Emergence delirium - Revision history

Bsumida1 at 01:45, 31 August 2022

2022-08-31T01:45:06Z

Bsumida1 at 01:33, 31 August 2022

2022-08-31T01:33:41Z

← Older revision		Revision as of 18:33, 30 August 2022
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	==== Inhalational agents (Sevofluorane) ====		==== Inhalational agents (Sevofluorane) ====
	Inhalational agents, ~~notable~~ sevofluorane, have been shown to increase the incidence of emergence delirium. In a 2007 study of 189 preschool and school-age children receiving either propofol or sevofluorane as their primary anesthetic, the incidence of emergence delirium was found to be significantly higher in both sevofluorane groups (as high as 42% in the preschool sevofluorane group 5 minutes after extubation).<ref>{{Cite journal\|last=Nakayama\|first=Shin\|last2=Furukawa\|first2=Hajime\|last3=Yanai\|first3=Hiromune\|date=2007\|title=Propofol reduces the incidence of emergence agitation in preschool-aged children as well as in school-aged children: a comparison with sevoflurane\|url=https://pubmed.ncbi.nlm.nih.gov/17285408/\|journal=Journal of Anesthesia\|volume=21\|issue=1\|pages=19–23\|doi=10.1007/s00540-006-0466-x\|issn=0913-8668\|pmid=17285408}}</ref> A proposed explanation for this is that sevoflurane may cause "differential recovery rates in brain function, due to differences in clearance of inhalational anesthetics from the central nervous system...whereas ~~audition~~ and locomotion recover first, cognitive function recovers later, resulting in [agitation]."<ref name=":1" />		Inhalational agents, notably sevofluorane, have been shown to increase the incidence of emergence delirium. In a 2007 study of 189 preschool and school-age children receiving either propofol or sevofluorane as their primary anesthetic, the incidence of emergence delirium was found to be significantly higher in both sevofluorane age groups (as high as 42% in the preschool sevofluorane group 5 minutes after extubation).<ref>{{Cite journal\|last=Nakayama\|first=Shin\|last2=Furukawa\|first2=Hajime\|last3=Yanai\|first3=Hiromune\|date=2007\|title=Propofol reduces the incidence of emergence agitation in preschool-aged children as well as in school-aged children: a comparison with sevoflurane\|url=https://pubmed.ncbi.nlm.nih.gov/17285408/\|journal=Journal of Anesthesia\|volume=21\|issue=1\|pages=19–23\|doi=10.1007/s00540-006-0466-x\|issn=0913-8668\|pmid=17285408}}</ref> A proposed explanation for this is that sevoflurane may cause "differential recovery rates in brain function, due to differences in clearance of inhalational anesthetics from the central nervous system...whereas [auditory centers] and locomotion recover first, cognitive function recovers later, resulting in [agitation]."<ref name=":1" />

	==== Pediatric patients between the ages of 2 and 5 ====		==== Pediatric patients between the ages of 2 and 5 ====
			Neuronal excitability is higher in pediatric patients which may contribute to emergence delirium. Studies have shown an increase in epileptiform discharges in children undergoing sevofluorane anesthesia.<ref name=":0">{{Cite journal\|last=Koch\|first=Susanne\|date=Dec 2018\|title=Emergence delirium in children is related to epileptiform discharges during anaesthesia induction - An observational study\|url=https://journals-lww-com.proxy1.library.jhu.edu/ejanaesthesiology/Fulltext/2018/12000/Emergence_delirium_in_children_is_related_to.5.aspx\|journal=European Journal of Anaesthesiology\|volume=35(12)\|pages=929-936}}</ref> Sevofluorane targets GABA receptors "enhancing neuronal inhibition, [blocks] potassium and hyperpolarization-activated cyclic nucleotide-gated cation channels, and binds [NMDA] receptors blocking glutamate release which may result in enhanced neuronal hyperexcitability."<ref name=":0" />

	==== Other risk factors ====		==== Other risk factors ====

	* Rapid awakening		* Rapid awakening
	* Preoperative anxiety		* Preoperative anxiety or baseline neuropsychiatric conditions (migraine, ADHD, epilepsy)
	* Preoperative medications (benzodiazepines~~, opioids~~, scopolamine)		* Preoperative medications (benzodiazepines, scopolamine)
	* Perioperative pain		* Perioperative pain

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	Emergence delirium may manifest as:		Emergence delirium may manifest as:

