Download Dr K Allopi - Emergence delirium in children

07 September 2012
No. 30
Emergence delirium in
children
K Allopi
Commentator: S Roberts
Moderator: C Kampik
Department of Anaesthetics
CONTENTS
INTRODUCTION ................................................................................................... 3
DEFINITION .......................................................................................................... 3
ASSESSMENT TOOLS OF EMERGENCE DELIRIUM......................................... 3
DIFFERENTIAL DIAGNOSIS ............................................................................... 5
RISK FACTORS FOR EMERGENCE DELIRIUM ................................................. 5
Age ..................................................................................................................... 5
Preoperative anxiety ......................................................................................... 6
Parental factors ................................................................................................. 6
Temperament of the child ................................................................................. 7
Type of surgical procedure............................................................................... 8
Pain..................................................................................................................... 8
PHARMACOLOGY ............................................................................................... 8
Inhalation anaesthetics .................................................................................... 8
Intravenous anaesthetics............................................................................... 10
Premedication................................................................................................. 11
Opioids ............................................................................................................ 13
5HT3 antagonist ............................................................................................. 15
RELATIONSHIP BETWEEN EMERGENCE DELIRIUM AND LONG-TERM
POSTOPERATIVE MALADAPTIVE BEHAVIOURS ........................................... 16
PREVENTION AND MANAGEMENT ................................................................. 18
CONCLUSION .................................................................................................... 19
REFERENCES.................................................................................................... 20
Page 2 of 22
INTRODUCTION
Emergence delirium (ED) has been identified as a significant problem in children
recovering from anaesthesia with a reported incidence ranging between 10-80%.
[1]
Agitated behaviour associated with ED places the patient at risk for harming
themselves or others, requires greater postoperative nursing resources, and
decreases parent and caregiver satisfaction with the health care experience. In
addition, this behaviour can dislodge cannulae, dressings, drains and catheters.
Eckenhoff et al first described this phenomenon in the early 1960's.[2]
Children anaesthetised with ether, cyclopropane, or ketamine undergoing
tonsillectomy, thyroidectomy and circumcision experienced crying, thrashing and
disorientation during emergence from anaesthesia. [2] With the popularity of the
newer inhalation agents desflurane and sevoflurane, numerous clinical studies
have been published questioning the association of these anaesthetics with an
increased incidence of emergence delirium.
DEFINITION
The term “emergence agitation” has been used interchangeably with “emergence
delirium” in the literature but there are differences in definitions and clinical
presentations. Agitation, which is described as excessive motor activity, is a
nonspecific symptom that incorporates discomfort, pain and anxiety.
Delirium on the other hand, is an acute state of confusion accompanied by
cognitive impairment including perceptual disturbances and hallucinations.
Cognitive impairment is difficult to diagnose in children and thus the terms are
used interchangeably. ED occurs within the first 30 minutes of recovery from
anaesthesia, is usually self-limited but can last up to 2 days.[5] It is often missed by
the attending anaesthetist as he/she begins the next case in theatre. Currently
there is no clear measurement tool to assess this phenomenon.
ASSESSMENT TOOLS OF EMERGENCE DELIRIUM
Sixteen rating scales and two visual analogue scales have been used to measure
ED in children. These scales are deficient in respects of scale content,
psychometric evaluation and included behaviours that are not specific to ED.
Furthermore, there is a lack of consensus on what level of behavioural
disturbance and for what period constitutes ED. [3] The PAED scale, a four-point
scale described by Watcha and Cravero’s five-point scale are the most commonly
used scales to assess ED. [6]
Page 3 of 22
The PAED scale is shown in Table 1 and has five items scored from 0 to 4 (with
reverse scoring where applicable). The scores are summed to obtain a total score
with a range of 0–20. The PAED scale is reported to have the advantage of being
validated and better reflects the presence of ED rather than pain. The PAED
scale’s first item, “The child makes eye contact with the caregiver,” and third item,
“The child is aware of his/her surroundings,” reflects disturbances in the child’s
consciousness during an ED reaction.
