Journal Reading of PGY

1. Journal Reading:
Emergence delirium in
Children
PGY 吳易儒

3. Purpose of Review
● Volatile agents (no evidence)
● Recent Findings:
○ preventing pre-OP anxiety
○ providing sufficient analgesia
○ intra-OP sedative agents: ketamine,
clonidine, dexmedetomidine,
gabapentine, midazolam, magnesium,
hydroxyzine, midazolam,
dexamethasone
● Tx :
○ propofol, opoid
○ dexmedetomidine(prevent PONV)

4. Introduction
● Adult: postopreative agitation
● Children: emergence delirium
● No strong evidence of:
○ pathophysiology of ED
○ the relation between ED and fast acting volatile agents

5. Cause of ED

6. Cause of ED
● post-operative pain
● pharmacokinetics
● pharmacodynamics of anesthetics agents

7. Cause of ED - post OP pain
● a study: 4 case with post-OP agitation (1 is children)
● paranoid sensation
● fear for anesthesiologists/surgeons
● but occurs in non-painful procedures (Pediatric imaging)

8. Cause of ED - Pharmacokinetics/dynamics
● Clearance of volatile agents from CNS : different recovery rate of brain
functions
● Late recovery of congitive function compared to audition and locomotion:
cause confusion state
● Sevoflurane and desflurane use increase incidence of ED
● Propofol, Sevoflurane or desflurane have preventive effect of ED
● The resting state and dynamic state can not be activated simultaneously
● Different cognitive control between children and adultes
● ASA 2012 found similar in EEG patteren in children’s ED and night terrors

9. ● resting state= resting functional connectivity network, when patients
are asked to think
● dynamic state= executive control network, when patients are focusing
on external environment

10. Clinical
presentation and
diagnostic criteria

11. Clinical presentations and diagnostic criteria
● ED incidence from 2-80% , different from
○ agent
○ preventive strategies
○ validated tools
○ different thresholds to score

12. Clinical presentations and diagnostic criteria
● Risk factors of ED:
○ have emergence agitation
○ preschool children(40% pre v.s. 11.5% school)
○ male
○ Sevolurane / desflurane use (v.s. isoflurane, halothane, iv agents)
○ ENT surgery
○ pre-OP anxiety

13. Clinical presentations and diagnostic criteria
● Vopel-Lewis (2003, Anesth Analg) : factors associated with ED
○ activity, rhythmicity, approachability, adaptability, intensity, mood, per- sistence, distractibility
and sensitivity
○ adaptability significantly associated with ED when facing anxicious
● Pre-OP anxiety is strong associated with ED

14. Clinical presentations and diagnostic criteria
● Classical predictors of pre-OP anxiety:
○ young age
○ parental anxiety
○ very few siblings
○ poor sociability
○ few social adaptative capability
○ poor quality of previous medical experience
○ lack of enrollment in a day care surgery
○ low rating for activity

15. Clinical presentations and diagnostic criteria
● ED= emotional agitation state (confusion of recognizing surrounding
environment)
○ soon(14 +- 11mins) ~ 45mins
○ no eye contact with surrounding person, inconsolable
● Paediatr Anaesth 2011, specific symptoms:(18m~ 6y)
○ involuntary agitation with kicking
○ absence of eye contact with caregivers or parents (with eyes staring or averting)
○ inconsolability and absence of awareness of the surroundings.

16. Clinical presentations and diagnostic criteria
● 2004, Sikich and
Lerman: Pediatric
Anesthesia
Emergence Delirium
(PAED) scale
● >10 , sensibility of
64% and a specificity
of 86%

17. Clinical presentations and diagnostic criteria
● 2010, Anesth Analg, mal-adaptive behavior in post-OP stage
○ sleep disturbances
○ bed wetting
○ temper tantrums
○ attention seeking
○ loneliness fear as well as high stress level for parents

18. Clinical presentations and diagnostic criteria
● Paediatr Anaesth 2010, risk factors of ED:
○ younger age
○ lower birth order
○ an inhibited temperament
○ pre-OP anxiety (in parents and children)
○ noninclusion in a day care surgery program
○ sevoflurane-based anesthesia
○ post-OP pain
● no study can clearly support, but parents should be informed

19. Prevention of ED

20. Prevention of ED - Pharmacological
● Propofol as induction showed no efficiency in decreasing ED, related to
its short half-life
● Premedicatio clonidine and melatonin decreased the incidence of ED
compared with midazolam.
● Dexmedetomine end of surgery (0.3 mg/kg) / continuously better than
○ propofol bolus of 1 mg/kg at the end of surgery
○ or contiouous ketamine
○ although it may increase the duration of PACU
○ but the effect of preventing ED and post operative N/V is recommended
○ recently found as effective as ACT-codeine association in preventing ED (pain part)

21. Prevention of ED - Pharmacological
● Propofol given at the end of surgery or continuous during surgery
● intraoperative fentanyl
● ketamine (systemically/regional)
● clonidine (systemically/regional)
● dexmedetomidine (systemically/regional);
● preoperative gabapentine
● intraoperative Mg infusion
● preoperative midazolam
● intraoperative dexamethasone

23. Prevention of ED - Non-pharmacological
● Cochrane Database Syst Rev 2009, focus on
decreasing the preoperative anxiety
● Strategies to decrease children and parents anxiety:
○ quiet induction with decreased sensory stimuli
○ music therapy,
○ distraction and hypnosis,
○ clown doctors acupressure,
○ videotapes information movies before induction
○ parents’ information
● Other study : parents present showed inconsistently
results

24. Prevention of ED - Non-pharmacological
● Anesthesiology 2007, Kain: family-based preparation: ADVANCE
strategy
○ Anxiety-reduction,
○ Distraction,
○ Video modeling and education,
○ Adding parents,
○ No excessive reassurance安慰,
○ Coaching,
○ Exposure/shaping
● More effective than premedication midazolam

25. Treatment of ED

26. Treatment of ED
● Pharmacologic treatment : iv sedative agents
○ midazolam 0.1 mg/kg [37]
○ propofol 0.5 – 1 mg/kg [38]
○ or opioid agents (iv fentanyl 1 – 2 mg/kg [39]
○ Dexmedetomine showed better than propofol in prevention but never been studied in
treatment
● All of these agents may delay discharge from PACU
● Physicians are encouraged to use compounds as analgesia or PONV
preventive agents: sufentanil, dexmedetomidine, clonidine or
ketamine.

27. Conclusion

28. Conclusion
● ED is common in
○ anesthetized preschool children
○ especially sevoflurane use
● Preventive strategies:
○ prevent pre-operative anxiety
○ treating post-OP pain
○ propofol at end of OP
○ intra-OP dexmedetomidine and dexamethasone
○ parents should be informed possible post-OP maladaptive behaviors

29. Thanks for your attention.