	* Increased agitation~~/Hyperexcitability~~		* Increased agitation or hyperexcitability
	* Disinhibition		* Disinhibition
	* Confusion		* Confusion
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	=== Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> ===		=== Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> ===
	A 2022 metanalysis of pediatric cases using sevofluorane as maintenance showed a significant reduction in emergence delirium with the use of Precedex (Dexmedetomidine), Ketamine, and Fentanyl.		A 2022 metanalysis of pediatric cases using sevofluorane as maintenance showed a significant reduction in emergence delirium with the use of Precedex (Dexmedetomidine), Ketamine, and Fentanyl.<ref name=":2">{{Cite journal\|last=Wang\|first=Wuchao\|last2=Huang\|first2=Panchuan\|last3=Gao\|first3=Weiwei\|last4=Cao\|first4=Fangli\|last5=Yi\|first5=Mingling\|last6=Chen\|first6=Liyong\|last7=Guo\|first7=Xiaoli\|date=2016-11-10\|title=Efficacy and Acceptability of Different Auxiliary Drugs in Pediatric Sevoflurane Anesthesia: A Network Meta-analysis of Mixed Treatment Comparisons\|url=https://www.nature.com/articles/srep36553\|journal=Scientific Reports\|language=en\|volume=6\|issue=1\|pages=36553\|doi=10.1038/srep36553\|issn=2045-2322}}</ref>

	===== Precedex =====		===== Precedex =====
	Precedex is a selective alpha-2 agonist which acts on the central nervous system to treat pain, provide sedation/anxiolysis, and decrease sympathetic tone. It can be bolused in small increments (4 mcg/dose) or run as a low-dose infusion intraoperatively and is commonly used in pediatrics for the prevention of emergence delirium and has been shown to significantly reduce agitation, cough, pain, post-op nausea/vomiting (PONV), and shivering in the PACU.<ref ~~name=":0"~~>{{Cite ~~web~~\|url=https://~~login~~.proxy1.library.jhu.edu/~~login?qurl~~=~~https://pubmed.ncbi.nlm.nih.gov%2f35085107%2f~~\|~~access-date~~=~~2022~~-~~08-30~~\|~~website~~=~~login.proxy1.library.jhu.edu~~}}</ref> Its use may be limited by hemodynamic effects (bradycardia, hypotension).		Precedex is a selective alpha-2 agonist which acts on the central nervous system to treat pain, provide sedation/anxiolysis, and decrease sympathetic tone. It can be bolused in small increments (4 mcg/dose) or run as a low-dose infusion intraoperatively and is commonly used in pediatrics for the prevention of emergence delirium and has been shown to significantly reduce agitation, cough, pain, post-op nausea/vomiting (PONV), and shivering in the PACU.<ref>{{Cite journal\|last=Sin\|first=Jeremy\|date=Jun 2022\|title=The Effect of Dexmedetomidine on Postanesthesia Care Unit Discharge and Recovery: A Systematic Review and Meta-Analysis\|url=https://pubmed-ncbi-nlm-nih-gov.proxy1.library.jhu.edu/35085107/\|journal=Anesth Analg\|volume=134(6)\|pages=1229-1244\|via=Pub Med}}</ref> Its use may be limited by hemodynamic effects (bradycardia, hypotension).