The second item on the PAED scale, “The child’s actions are purposeful,”
addresses changes in the child’s cognition during an ED reaction. The inclusion of
items that reflect disturbances in consciousness and cognition may be pivotal in
differentiating ED from pain. The authors of the PAED scale have described a
sensitivity of 0.64 and a specificity of 0.86 with a PAED score of >=10. [4] However
the PAED scale is cumbersome in clinical practice.
The Watcha scale is a four-point scale as shown in Table 2 and defines ED at a level of 3 or 4 at any time. The
Watcha scale has a higher correlation than Cravero with respect to the PAED scale.
Page 4 of 22
The Cravero scale shown in Table 3 is a five-point scale. The definition for ED in
this scale is reached if level 4 or 5 was evident and present for at least 3 minutes.
The Cravero scale has the advantage of simplicity.
Subjective assessment of ED is highly likely to score positive on all three scales.
Although all three scales have their limitations, they appear to be reasonably
reliable in detecting ED in clinical practice. The Watcha scale and the PAED scale
when >12 give the highest sensitivity in detecting ED. However, no scale appears
to match the discriminating ability of an experienced observer.
DIFFERENTIAL DIAGNOSIS
Agitation on emergence may relate to many sources of distress for a child – pain,
hunger, parental separation, cold and continuation of preoperative distress. It is
important to remember that several life threatening conditions e.g. hypoxia, severe
hypercapnia, hypotension, hypoglycaemia, increased intracranial pressure may
also result in disorientation and altered mental status. These entities must be
diagnosed and treated promptly. Bladder distension may also yield a similar
clinical picture.
RISK FACTORS FOR EMERGENCE DELIRIUM
Although there is ample published literature regarding emergence delirium, little is
known about the pathophysiology, causal factors and appropriate remedy for this
phenomenon. Emergence delirium appears to be a multifactorial syndrome
resulting from an interplay of patient characteristics, age, anaesthetic factors,
surgical factors, family and environmental attributes.
Age
Preschool boys aged 2-6 years have higher rates of ED compared to school
boys.[5] Authors attributed this to rapid awakening and psychological immaturity.
Page 5 of 22
There is a role of brain maturation and physiologic development to the
susceptibility of the young age group to delirium. Preschool children may share
some of the vulnerabilities to delirium experienced by geriatric patients. For older
adults, aging decreases brain volume and weight with a concomitant decline in
brain blood flow and neuron loss in the neocortex and hippocampus. The locus
caeruleus and the substantia nigra can lose as much as 35% of their neurons in a
normal aging process, decreasing levels of norepinephrine, acetylcholine,
dopamine, and γ-aminobutyric acid. The paediatric brain is almost a mirror image
of this process. The maturation of the hippocampus and later the prefrontal
regions allow for the expression of semantic and episodic memory. Subcortical
cholinergic nuclei provide input to the cortex and hippocampus. The development
of cholinergic function and the hippocampus may, therefore, be clues to the
relative susceptibility of younger children to delirium.
Preoperative anxiety
Preoperative anxiety has been associated with increased postoperative agitation
as demonstrated by Aono et al. [7] Table 4
Twenty of 27 boys (74.1%) in the anxious group showed problematic behaviour
during emergence, compared with 5 of 79 boys (6.3%) in the calm group
(P<0.0001). The incidence of problematic behaviour during emergence from
halothane anaesthesia was significantly greater in boys showing anxiety during
induction, compared with boys not showing signs of anxiety during that period.
Parental factors
Fortier et al have shown that parental anxiety is a risk factor for high levels of child
anxiety across the perioperative setting, from the preoperative holding area, up to
two weeks postoperatively and therefore could be a contributing factor to ED. [8]
Page 6 of 22
Table 5 [8]
The EASI is a widely used parent-report measure of a child’s temperament with
regard to emotionality (e.g. child is easily upset ⁄ frightened), activity (e.g. child
fidgets or cannot sit still long), sociability (e.g. child makes friends easily), and
impulsivity (e.g. child has difficulty with self-control) that has good validity and
test–retest reliability. The state-trait anxiety inventory (STAI) is a self-report
measure of parental situational (state) and general (trait) anxiety that has been
well validated. There is a positive effect of parental presence in most studies and
many hospitals today welcome early parental presence in the recovery room.
