Emergence delirium
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| Anesthetic management |
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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.[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 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.[2]
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.[2] 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
- ↑ 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 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
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