Delirium after anesthesia, also known as emergence delirium (ED) is a clinical condition in which patients have alterations to their attention, awareness, and perceptions. In children, this often results in behavioral disturbances such as crying, sobbing, thrashing and disorientation [1]. Emergence delirium can be a difficult diagnosis to make as most children are in distress postoperatively when awaking from anesthesia. Thus, ED is often a diagnosis of exclusion, and it is important to rule out other causes of altered mental status before ED is established [2]. There is no definitive cause of ED, but risk factors include pain, preoperative anxiety, type of surgical procedures such as ear, nose and throat surgery, temperament of the child, and type of anesthetics used [3]. Its onset is usually at the start of emergence but can occur up to 45 minutes after emergence from anesthesia. A typical clinical picture of ED may present with kicking, head thrusting, poor eye contact, and inconsolable moods [2]. Due to the large range of behaviors in children, the Pediatric Anesthesia Emergence Delirium (PAED) scale was created to assess these behaviors in a reliable way [6].
As the cause of ED is largely unknown, management is guided by targeting risk factors and prevention measures. It is important to first classify children as high or low risk for ED, as physicians can then modify their anesthesia technique to minimize exposures to agents and drugs that are associated with a higher risk of delirium. One example of modifying anesthetic technique is the use of total intravenous anesthesia (TIVA), which aims to use IV anesthetics such as propofol rather than gaseous inductions with sevoflurane. TIVA and propofol have both shown significant reductions in the risk of developing ED [4]. Other studies have explored the use of prophylactic benzodiazepines and a-2 agonists. One study found that oral administration of midazolam (brand name Versed) 10-45 minutes before induction significantly decreased ED in younger patients [5].
Currently, there is no strong evidence of long-term effects and outcomes in children who developed emergence delirium after anesthesia. Some studies have found an association between ED and postoperative maladaptive behavior changes, but these outcomes were based off a 2-week follow up period and further, no cause-effect relationship was established [7]. These maladaptive behaviors may include increased general anxiety, sleep disturbance, nighttime crying, separation anxiety, temper tantrums and enuresis [8]. Further research must be done to evaluate for long-term consequences in pediatric patients to ensure proper postoperative management and, ultimately, long-term wellbeing.
While emergence delirium remains poorly understood in terms of mechanism and causes, detecting risk factors preoperatively and using evidence-based prevention methods can significantly help to reduce the incidence of ED. Long-term consequences from ED remain largely unstudied, and future studies should aim to explore potential chronic maladaptive behaviors in children who experience delirium after anesthesia.
References
- Eckenhoff, James E., et al. “The incidence and etiology of postanesthetic excitement a Clinical Survey.” Anesthesiology, vol. 22, no. 5, 1 Sept. 1961, pp. 667–673, pubs.asahq.org/anesthesiology/article/22/5/667/15930/the-incidence-and-etiology-of-postanesthetic, 10.1097/00000542-196109000-00002.
- Nair, S., and A. Wolf. “Emergence Delirium after Paediatric Anaesthesia: New Strategies in Avoidance and Treatment.” BJA Education, vol. 18, no. 1, Jan. 2018, pp. 30–33, 10.1016/j.bjae.2017.07.001.
- Kwak, Kyung Hwa. “Emergence Agitation/Delirium: We Still Don’t Know.” Korean Journal of Anesthesiology, vol. 59, no. 2, 2010, p. 73, 10.4097/kjae.2010.59.2.73.
- Kanaya, Akihiro, et al. “Lower Incidence of Emergence Agitation in Children after Propofol Anesthesia Compared with Sevoflurane: A Meta-Analysis of Randomized Controlled Trials.” Journal of Anesthesia, vol. 28, no. 1, 26 June 2013, pp. 4–11, 10.1007/s00540-013-1656-y.
- Zhang, Chengmi, et al. “Prophylactic Midazolam and Clonidine for Emergence from Agitation in Children after Emergence from Sevoflurane Anesthesia: A Meta-Analysis.” Clinical Therapeutics, vol. 35, no. 10, Oct. 2013, pp. 1622–1631, 10.1016/j.clinthera.2013.08.016.
- Sikich, Nancy, and Jerrold Lerman. “Development and Psychometric Evaluation of the Pediatric Anesthesia Emergence Delirium Scale.” Anesthesiology, vol. 100, no. 5, May 2004, pp. 1138–1145, 10.1097/00000542-200405000-00015.
- Kain, Zeev N., et al. “Preoperative Anxiety and Emergence Delirium and Postoperative Maladaptive Behaviors.” Anesthesia & Analgesia, Dec. 2004, pp. 1648–1654, 10.1213/01.ane.0000136471.36680.97.
- Menser, Carrie, and Heidi Smith. “Emergence Agitation and Delirium: Considerations for Epidemiology and Routine Monitoring in Pediatric Patients.” Local and Regional Anesthesia, vol. Volume 13, July 2020, pp. 73–83, 10.2147/lra.s181459.