	===== Ketamine and Fentanyl =====		===== Ketamine and Fentanyl =====
	Ketamine is an NMDA receptor antagonist which also has sedative and analgesic effects. In the above study, it had almost equal efficacy in treating emergence delirium when compared to Precedex.<ref name=":0" /> Similar to Precedex, it can be given in small boluses (10 mg/dose) or run as a low-dose infusion intraoperatively. Its use may be limited by concern for its dissociative effects. These are usually decreased with perioperative administration of benzodiazepine (i.e. Versed) but can also be prevented with concurrent use of Precedex. In a corresponding manner, ketamine provides hemodynamic stability which may balance/prevent the bradycardia and hypotension observed with Precedex when used in combination.<ref>{{Cite journal\|last=Kim\|first=Joong-Goo\|last2=Lee\|first2=Han-Bin\|last3=Jeon\|first3=Sang-Beom\|date=2019\|title=Combination of Dexmedetomidine and Ketamine for Magnetic Resonance Imaging Sedation\|url=https://www.frontiersin.org/articles/10.3389/fneur.2019.00416\|journal=Frontiers in Neurology\|volume=10\|doi=10.3389/fneur.2019.00416/full\|issn=1664-2295}}</ref>		Ketamine is an NMDA receptor antagonist which also has sedative and analgesic effects. In the above study, it had almost equal efficacy in treating emergence delirium when compared to Precedex.<ref name=":2" /> Similar to Precedex, it can be given in small boluses (10 mg/dose) or run as a low-dose infusion intraoperatively. Its use may be limited by concern for its dissociative effects. These are usually decreased with perioperative administration of benzodiazepine (i.e. Versed) but can also be prevented with concurrent use of Precedex. In a corresponding manner, ketamine provides hemodynamic stability which may balance/prevent the bradycardia and hypotension observed with Precedex when used in combination.<ref>{{Cite journal\|last=Kim\|first=Joong-Goo\|last2=Lee\|first2=Han-Bin\|last3=Jeon\|first3=Sang-Beom\|date=2019\|title=Combination of Dexmedetomidine and Ketamine for Magnetic Resonance Imaging Sedation\|url=https://www.frontiersin.org/articles/10.3389/fneur.2019.00416\|journal=Frontiers in Neurology\|volume=10\|doi=10.3389/fneur.2019.00416/full\|issn=1664-2295}}</ref>

	Fentanyl is a mu-opioid receptor agonist which may nonspecifically reduce emergence delirium by treating perioperative pain. It may be limited by an increased risk of PONV.		Fentanyl is a mu-opioid receptor agonist which may nonspecifically reduce emergence delirium by treating perioperative pain. It may be limited by an increased risk of PONV.
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	* Consider other sources of discomfort (full bladder, hypothermia)		* Consider other sources of discomfort (full bladder, hypothermia)
			*If acutely agitated and danger to self/others, consider haloperidol
			*Avoid additional benzodiazepines as this may worsen delirium

	== References ==		== References ==

	[[Category:Comorbidities]]		[[Category:Comorbidities]]

Bsumida1 at 01:04, 31 August 2022

2022-08-31T01:04:29Z

Show changes

Bsumida1 at 00:10, 31 August 2022

2022-08-31T00:10:52Z

← Older revision		Revision as of 17:10, 30 August 2022
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	===== Precedex =====		===== Precedex =====
	Precedex is a selective alpha-2 agonist which acts on the central nervous system to treat pain, provide sedation/anxiolysis, and decrease sympathetic tone. It can be bolused in small increments (4 mcg/dose) intraoperatively and is commonly used in pediatrics for the prevention of emergence delirium and has been shown to significantly reduce agitation, cough, pain, post-op nausea/vomiting (PONV), and shivering in the PACU.<ref name=":0">{{Cite web\|url=https://login.proxy1.library.jhu.edu/login?qurl=https://pubmed.ncbi.nlm.nih.gov%2f35085107%2f\|access-date=2022-08-30\|website=login.proxy1.library.jhu.edu}}</ref>		Precedex is a selective alpha-2 agonist which acts on the central nervous system to treat pain, provide sedation/anxiolysis, and decrease sympathetic tone. It can be bolused in small increments (4 mcg/dose) or run as a low-dose infusion intraoperatively and is commonly used in pediatrics for the prevention of emergence delirium and has been shown to significantly reduce agitation, cough, pain, post-op nausea/vomiting (PONV), and shivering in the PACU.<ref name=":0">{{Cite web\|url=https://login.proxy1.library.jhu.edu/login?qurl=https://pubmed.ncbi.nlm.nih.gov%2f35085107%2f\|access-date=2022-08-30\|website=login.proxy1.library.jhu.edu}}</ref> Its use may be limited by hemodynamic effects (bradycardia, hypotension).

	===== Ketamine and Fentanyl =====		===== Ketamine and Fentanyl =====
	Ketamine is an NMDA receptor antagonist which also has sedative and analgesic effects. In the above study, it had almost equal efficacy in treating emergence delirium.<ref name=":0" /> It may ~~provide synergistic benefit~~ with Precedex ~~not only~~		Ketamine is an NMDA receptor antagonist which also has sedative and analgesic effects. In the above study, it had almost equal efficacy in treating emergence delirium when compared to Precedex.<ref name=":0" /> Similar to Precedex, it can be given in small boluses (10 mg/dose) or run as a low-dose infusion intraoperatively. Its use may be limited by concern for its dissociative effects. These are usually decreased with perioperative administration of benzodiazepine (i.e. Versed) but can also be prevented with concurrent use of Precedex. In a corresponding manner, ketamine provides hemodynamic stability which may balance/prevent the bradycardia and hypotension observed with Precedex.

