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

2. Overview Introduction Method Results Discussion Implications
Conclusion

3. 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

4. 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

5. 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

6. 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

7. 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

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

9. Any questions?