 6

Non-pharmacological:
* Preoperative parental and child education e.g. videos, leaflets, pre-admission visit, familiarisation with anaesthetic technique e.g. facemask, cannula.

• Play therapy and discussions with psychologists.
• Distraction e.g. toys, books and familiar videos or music.
• Age appropriate, effective communication with the patient and their parent.
• Presence of a calm parent at induction.
• Involvement of the child in the anaesthetic e.g. choosing a “flavour” of the anaesthetic mask.
• Adjustment of environment e.g. minimal persons in anaesthetic room.
• Deep breathing and relaxation tasks if age appropriate.

Pharmacological:
* Benzodiazepines e.g. midazolam (oral or buccal).

• Alpha-2 receptor agonists e.g. clonidine.
• NMDA receptor antagonists e.g. ketamine.
• Opioids.

Question 7

When is the use of sedative premedication not recommended in children?

Answer 7

• Known or predicted difficult airway or intubation.
• Risk of hypoventilation e.g. obstructive sleep apnoea, raised BMI.
• Aspiration risk e.g. emergency surgery/child that has not been starved.
• Reduced conscious level.
• Sepsis/systemic infection.
• Allergy to anxiolytic medication.