1. Emergence Delirium in Pediatric Patients Updated May 2019
Valerie Au, M.D.
Andrew Infosino, M.D.
Department of Anesthesia and Perioperative Care
University of California, San Francisco

2. Disclosures
No relevant financial relationships

3. Learning Objectives
Recognize emergence delirium in pediatric patients in the recovery room and differentiate it from agitation due to pain.
Compare and contrast the PAED, Cravero and Watcha numerical scales for rating emergence delirium
Identify the risk factors for emergence delirium in pediatric patients
Describe approaches for reducing the incidence of emergence delirium
Develop an algorithm for treating emergence delirium in the recovery room

4. Emergence Delirium: What is it?
Dissociated state of consciousness after anesthesia
Crying, thrashing, kicking, uncooperative
Incoherent, inconsolable and combative
No eye contact, no recognition of familiar objects, parents or caregivers
Photo (not copyrighted)

5. Emergence Delirium: What is it?
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
11/27/2019
Emergence Delirium: What is it?
Occurs in 10 – 20% of children who have anesthetics1
Most common from age 2 – 5 years1
Emergence delirium usually lasts from 3 – 45 minutes with a mean duration of 14 minutes2
90 – 95% of cases resolve by themselves in less than 30 minutes3
3. Korean J Anesthesiol. 2010 Aug;59(2): doi: /kjae Epub 2010 Aug 20.
The effect of propofol on emergence agitation in children receiving sevoflurane for adenotonsillectomy.
Lee CJ1, Lee SE, Oh MK, Shin CM, Kim YJ, Choe YK, Cheong SH, Lee KM, Lee JH, Lim SH, Kim YH, Cho KR.
Cote C, A Practice of Anesthesia for Infants and Children 6e
Voepel-Lewis et al., Anesth Analg 2003; 96:
Lee CJ et al., Korean J Anesthesiol 2010; 59:75-81

6. Emergence Delirium: Why is it a problem?
Can harm parents or caregivers
Can harm themselves
Can pull out IVs, pull off monitors and remove dressings
Pixabay License Free for commercial use  No attribution required

7. Emergence Delirium: What is the impact?
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
11/27/2019
Emergence Delirium: What is the impact?
Requires increased nursing resources
Additional medication administration
Longer recovery room stays and increased costs
Frightening to parents
Decreased parental satisfaction scores
Post-operative behavioral changes
In prospective cohort study – prolonged PACU stay by 16 minutes or more
Adverse events – increased bleeding, pulling out Ivs or drains, increased pain, minor injury of a nurse

8. Emergence Delirium: What is the impact?
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
11/27/2019
Emergence Delirium: What is the impact?
Post-operative behavioral changes
Increased general anxiety
Problems with separation
Sleep disturbances
Bedwetting
Temper tantrums
Eating disturbances
Pixabay LicenseFree for commercial use  No attribution required

9. Differentiating Emergence Delirium (ED) from post-operative pain
Both can be difficult to assess in preverbal children and preschoolers
Both present similarly with crying, thrashing and inconsolability
ED can occur after non-painful procedures such as MRIs

10. How Do You Measure Emergence Delirium?
Simple screening tools for PACU nursing, but with low specificity for distinguishing delirium from agitation/pain
Watcha Scale
Cravero Scale
More complex validated scale with higher specificity for delirium
PAED Scale
License: Creative Commons 4.0 BY-NC 

11. ED Assessment Tools: WATCHA SCALE Behavior
Score
Calm 1
Crying, can be consoled 2
Crying, cannot be consoled 3
Agitated, thrashing around 4
Scores ≥ 3 indicative of emergence delirium

12. ED Assessment Tools: CRAVERO SCALE Behavior Score 1 2 3 4 5
Obtunded, no response to stimulation 1
Asleep, responds to stimulation 2
Awake and responsive 3
Crying for > 3 minutes 4
Thrashing behavior requiring restraints 5
Scores ≥ 4 indicative of emergence delirium

13. Scores > 12: very sensitive and specific for ED
ED Assessment Tools:
PAED SCALE
Behavior
Not at all
Just a little
Quite a bit
Very much
Extremely
Eye contact 4 3 2 1
Purposeful actions
Aware of surroundings
Restless
Inconsolable
Scores > 12: very sensitive and specific for ED
Bajwa SA et al., Ped Anesth 2010; 20:

14. Question:
What can we do as anesthesiologists to reduce the incidence of emergence delirium?

15. Answers: Identify risk factors
Determine best anesthetic approach to decrease the incidence of ED in high risk cases

16. Emergence Delirium: Risk Factors
Age – highest incidence in 2-5 year-olds1
Anxiety – higher incidence in preexisting anxiety of patients and/or parents2
Surgical factors – associated with ENT/ophthalmological procedures3
Volatile anesthetics3
Prior history of emergence delirium
Cote, A Practice of Anesthesia for Infants and Children 6e
Kain et al. Anesth Analg 2004; 99:1648–1654
Voepel-Lewis et al., Anesth Analg 2003; 96:

17. Treating Preoperative Anxiety
Preoperative counseling and education
Child Life services
Parental presence during induction
Distraction techniques: videos, music, video games, virtual reality headsets
Allowing the child to bring a favorite stuffed animal or blanket into the operating room
Pharmacologic preoperative anxiolysis

18. Pharmacological Approaches
Effective
Ineffective
Propofol
Preop oral midazolam
Dexmedetomidine
Preop gabapentin
Clonidine
Melatonin
Ketamine
Magnesium
Fentanyl
5-HT3 antagonists
IV Midazolam at end
Parental presence at emergence
Peri-op analgesia

19. Reducing ED: Propofol
Propofol based anesthetic (induction and maintenance infusion) decreases the incidence of ED compared to either desflurane or sevoflurane 1,2
Propofol bolus at induction alone does not decrease the incidence of ED1
Propofol bolus (1mg/kg) at the end of a sevoflurane based anesthetic decreases the incidence of ED vs placebo without lengthening recovery time3
Dahmani et al, BJA, 2010; 104:216-23
Kanaya et al, J Anesth 2014; 28:4-11
Van Hoff et al, Pediatric Anesthesia, 2015; 25:668-76

20. Reducing ED: Alpha-2 Agonists
Dexmedetomidine IV bolus prior to end of a sevoflurane based anesthetic decreases the incidence of ED1,2,3,4
Both IV bolus and infusions are effective1
May increase emergence, extubation and PACU times3,4
Clonidine also decreases the incidence of ED2
Pickard et al, BJA, 2014; 112:982-90
Dahmani et al, BJA, 2010; 104:216-23
Zhu et al, PLoS ONE 2015
Zhang PLoS ONE 2014
Pickard et al, BJA, 2014; 112:982-90
Dahmani et al, BJA, 2010; 104:216-23
Zhu et al, PLoS ONE 2015; 10(4): e
Zhang et al., PLoS ONE 2014; 16:e99718

21. Reducing ED: Ketamine
Ketamine 6 mg/kg PO preoperatively decreases the incidence of ED1
Ketamine 0.25 mg/kg IV 10 minutes prior to the end of surgery decreases the incidence of ED2
Does not lengthen recovery time2
1. Kararmaz A, Kaya S, Turhanoglu S, Ozyilmaz MA. Oral ketamine
premedication can prevent emergence agitation in
children after desflurane anaesthesia. Paediatr Anaesth 2004;
14: 477–82
IBRAHIM ABU-SHAHWAN M D AND KHALID CHOWDARY Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia Pediatric Anesthesia : 846–850
Kararmaz A et al., Paediatr Anesth 2004; 14:
Abu-Shawan I and Chowdary K. Pediatric Anesthesia 2007; 14:846-50

22. Reducing ED: Fentanyl
Fentanyl prior to end of surgery decreases the incidence of ED1,2,3
Fentanyl 1 mcg/kg bolus at end of surgery effective1
IV and intranasal found to be effective3
Increase in PONV1,3
Can increase in emergence time and recovery time1,3
Kim N, Park JH, Lee JS, Choi T, Kim M. Effects of intravenous fentanyl around the end of surgery on emergence agitation in children: systematic review and meta-analysis. Ped Anesth 2017; 27:885–892
Dahmani S, Stany I, Brasher C, et al. Pharmacological prevention of sevoflurane and desflurane-related emergence agitation in children: a meta-analysis of published studies. Br J Anaesth 2010; 104: 216–23
Shi F, Xiao Y, Xiong W, Zhou Q, Yang P, Huang X. Effects of fentanyl on emergence agitation in children under sevoflurane anesthesia: Meta-analysis of Randomized Controlled Trials. Plos One :e
Kim et al., Ped Anesth 2017; 27:
Dahmani et al., BJA 2010; 104:
Shi et al., Plos One :e