	Fentanyl is a mu-opioid receptor agonist which may nonspecifically reduce emergence delirium by treating perioperative pain. It may be limited by an increased risk of PONV.		Fentanyl is a mu-opioid receptor agonist which may nonspecifically reduce emergence delirium by treating perioperative pain. It may be limited by an increased risk of PONV.

Bsumida1: Created page with "{{Infobox comorbidity | other_names = | anesthetic_relevance = | specialty = | signs_symptoms = | diagnosis = | treatment = | image = | caption = }} Emergence delirium or post-anesthetic delirium is a transient state of agitation, confusion/disorientation, and irritability that occurs after the withdrawal of anesthesia.{{Cite journal|last=Barreto|first=Ana Carolina Tavares Paes|last2=Paschoal|first2=Ana Carolina Rangel da Rocha|last3=Farias|first3=Carolina..."

2022-08-30T23:58:21Z

Created page with "{{Infobox comorbidity | other_names = | anesthetic_relevance = | specialty = | signs_symptoms = | diagnosis = | treatment = | image = | caption = }} Emergence delirium or post-anesthetic delirium is a transient state of agitation, confusion/disorientation, and irritability that occurs after the withdrawal of anesthesia.<ref>{{Cite journal|last=Barreto|first=Ana Carolina Tavares Paes|last2=Paschoal|first2=Ana Carolina Rangel da Rocha|last3=Farias|first3=Carolina..."

New page

{{Infobox comorbidity
| other_names =
| anesthetic_relevance =
| specialty =
| signs_symptoms =
| diagnosis =
| treatment =
| image =
| caption =
}}

Emergence delirium or post-anesthetic delirium is a transient state of agitation, confusion/disorientation, and irritability that occurs after the withdrawal of anesthesia.<ref>{{Cite journal|last=Barreto|first=Ana Carolina Tavares Paes|last2=Paschoal|first2=Ana Carolina Rangel da Rocha|last3=Farias|first3=Carolina Barbosa|last4=Borges|first4=Paulo Sérgio Gomes Nogueira|last5=Andrade|first5=Rebeca Gonelli Albanez da Cunha|last6=de Orange|first6=Flávia Augusta|date=2018-03-01|title=Risk factors associated with anesthesia emergence delirium in children undergoing outpatient surgery|url=https://www.sciencedirect.com/science/article/pii/S0104001417301343|journal=Brazilian Journal of Anesthesiology (English Edition)|language=en|volume=68|issue=2|pages=162–167|doi=10.1016/j.bjane.2017.11.002|issn=0104-0014}}</ref> It is associated with prolonged post-op recovery time and increases the risk for other perioperative complications.

This article will discuss risk factors and management considerations. The topic of delayed emergence is a related but separate discussion.

== Anesthetic implications ==
Emergence delirium is a well known phenomenon in pediatric anesthesia. Pediatric anesthesia providers are particularly wary due to concern for laryngospasm. Regardless of age, emergence delirium can carry with it a higher risk of post-op pulmonary and surgical complications in patients with additional comorbidities (low FRC due to morbid obesity, chronic hypoxemia due to COPD or interstitial lung disease, risk of aspiration, delicate surgical sites particularly at the head/neck).

=== Preoperative optimization ===

=== Intraoperative management ===
A 2022 metanalysis of pediatric cases using sevofluorane as maintenance showed a significant reduction in emergence delirium with the use of Precedex (Dexmedetomidine), Ketamine, and Fentanyl.

===== Precedex =====
Precedex is a selective alpha-2 agonist which acts on the central nervous system to treat pain, provide sedation/anxiolysis, and decrease sympathetic tone. It can be bolused in small increments (4 mcg/dose) intraoperatively and is commonly used in pediatrics for the prevention of emergence delirium and has been shown to significantly reduce agitation, cough, pain, post-op nausea/vomiting (PONV), and shivering in the PACU.<ref name=":0">{{Cite web|url=https://login.proxy1.library.jhu.edu/login?qurl=https://pubmed.ncbi.nlm.nih.gov%2f35085107%2f|access-date=2022-08-30|website=login.proxy1.library.jhu.edu}}</ref>

===== Ketamine and Fentanyl =====
Ketamine is an NMDA receptor antagonist which also has sedative and analgesic effects. In the above study, it had almost equal efficacy in treating emergence delirium.<ref name=":0" /> It may provide synergistic benefit with Precedex not only

Fentanyl is a mu-opioid receptor agonist which may nonspecifically reduce emergence delirium by treating perioperative pain. It may be limited by an increased risk of PONV.