Temperament of the child
Voepel-Lewis et al found that low adaptability in children is associated with
increased incidence of EA. [9] Table 6 Kain et al have also shown that ED was
higher among children who are more emotional, more impulsive and less sociable
[19]
. Voepel-Lewis et al also showed that children with attention deficit hyperactivity
disorder are more likely to have emergence delirium.
Page 7 of 22
Type of surgical procedure
Surgical procedures involving the ears, eyes, tonsils, thyroid and urological
surgeries have been associated with higher rates of ED. When Eckenhoff et al
first described ED in 1961, he attributed the increased incidence among
otolaryngologic procedures to the “sense of suffocation”.[2] Voepel-Lewis has
shown in a prospective cohort study that the otolaryngologic procedures are an
independent risk factor for ED.[9] Forty-two (26%) and 23 (28%) children who
underwent otorhinolaryngologic and ophthalmologic procedures, respectively,
experienced ED, compared with urologic (15%), orthopaedic (15%), general
surgical (12%), and other (6%) procedures (P=0.02).
Pain
Pain has been the most confounding variable that poses a diagnostic dilemma
when assessing a child’s behaviour upon emergence because of the overlapping
clinical picture with ED, especially in pre-verbal children. Pain has been
acknowledged as a major risk factor for ED. Although it is a risk factor, studies
have shown ED to occur when there is adequate pain control from caudal blocks
[10]
, non-painful procedures such as MRI scans and in the presence of no surgery
[11]
. This suggests the presence of ED despite adequate pain control and thus pain
cannot be pointed out as the sole contributing factor to ED. Several studies have
been done in order to study the causal effect of pain and ED and to decrease the
incidence of ED by treating pain with different modalities.[5]
PHARMACOLOGY
Inhalation anaesthetics
Emergence agitation was reported as a problem in general anaesthesia recovery
before the development of the modern inhalational agents (sevoflurane and
desflurane), and ED has been shown to occur with the use of all anaesthetic
gases.
Page 8 of 22
The increased use of sevoflurane and desflurane in recent years has been
associated with a higher incidence of ED compared with isoflurane and halothane.
(Table 7) [12]
This phenomenon is thought to be due to the low blood-gas solubility and rapid
recovery characteristics of sevoflurane and desflurane. ED has been attributed to
shorter duration surgeries that allowed for rapid washout of anaesthetics from the
body, causing rapid emergence before analgesics had time to act and reach their
peak effect. In a comparative evaluation of the incidence of emergence agitation
and post-operative recovery profile in paediatric patients after isoflurane,
sevoflurane and desflurane anaesthesia, Singh et al found a higher number of
patients in the sevoflurane group were agitated in the recovery period and
required rescue medications compared with desflurane and isoflurane. [1]
Table 7
Although the rapid emergence following sevoflurane has been speculated to be
the cause of ED, Cohen et al compared emergence from sevoflurane and
propofol, which allows a fast recovery. [13] They found that rapid emergence from
propofol was smooth and pleasant compared to sevoflurane and concluded that
ED was not related to the speed of recovery. In fact, delaying emergence by
stepwise decrease of sevoflurane did not reduce the incidence of ED as shown by
Oh et al. [14]
Similarly, Grundmann et al have shown that in children, TIVA with remifentanil and
propofol is a well-tolerated anaesthetic method, with a lower perioperative heart
rate and less postoperative agitation compared with a desflurane-N2O based
anaesthesia. [15] Therefore, ED is not related to the rapid recovery but could be
related to the intrinsic property of inhalation anaesthetics. Adding nitrous oxide to
anaesthesia with sevoflurane reduces the minimum alveolar concentration (MAC)
of sevoflurane, meaning that lower concentrations of the anaesthetic can be used,
thereby reducing the incidence of emergence delirium. [43]
Page 9 of 22
Intravenous anaesthetics
Propofol
Ibrahim et al showed that the addition of propofol 1 mg/kg at the end of
sevoflurane general anaesthesia can significantly decrease the incidence of ED in
children undergoing magnetic resonance imaging (MRI). [16] An extensive literature
review was performed by Logan Key et al that evaluated three categories of
anaesthesia techniques: sevoflurane inhalational general anaesthetic, propofol as
an adjunct to sevoflurane general anaesthetic, and propofol total intravenous
anaesthesia (TIVA) techniques.[12] Table 8
They concluded that there is an advantage to either propofol TIVA or adjunctive
propofol with sevoflurane (compared with sevoflurane alone) and that the use of
propofol is associated with a reduction in the incidence of emergence agitation.
