Paediatric Emergence Delirium Audit Dr Chris Hoy Anaesthetist Dr Joanne Kerins FY1 Ninewells Hospital

Overview Introduction Method Results Discussion Implications Conclusion

Introduction Transient post-anaesthesia state of delirium Irritable, uncooperative, incoherent and inconsolably crying Risk of injury and disrupting wound Short-acting volatile anaesthetics treatment of emergence delirium includes reassurance, parental presence and analgesia increased risk of post-operative anxiety, enuresis and night-time crying for up to 2 weeks

Method 43 surgical paediatric cases Aged between 5 months and 15 years Type of procedure, anaesthesia and analgesia Identify risk factors and assess possible strategies to avoid 8 working days Volatile or TIVA Opioids or nerve block Recovery and on return to ward Watcha scale is a simple clinical tool which has been found to have a high sensitivity, in comparison with other scales A later recording, 30 minutes after returning from theatre, was also documented in 22 cases

Results 8 children (19%) had a post-operative Watcha Score of 3 or 4 All had received volatile anaesthesia and were aged between 5 months and 5 years old 4 had been given opioids and 2 had received a nerve block; 3 patients did not have opioids or a nerve block 93%) used volatile anaesthesia 8 children (19%) who had a post-operative Watcha Score of 3 or 4 7 children (16%) scored 3 on the scale during their recovery 1 child scored 4: agitated and thrashing around no obvious correlation between the use of opioids or nerve block

Discussion Risk factors Age between 2 and 5 years Short acting volatile anaesthetics Type of surgery - otorhinolaryngological and ophthalmological procedures Limitations Subjective assessment tool Post-operative pain Few TIVA cases to compare the children who scored highly in assessment for emergence delirium were between 5 months and 5 years Short-acting volatile anaesthetics were used in all of the cases with high scores Sevoflurane- rapid emergence which can create a dissociate state and irritating effect on the central nervous system post-operative pain which can present in a similar manner pain is not the cause of emergence delirium as cases have occurred after magnetic resonance imaging Cravero scale and the Paediatric Anaesthesia Emergence Delirium scale

Implications Preventative measures Perioperative analgesia The use of propofol Premedication with midazolam Risk of prolonging recovery fentanyl or ketamine before the end of the procedure or clonidine given caudally modify emergence, ie. an end-intervention bolus preoperative anxiety can be associated

Conclusion Predictable age range of paediatric patients Associated with volatile agents Consideration of preventative measures

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