=== Postoperative management ===

== Related surgical procedures ==

== Pathophysiology ==

==== Inhalational agents (Sevofluorane) ====
Inhalational agents, notable sevofluorane, have been shown to increase the incidence of emergence delirium. In a 2007 study of 189 preschool and school-age children receiving either propofol or sevofluorane as their primary anesthetic, the incidence of emergence delirium was found to be significantly higher in both sevofluorane groups (as high as 42% in the preschool sevofluorane group 5 minutes after extubation

=== Other risk factors ===

* Pediatric patients between the ages of 2 and 5
* Rapid awakening
* Preoperative anxiety
* Preoperative medications (benzodiazepines, opioids, scopolamine)
* Perioperative pain

== Signs and symptoms ==
Emergence delirium may manifest as:

* Increased agitation/Hyperexcitability
* Disinhibition
* Confusion

== Diagnosis ==

== Treatment ==
Reorientation

Treat acute pain

Consider other sources of discomfort (full bladder, hypothermia)

=== Medication ===

=== Surgery ===

=== Prognosis ===

== Epidemiology ==

== References ==

[[Category:Comorbidities]]

← Older revision		Revision as of 18:45, 30 August 2022
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	\| anesthetic_relevance = High		\| anesthetic_relevance = High
	\| anesthetic_management = Use of sedative/anxiolytic/analgesic agents (Precedex, Ketamine, Fentanyl) for prevention		\| anesthetic_management = Use of sedative/anxiolytic/analgesic agents (Precedex, Ketamine, Fentanyl) for prevention
	\| specialty = Anesthesiology		\| specialty = General/Pediatric Anesthesiology
	\| signs_symptoms = Agitation, confusion, hyperarousal		\| signs_symptoms = Agitation, confusion, hyperarousal
			\| diagnosis = Clinical
	\| treatment = Reorientation, adequate analgesia		\| treatment = Reorientation, adequate analgesia
	\| image =		\| image =
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	Emergence delirium or post-anesthetic delirium is a transient state of agitation, confusion/disorientation, and irritability that occurs after the withdrawal of anesthesia.<ref>{{Cite journal\|last=Barreto\|first=Ana Carolina Tavares Paes\|last2=Paschoal\|first2=Ana Carolina Rangel da Rocha\|last3=Farias\|first3=Carolina Barbosa\|last4=Borges\|first4=Paulo Sérgio Gomes Nogueira\|last5=Andrade\|first5=Rebeca Gonelli Albanez da Cunha\|last6=de Orange\|first6=Flávia Augusta\|date=2018-03-01\|title=Risk factors associated with anesthesia emergence delirium in children undergoing outpatient surgery\|url=https://www.sciencedirect.com/science/article/pii/S0104001417301343\|journal=Brazilian Journal of Anesthesiology (English Edition)\|language=en\|volume=68\|issue=2\|pages=162–167\|doi=10.1016/j.bjane.2017.11.002\|issn=0104-0014}}</ref> It is associated with prolonged post-op recovery time and increases the risk for other perioperative complications.		Emergence delirium or post-anesthetic delirium is a transient state of agitation, confusion/disorientation, and irritability that occurs after the withdrawal of anesthesia.<ref>{{Cite journal\|last=Barreto\|first=Ana Carolina Tavares Paes\|last2=Paschoal\|first2=Ana Carolina Rangel da Rocha\|last3=Farias\|first3=Carolina Barbosa\|last4=Borges\|first4=Paulo Sérgio Gomes Nogueira\|last5=Andrade\|first5=Rebeca Gonelli Albanez da Cunha\|last6=de Orange\|first6=Flávia Augusta\|date=2018-03-01\|title=Risk factors associated with anesthesia emergence delirium in children undergoing outpatient surgery\|url=https://www.sciencedirect.com/science/article/pii/S0104001417301343\|journal=Brazilian Journal of Anesthesiology (English Edition)\|language=en\|volume=68\|issue=2\|pages=162–167\|doi=10.1016/j.bjane.2017.11.002\|issn=0104-0014}}</ref> It is associated with prolonged post-op recovery time and increases the risk for other perioperative complications.