23. Reducing ED: Midazolam
Meta-analysis by Dahmani et al. of 4 studies demonstrated that oral midazolam does NOT decrease the incidence of ED1
Study by Cho et al2 and a study by Kim et al3 both demonstrated that IV midazolam given prior to emergence DOES decrease the incidence of ED
Dahmani S, Stany I, Brasher C, et al. Pharmacological prevention of sevoflurane and desflurane-related emergence agitation in children: a meta-analysis of published studies. Br J Anaesth 2010; 104: 216–23
Cho EJ, Yoo SZ, Cho JE, Lee HW. Comparison of effects of 0.03 and 0.05 mg/kg midazolam with placebo on prevention of emergence agitation in children having strabismus surgery. Anesthesiology 2014; 210:
Kim KM, Lee KH, Kim YH, Ko MJ, Jun J, Kang E. Comparison of effects of intravenous midazolam and ketamine on emergence agitation in children: randomized controlled trial. J International Med Res. 2016; 44:258–266.
Dahmani et al., BJA 2010; 104:
Cho et al., Anesthesiology 2014; 2010:
Kim et al., Ped Anesth 2017; 27:

24. Reducing ED: What Doesn’t Work? Gabapentin Magnesium Melatonin
5-HT3 Antagonists
Acupuncture
Ketorolac
Dahmani et al., BJA 2010; 104:

25. A Case…
A 4 year old with history of emergence delirium after a previous anesthetic presents for T & A. What should I do to decrease this patient’s risk of emergence delirium?

26. Recommendations For High Risk Cases
Minimize preoperative anxiety in parents and patient including nonpharmacologic techniques
Propofol based anesthetic, rather than sevoflurane
Dexmedetomidine 0.3 – 0.5 mcg/kg IV prior to emergence

27. Question:
What can we do as anesthesiologists to treat emergence delirium in the recovery room?

28. Answers: Rule out other causes of agitation in the recovery room
Reassure parents
Educate PACU nurses
Pharmacologic treatment

29. Ruling Out Other Causes
Hypoxemia – check O2 Sat
Urinary retention – evaluate IVFs given and last void
Irritation from foley catheter
Hypoglycemia – check blood glucose in at risk patients
Pain – evaluate for pain and treat with appropriate medication (e.g. fentanyl)

30. Emergence Delirium: Treatment
Tincture of Time: Remember that the vast majority of cases of of emergence delirium resolve by themselves in less than 30 minutes
Reassure parents
Educate PACU nurses and parents
Pixabay LicenseFree for commercial use  No attribution required

31. Emergence Delirium: Treatment
If emergence delirium persists in the PACU consider IV bolus of either:
Dexmedetomidine ( mcg/kg)
Propofol (1-2 mg/kg)
Remember to have emergency airway equipment available at the bedside
Ketamine and midazolam are often considered as sedatives for patients with extreme agitation or delirium. However,
- there is little evidence for the efficacy of ketamine and it can cause significant other post-op issues such as nightmares and hallucinations
- midazolam, although it has been reported, is also not currently recommended for treatment of delirium and is implicated in contributing to delirium in adult ICU patients

32. Conclusions ED is a complex behavioral state that is poorly understood
ED is difficult to distinguish from agitation/pain
PAED is best current assessment tool for ED
Propofol based anesthetic with Dexmedetomidine is best approach to decrease the incidence of ED in high risk cases
Consider Dexmedetomidine or Propofol IV bolus to manage ED in PACU

