Difference between revisions of "Emergence delirium"
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{{Infobox comorbidity | {{Infobox comorbidity | ||
| other_names = | | other_names = | ||
| anesthetic_relevance = | | anesthetic_relevance = High | ||
| | | anesthetic_management = Use of sedative/anxiolytic/analgesic agents (Precedex, Ketamine, Fentanyl) for prevention | ||
| | | specialty = Anesthesiology | ||
| | | signs_symptoms = Agitation, confusion, hyperarousal | ||
| treatment = | | treatment = Reorientation, adequate analgesia | ||
| image = | | image = | ||
| caption = | | caption = | ||
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== 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 can carry with it a higher risk of post-op pulmonary and surgical complications | 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). | ||
== | == 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. -->== | ||
It has been noted that there is an increased risk of emergence delirium in pediatric patients undergoing tonsillectomy/adenoidectomies, eye surgery, and middle ear surgery as well as adult patients undergoing nasal surgery.<ref name=":1">{{Cite journal|last=Lee|first=Seok-Jin|date=Dec 2020|title=Emergence agitation: current knowledge and unresolved questions|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714637/|journal=Korean J Anesthesiol|volume=73(6)|pages=471-485|via=Pub Med Central}}</ref> Patients undergoing emergency surgery (as opposed to elective surgery) may also be at higher risk. | |||
== | == Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. -->== | ||
==== | ==== 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" /> | |||
== | ==== Pediatric patients between the ages of 2 and 5 ==== | ||
=== Other risk factors === | ==== Other risk factors ==== | ||
* Rapid awakening | * Rapid awakening | ||
* Preoperative anxiety | * Preoperative anxiety | ||
| Line 47: | Line 34: | ||
* Perioperative pain | * Perioperative pain | ||
== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> == | == Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. -->== | ||
Emergence delirium may manifest as: | Emergence delirium may manifest as: | ||
| Line 54: | Line 41: | ||
* Confusion | * Confusion | ||
== | == 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. | |||
===== 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). | |||
===== 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> | |||
=== | 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<!-- Describe how this comorbidity may influence postoperative management. --> === | |||
* Reorientation | |||
* Treat acute pain | |||
* Consider other sources of discomfort (full bladder, hypothermia) | |||
== References == | == References == | ||
[[Category:Comorbidities]] | [[Category:Comorbidities]] | ||
Revision as of 17:04, 30 August 2022
| Anesthetic relevance |
High |
|---|---|
| Anesthetic management |
Use of sedative/anxiolytic/analgesic agents (Precedex, Ketamine, Fentanyl) for prevention |
| Specialty |
Anesthesiology |
| Signs and symptoms |
Agitation, confusion, hyperarousal |
| Diagnosis |
{{{diagnosis}}} |
| Treatment |
Reorientation, adequate analgesia |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Emergence delirium or post-anesthetic delirium is a transient state of agitation, confusion/disorientation, and irritability that occurs after the withdrawal of anesthesia.[1] 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 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).
Related surgical procedures
It has been noted that there is an increased risk of emergence delirium in pediatric patients undergoing tonsillectomy/adenoidectomies, eye surgery, and middle ear surgery as well as adult patients undergoing nasal surgery.[2] Patients undergoing emergency surgery (as opposed to elective surgery) may also be at higher risk.
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).[3] 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]."[2]
Pediatric patients between the ages of 2 and 5
Other risk factors
- Rapid awakening
- Preoperative anxiety
- Preoperative medications (benzodiazepines, opioids, scopolamine)
- Perioperative pain
Signs and symptoms
Emergence delirium may manifest as:
- Increased agitation/Hyperexcitability
- Disinhibition
- Confusion
Management
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) 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.[4] Its use may be limited by hemodynamic effects (bradycardia, hypotension).
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.[4] 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.[5]
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
- Reorientation
- Treat acute pain
- Consider other sources of discomfort (full bladder, hypothermia)
References
- ↑ Barreto, Ana Carolina Tavares Paes; Paschoal, Ana Carolina Rangel da Rocha; Farias, Carolina Barbosa; Borges, Paulo Sérgio Gomes Nogueira; Andrade, Rebeca Gonelli Albanez da Cunha; de Orange, Flávia Augusta (2018-03-01). "Risk factors associated with anesthesia emergence delirium in children undergoing outpatient surgery". Brazilian Journal of Anesthesiology (English Edition). 68 (2): 162–167. doi:10.1016/j.bjane.2017.11.002. ISSN 0104-0014.
- ↑ 2.0 2.1 Lee, Seok-Jin (Dec 2020). "Emergence agitation: current knowledge and unresolved questions". Korean J Anesthesiol. 73(6): 471–485 – via Pub Med Central.
- ↑ Nakayama, Shin; Furukawa, Hajime; Yanai, Hiromune (2007). "Propofol reduces the incidence of emergence agitation in preschool-aged children as well as in school-aged children: a comparison with sevoflurane". Journal of Anesthesia. 21 (1): 19–23. doi:10.1007/s00540-006-0466-x. ISSN 0913-8668. PMID 17285408.
- ↑ 4.0 4.1 login.proxy1.library.jhu.edu https://login.proxy1.library.jhu.edu/login?qurl=https://pubmed.ncbi.nlm.nih.gov%2f35085107%2f. Retrieved 2022-08-30. Missing or empty
|title=(help) - ↑ Kim, Joong-Goo; Lee, Han-Bin; Jeon, Sang-Beom (2019). "Combination of Dexmedetomidine and Ketamine for Magnetic Resonance Imaging Sedation". Frontiers in Neurology. 10. doi:10.3389/fneur.2019.00416/full. ISSN 1664-2295.