	This article will discuss risk factors and management considerations. The ~~topic~~ of delayed emergence ~~is a~~ related but separate ~~discussion~~.		This article will discuss risk factors and management considerations of emergence delirium. The topics of delayed emergence and hypoactive post-anesthetic delirium are related but separate discussions.

	== Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. --> ==		== Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. --> ==
	Emergence delirium is a well known phenomenon in pediatric anesthesia. Pediatric anesthesia providers are particularly wary due to concern for laryngospasm. Regardless of age, emergence delirium in both pediatric and adult patients can carry with it a higher risk of post-op pulmonary and surgical complications, particularly those with additional comorbidities (e.g. low ~~FRC~~ due to morbid obesity, chronic hypoxemia due to COPD or interstitial lung disease, risk of aspiration, delicate surgical sites at the head/neck).		Emergence delirium is a well known phenomenon in pediatric anesthesia. Pediatric anesthesia providers are particularly wary due to concern for laryngospasm. Regardless of age, emergence delirium in both pediatric and adult patients can carry with it a higher risk of post-op pulmonary and surgical complications, particularly those with additional comorbidities (e.g. low functional residual capacity due to morbid obesity, chronic hypoxemia due to COPD or interstitial lung disease, risk of aspiration, delicate surgical sites at the head/neck).

	== Related surgical procedures<!-- List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae. If none, this section may be removed. -->==		== Related surgical procedures<!-- List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae. If none, this section may be removed. -->==
Line 23:		Line 24:

	==== Inhalational agents (Sevofluorane) ====		==== Inhalational agents (Sevofluorane) ====
	Inhalational agents, notably sevofluorane, have been shown to increase the incidence of emergence delirium. In a 2007 study of 189 preschool and school-age children receiving either propofol or sevofluorane as their primary anesthetic, the incidence of emergence delirium was found to be significantly higher in both sevofluorane age groups (as high as 42% in the preschool sevofluorane group 5 minutes after extubation).<ref>{{Cite journal\|last=Nakayama\|first=Shin\|last2=Furukawa\|first2=Hajime\|last3=Yanai\|first3=Hiromune\|date=2007\|title=Propofol reduces the incidence of emergence agitation in preschool-aged children as well as in school-aged children: a comparison with sevoflurane\|url=https://pubmed.ncbi.nlm.nih.gov/17285408/\|journal=Journal of Anesthesia\|volume=21\|issue=1\|pages=19–23\|doi=10.1007/s00540-006-0466-x\|issn=0913-8668\|pmid=17285408}}</ref> A proposed explanation for this is that sevoflurane may cause "differential recovery rates in brain function, due to differences in clearance of inhalational anesthetics from the central nervous system...whereas [auditory centers] and locomotion recover first, cognitive function recovers later, resulting in [agitation]."<ref name=":1" />		Inhalational agents, notably sevofluorane, have been shown to increase the incidence of emergence delirium. In a 2007 study of 189 preschool and school-age children receiving either propofol or sevofluorane as their primary anesthetic, the incidence of emergence delirium was found to be significantly higher in both sevofluorane age groups (as high as 42% in the preschool sevofluorane group 5 minutes after extubation compared to <10% in both propofol groups).<ref>{{Cite journal\|last=Nakayama\|first=Shin\|last2=Furukawa\|first2=Hajime\|last3=Yanai\|first3=Hiromune\|date=2007\|title=Propofol reduces the incidence of emergence agitation in preschool-aged children as well as in school-aged children: a comparison with sevoflurane\|url=https://pubmed.ncbi.nlm.nih.gov/17285408/\|journal=Journal of Anesthesia\|volume=21\|issue=1\|pages=19–23\|doi=10.1007/s00540-006-0466-x\|issn=0913-8668\|pmid=17285408}}</ref> A proposed explanation for this is that sevoflurane may cause "differential recovery rates in brain function, due to differences in clearance of inhalational anesthetics from the central nervous system...whereas [auditory centers] and locomotion recover first, cognitive function recovers later, resulting in [agitation]."<ref name=":1" />