33. References: References:
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
11/27/2019
References: References:
Abu-Shahwan MD, Chowdary K. Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia. Pediatric Anesthesia : 846–850
Bajwa SA, Costi D, Cyna AM. A comparison of emergence delirium scales following general anesthesia in children. Pediatric Anesthesia 2010; 20:
Cho EJ, Yoo SZ, Cho JE, Lee HW. Comparison of effects of 0.03 and 0.05 mg/kg midazolam with placebo on prevention of emergence agitation in children having strabismus surgery. Anesthesiology 2014; 210:
Cote, C, Jerrold L, Anderson Brian (2013) A Practice of Anesthesia for Infants and Children 6e. Philadelphia, PA. Saunders
Dahmani S, Stany I, Brasher C, et al. Pharmacological prevention of sevoflurane and desflurane-related emergence agitation in children: a meta-analysis of published studies. Br J Anaesth 2010; 104: 216–23
Dahmani S, Delivet H, Hilly J. Emergence delirium in children: an update. Curr Opin Anesthesiol 2014; 27: 309– 315.
Kararmaz A, Kaya S, Turhanoglu S, Ozyilmaz MA. Oral ketamine premedication can prevent emergence agitation in children after desflurane anaesthesia. Paediatr Anesth 2004; 14:
Kain ZN, Caldwell-Andrews AA, Maranets I, et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviours. Anesth Analg 2004; 99:1648–1654
Kanaya A, Kuratani N, SatohD, Kurosawa S. Lower incidence of emergence agitation in children after propofol anesthesia compared with sevoflurane: a meta-analysis of randomized controlled trials. J Anesth 2014; 28:4–11
Kim KM, Lee KH, Kim YH, Ko MJ, Jun J, Kang E. Comparison of effects of intravenous midazolam and ketamine on emergence agitation in children: randomized controlled trial. J International Med Res. 2016; 44:258–266
Kim N, Park JH, Lee JS, Choi T, Kim M. Effects of intravenous fentanyl around the end of surgery on emergence agitation in children: systematic review and meta-analysis. Ped Anesth 2017; 27:885–892

34. References: References (cont.):
[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
11/27/2019
References: References (cont.):
Lee CJ et al. The effect of Propofol on emergence agitation in children receiving sevoflurane for adenotonsillectomy. Korean J Anesthesiol :59:75-81
Pickard A, Davies P, Birnie K, Beringer R. Systematic review and meta-analysis of the effect of intraoperative a2- adrenergic agonists on postoperative behavior in children. . Br J Anaesth 2014;
Shi F, Xiao Y, Xiong W, Zhou Q, Yang P, Huang X. Effects of fentanyl on emergence agitation in children under sevoflurane anesthesia: Meta-analysis of Randomized Controlled Trials. Plos One :e
Van Hoff SL, O’Neill ES, Cohen LC, Collins BA. Does a prophylactic dose of Propofol reduce emergence agitation in children receiving anesthesia? A systematic review and meta-analysis. Paediatr Anaesth 2015; 25:668-76
Vlajkovic G, Sindjelic R. Emergence delirium in children: many questions, few answers. Anesthesia & Analgesia 2007; 104:84-91
Voepel-Lewis T, Malviya S, Tait AR. A Prospective Cohort Study of Emergence Agitation in the Pediatric Postanesthesia Care Unit. Anesth Analg 2003; 96:
Zhang C, Hu J, Liu X, Yan J. effects of intravenous dexmedetomidine on emergence agitation in children under sevoflurane anesthesia: a meta-analysis of randomized controlled trials. PLoS ONE 2014; 16:e99718
Zhu M, Wang H, Zhu A, Niu K, Wang G. Meta-Analysis of Dexmdetomidine on Emergence Agitation and Recovery Profiles in Children after Sevoflurane Anesthesia: Different Administration and Different Dosage. PLoS ONE 2015; 10(4): e
Bajwa S, Franzca D, Cyna A. A comparison of emergence delirium scales following general anesthesia in children. Ped Anesth 2010; 20:
Dahmani S, Delivet H, Hilly J. Emergence delirium in children: an update. Curr Opin Anesthesiol 2014; 27: 309–315.
Mason KP. Paediatric emergence delirium: a comprehensive review and interpretation of the literature. Brit J of Anaesth 2017; 118:
Somaini M, Engelhardt T, Fumagalli R, Ingelmo PM. Emergence delirium or pain after anesthesia-how to distinguish between the two in young children: a retrospective analysis of observational studies. Br J Anaesth 2016; 116:377–83.
Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics 2006; 118:651-8 
Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology 2004; 100:1138–45
Vlajkovic GP, Sindjelic RP. Emergence delirium in children: many questions, few answers. Anesth Analg 2007; 104:84–91