The limitations to a TIVA approach in our setting are that it is expensive and the
child will usually require an initial gas induction before inserting the intravenous
line.
Table 8
Page 10 of 22
Ketamine
Ketamine has been established as a safe and effective sedative for painful
paediatric procedures. This dissociative agent can induce dreaming and
hallucinations during recovery, and occasional unpleasant reactions and
nightmares have traditionally limited its use in adults. Children 15 years old and
younger, however, are much less prone to such unpleasant recovery reactions
and display milder reactions when they occur.[26]
In a randomized double blinded study involving 85 premedicated children
undergoing dental repair, Ibrahim et al concluded that the addition of ketamine
0.25 mg/kg 10 min before the end of surgery, significantly decreased the
incidence of emergence agitation in children after sevoflurane general
anaesthesia. There was no statistically significant difference in pain scores, time
to eye opening or recovery room discharge time between the placebo (saline) and
ketamine groups.[27] Table 9
Table 9
Kararmaz et al found that 6 mg/kg oral ketamine given to children 30 minutes
before adenotonsillectomy under desflurane anaesthesia reduced ED incidence
from 56% to 18% without delaying recovery. [28] Dalens et al showed a reduced
incidence of ED in children given 0.25 mg/kg of ketamine administered
intravenously at the end of MRI procedures while under sevoflurane anaesthesia
(12% vs 36% in the control group). [29] In our setting, ketamine may be the answer
for a child at risk for emergence delirium as it is relatively cheap, easy to
administer and lacks respiratory depressive effects.
Premedication
Benzodiazepines
Although benzodiazepines do reduce anxiety their effect on ED is uncertain. The
influence of midazolam on emergence behaviour seems to be somewhat
controversial. Few studies have shown that midazolam premedication decreases
agitation postoperatively following sevoflurane [19] while others have shown no
Page 11 of 22
effect [17,18]. Christian el al compared premedication of 1 mg/kg midazolam with 0.5
mg/kg and found no statistically significant difference in emergence behaviour but
negative behavioural changes occurred more frequently in children younger than
3 years of age. The amnesia surrounding induction after midazolam
premedication might increase postoperative anxiety [17]. Therefore upon
awakening, premedicated children could be disorientated and agitated in the belief
that surgery was not over. Naturally this would more readily occur in younger
children who often do not yet understand their surroundings, especially when not
fully alert.
Phenothiazines
Trimeprazine (Vallergan) has powerful antihistaminic, anti-emetic, antipruritic and
sedative actions. Patel et al randomly assigned 90 children to one of three groups
for premedication with oral midazolam 0.5 mg.kg-1, diazepam 0.25 mg.kg-1 with
droperidol 0.25 mg.kg-1, or trimeprazine 2 mg.kg-1. On arrival at the anaesthetic
room, anxiolysis was satisfactory in 26 out of 29 (90%) children who received
midazolam compared with 23 out of 29 (79%) who received diazepam-droperidol
and 18 out of 29 (62%) who received trimeprazine (P < 0.05).[42]
Dexmedetomidine and clonidine
Dexmedetomidine, a selective alpha 2-agonist has sedative, analgesic and
anxiolytic effects after IV administration. Shukry et al conducted a double-blinded
randomized prospective study that showed that the perioperative infusion of 0.2
µg/kg/hr dexmedetomidine decreases the incidence and frequency of ED in
children after sevoflurane-based GA without prolonging the time to extubate or
discharge. [30] Table 10, The incidence of ED was statistically significantly different
between the two groups, 26% in the dexmedetomidine group (Group D) vs 60.8%
in the saline group (Group S) (P = 0.036).