	==== Pediatric patients between the ages of 2 and 5 ====		==== Pediatric patients between the ages of 2 and 5 ====
	Neuronal excitability is higher in pediatric patients which may contribute to emergence delirium. Studies have shown an increase in epileptiform discharges in children undergoing sevofluorane anesthesia.<ref name=":0">{{Cite journal\|last=Koch\|first=Susanne\|date=Dec 2018\|title=Emergence delirium in children is related to epileptiform discharges during anaesthesia induction - An observational study\|url=https://journals-lww-com.proxy1.library.jhu.edu/ejanaesthesiology/Fulltext/2018/12000/Emergence_delirium_in_children_is_related_to.5.aspx\|journal=European Journal of Anaesthesiology\|volume=35(12)\|pages=929-936}}</ref> Sevofluorane targets GABA receptors "enhancing neuronal inhibition, [blocks] potassium and hyperpolarization-activated cyclic nucleotide-gated cation channels, and binds [NMDA] receptors blocking glutamate release which may result in enhanced neuronal hyperexcitability."<ref name=":0" />		Neuronal excitability is higher in pediatric patients which may contribute to their increased proclivity for emergence delirium. Studies have shown an increase in epileptiform discharges in children undergoing sevofluorane anesthesia.<ref name=":0">{{Cite journal\|last=Koch\|first=Susanne\|date=Dec 2018\|title=Emergence delirium in children is related to epileptiform discharges during anaesthesia induction - An observational study\|url=https://journals-lww-com.proxy1.library.jhu.edu/ejanaesthesiology/Fulltext/2018/12000/Emergence_delirium_in_children_is_related_to.5.aspx\|journal=European Journal of Anaesthesiology\|volume=35(12)\|pages=929-936}}</ref> Sevofluorane targets GABA receptors "enhancing neuronal inhibition, [blocks] potassium and hyperpolarization-activated cyclic nucleotide-gated cation channels, and binds [NMDA] receptors blocking glutamate release which may result in enhanced neuronal hyperexcitability."<ref name=":0" />

	==== Other risk factors ====		==== Other risk factors ====
Line 45:		Line 46:

	=== Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> ===		=== Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> ===
	A 2022 metanalysis of pediatric cases using sevofluorane as maintenance showed a significant reduction in emergence delirium with the use of Precedex ~~(Dexmedetomidine)~~, Ketamine, and Fentanyl.<ref name=":2">{{Cite journal\|last=Wang\|first=Wuchao\|last2=Huang\|first2=Panchuan\|last3=Gao\|first3=Weiwei\|last4=Cao\|first4=Fangli\|last5=Yi\|first5=Mingling\|last6=Chen\|first6=Liyong\|last7=Guo\|first7=Xiaoli\|date=2016-11-10\|title=Efficacy and Acceptability of Different Auxiliary Drugs in Pediatric Sevoflurane Anesthesia: A Network Meta-analysis of Mixed Treatment Comparisons\|url=https://www.nature.com/articles/srep36553\|journal=Scientific Reports\|language=en\|volume=6\|issue=1\|pages=36553\|doi=10.1038/srep36553\|issn=2045-2322}}</ref>		A 2022 metanalysis of pediatric cases using sevofluorane as maintenance showed a significant reduction in emergence delirium with the use of Precedex, Ketamine, and Fentanyl.<ref name=":2">{{Cite journal\|last=Wang\|first=Wuchao\|last2=Huang\|first2=Panchuan\|last3=Gao\|first3=Weiwei\|last4=Cao\|first4=Fangli\|last5=Yi\|first5=Mingling\|last6=Chen\|first6=Liyong\|last7=Guo\|first7=Xiaoli\|date=2016-11-10\|title=Efficacy and Acceptability of Different Auxiliary Drugs in Pediatric Sevoflurane Anesthesia: A Network Meta-analysis of Mixed Treatment Comparisons\|url=https://www.nature.com/articles/srep36553\|journal=Scientific Reports\|language=en\|volume=6\|issue=1\|pages=36553\|doi=10.1038/srep36553\|issn=2045-2322}}</ref>

