1. Emergence Delirium
Jane Bolton
CN PARU RAH

2. Postoperative Neurobehavioral Disturbances
3 distinct forms :
emergence delirium
postoperative delirium
postoperative cognitive decline

3. Emergence delirium Definition
Altered state of consciousness & agitation during emergence from anaesthesia
Usually lasts 15 – 30 mins, no interval
Poorly understood
Lack of studies
Affects about 5-20 % of patient population
Emergence delirium Definition

4. RECOGNITION of CONDITION
extremely important
allows for appropriate treatment
hastens response time
hastens treatment time
improves outcome
Recognition

5. Risk Factors Non modifiable : age cognitive impairment dementia
depression
comorbid disease
type of surgery
genetic factors
Risk Factors

6. Risk Factors Modifiable : infection & inflammation
metabolic disturbances
medication
pain & discomfort
sleep disruption
Risk Factors

7. Physiological
hypoxemia, hypercarbia, hyponatremia, hypoglycemia
head injury, dementia, sepsis, alcohol withdrawal, airway obstruction
full bladder, pain, hypothermia, sensory overload or deprivation
Causes

8. Causes Pharmacological : Ketamine Droperidol Benzodiazepines Opioids
Atropine
Scopolamine
Inhalation agents eg sevoflurane, desflurane
Causes

9. Signs and symptoms excitement alternating with sedation
excitement and disorientation
inappropriate behaviour and language
violence and threatening behaviour
unresponsive to commands
disinhibited behaviour
Signs and symptoms

10. Treatment Patient and staff safety top priority
Treat possible cause with :
oxygen
F & E replacement
analgesia
warming
IDC
sedation
Treatment

11. Violent Patient Protocol
Protocol is located in PARU
calm patient
assistance : anaesthetist, code black
safety top priority
TC to coordinate response team
chemical sedation: IV Haloperidol 1mg-10mgs
physical restraint if threatening
Violent Patient Protocol

12. Treatment Code Black if uncontrollable & dangerous Medications :
Haloperidol 1 mg per ml up to 10 mgs
Olanzapine IV or wafer for longer effect
Literature suggests midazolam if above drugs are ineffective but in practice this can exacerbate situation
Treatment

13. Treatment calming reassurance quiet orientation to time and place
do not yell at patient
do not try and reason or argue
reduce number of people at scene
explain procedures to patient
gentle physical restraint as a last resort
References :
1. Delirium during emergence from anaesthesia : a case study
Crit Care Nurse February Vol. 23 no
2. Anticipating and managing postoperative delirium and cognitive decline in adults
BMJ ; 343:d4331
Treatment