	===== Precedex =====		===== Precedex =====
	Precedex is a selective alpha-2 agonist which acts on the central nervous system to treat pain, provide sedation/anxiolysis, and decrease sympathetic tone. It can be bolused in small increments (4 mcg/dose) or run as a low-dose infusion intraoperatively and is commonly used in pediatrics for the prevention of emergence delirium ~~and~~ has been shown to significantly reduce agitation, cough, pain, post-op nausea/vomiting (PONV), and shivering in the PACU.<ref>{{Cite journal\|last=Sin\|first=Jeremy\|date=Jun 2022\|title=The Effect of Dexmedetomidine on Postanesthesia Care Unit Discharge and Recovery: A Systematic Review and Meta-Analysis\|url=https://pubmed-ncbi-nlm-nih-gov.proxy1.library.jhu.edu/35085107/\|journal=Anesth Analg\|volume=134(6)\|pages=1229-1244\|via=Pub Med}}</ref> Its use may be limited by hemodynamic effects (bradycardia, hypotension).		Precedex (Dexmedetomidine) is a selective alpha-2 agonist which acts on the central nervous system to treat pain, provide sedation/anxiolysis, and decrease sympathetic tone. It can be bolused in small increments (4 mcg/dose) or run as a low-dose infusion intraoperatively and is commonly used in pediatrics for the prevention of emergence delirium. It has been shown to significantly reduce agitation, cough, pain, post-op nausea/vomiting (PONV), and shivering in the PACU.<ref>{{Cite journal\|last=Sin\|first=Jeremy\|date=Jun 2022\|title=The Effect of Dexmedetomidine on Postanesthesia Care Unit Discharge and Recovery: A Systematic Review and Meta-Analysis\|url=https://pubmed-ncbi-nlm-nih-gov.proxy1.library.jhu.edu/35085107/\|journal=Anesth Analg\|volume=134(6)\|pages=1229-1244\|via=Pub Med}}</ref> Its use may be limited by hemodynamic effects (bradycardia, hypotension).

	===== Ketamine and Fentanyl =====		===== Ketamine and Fentanyl =====
	Ketamine is an NMDA receptor antagonist which also has sedative and analgesic effects. In the above study, it had almost equal efficacy in treating emergence delirium when compared to Precedex.<ref name=":2" /> Similar to Precedex, it can be given in small boluses (10 mg/dose) or run as a low-dose infusion intraoperatively. Its use may be limited by concern for its dissociative effects. These are usually decreased with perioperative administration of benzodiazepine (i.e. Versed) but can also be prevented with concurrent use of Precedex. In a corresponding manner, ketamine provides hemodynamic stability which may balance/prevent the bradycardia and hypotension observed with Precedex when used in combination.<ref>{{Cite journal\|last=Kim\|first=Joong-Goo\|last2=Lee\|first2=Han-Bin\|last3=Jeon\|first3=Sang-Beom\|date=2019\|title=Combination of Dexmedetomidine and Ketamine for Magnetic Resonance Imaging Sedation\|url=https://www.frontiersin.org/articles/10.3389/fneur.2019.00416\|journal=Frontiers in Neurology\|volume=10\|doi=10.3389/fneur.2019.00416/full\|issn=1664-2295}}</ref>		Ketamine is an NMDA receptor antagonist which also has sedative and analgesic effects. In the above study, it had almost equal efficacy in treating emergence delirium when compared to Precedex.<ref name=":2" /> Similar to Precedex, it can be given in small boluses (10 mg/dose) or run as a low-dose infusion intraoperatively. Its use may be limited by concern for its dissociative/hallucinogenic effects. These are usually decreased with perioperative administration of benzodiazepine (i.e. Versed) but can also be prevented with concurrent use of Precedex. In a corresponding manner, ketamine provides hemodynamic stability which may balance/prevent the bradycardia and hypotension observed with Precedex when used in combination.<ref>{{Cite journal\|last=Kim\|first=Joong-Goo\|last2=Lee\|first2=Han-Bin\|last3=Jeon\|first3=Sang-Beom\|date=2019\|title=Combination of Dexmedetomidine and Ketamine for Magnetic Resonance Imaging Sedation\|url=https://www.frontiersin.org/articles/10.3389/fneur.2019.00416\|journal=Frontiers in Neurology\|volume=10\|doi=10.3389/fneur.2019.00416/full\|issn=1664-2295}}</ref>

	Fentanyl is a mu-opioid receptor agonist which may nonspecifically reduce emergence delirium by treating perioperative pain. It may be limited by an increased risk of PONV.		Fentanyl is a mu-opioid receptor agonist which may nonspecifically reduce emergence delirium by treating perioperative pain. It may be limited by an increased risk of PONV.