Table 10
A decreased ED incidence was also seen in a study by Berrin et al after a dose of
1µg/kg dexmedetomidine post sevoflurane gas induction in children undergoing
MRI. The incidence of emergence agitation was 47.6% in the placebo group, and
4.8% in the dexmedetomidine group (P = 0.002). [11]
Page 12 of 22
Dexmedetomidine has also been studied as a premedication against midazolam.
[31]
Subjects received 4 µg/kg of oral dexmedetomidine or 0.5 mg/kg of midazolam
orally prior to anaesthesia induction. Subjects’ anxiety over parental separation,
acceptance of anaesthesia masks, and presence and severity of ED were
evaluated.
There were no statistically significant differences in parental separation anxiety,
mask acceptance and ED occurrence between the 2 groups. In this study,
dexmedetomidine produced no common side effects (blood pressure and heart
rate fluctuation), which may indicate that oral administration with a 16%
bioavailability versus 82% in buccal preparations results in fewer side effects but
requires higher dosing to gain therapeutic effects. Dexmedetomidine reduces
norepinephrine release and sympathetic activity, which could explain its role in
achieving superior sedation and preventing ED.
Intravenous clonidine 3ug/kg reduced the incidence of post sevoflurane ED from
39% in the control group to 5% in the clonidine group with no delay in fitness to
discharge [32]. Moreover, intraoperative administration of 2 µg/kg i.v. clonidine
decreased the incidence of ED from 80% in the control group to 10% in the
clonidine group [33]. Oral clonidine 4 µg/kg given thirty minutes prior to sevoflurane
anaesthesia induction in preschool children is associated with a significant
reduction in ED compared to midazolam 0.5 mg/kg (25% vs. 60%).[34]
Opioids
Fentanyl
Fentanyl is a potent opioid, which can decrease ED following sevoflurane and
desflurane anaesthesia. Cravero et al have shown that fentanyl 1 µg/kg IV given
10 minutes before the discontinuation of the sevoflurane anaesthetic in patients
undergoing magnetic resonance imaging decreased the incidence of ED from
56% to 12% (P=0.02). [20] Inomata et al studied the effect of fentanyl infusion on
the intubating conditions as well as emergence agitation in children anesthetized
with sevoflurane.
They recommended a bolus of 2 µg/kg followed by an infusion of 1 µg/kg/hr for a
smooth emergence.[21] Intranasal fentanyl 2 µg/kg after induction with sevoflurane
resulted in therapeutic serum levels of fentanyl and decreased agitation after ear
tube placement.[22] In a randomized controlled trial, patients were treated with
either with a placebo or a 1- to 1.5-ug/kg dose of fentanyl before inserting a
laryngeal mask airway. Between the two treatments, there was a significant
difference in the frequency of emergence agitation (P = 0.04) but no postoperative
adverse effects such as postoperative nausea and vomiting. [11]
Page 13 of 22
Table 11
Alfentanil
There are positive results regarding the use of alfentanil on the incidence of
emergence delirium. One hundred and five children, were randomly allocated to
receive normal saline (control group), alfentanil 10 µg/kg (A10) or 20 µg/kg (A20),
1 minute post sevoflurane induction. [24] The incidence of severe agitation was
significantly lower in the A10 and A20 groups compared with those in the control
group (11/32 and 12/34 vs. 24/34, respectively) (P=0.007, 0.006, respectively).
PAED scales were significantly different between the three groups (P=0.008), and
lower in the A10 and A20 groups than that in the control group (P=0.044, 0.013,
respectively).Table 12 There was also no significant delay in recovery, no
significant hypotension and no difference in the side effects of alfentanil such as
cough or chest wall rigidity between groups.
Table 12
Remifentanil
In preschool aged children undergoing adenotonsillectomy with sevoflurane
general anaesthesia, after propofol and fentanyl induction, intraoperative
remifentanil decreased the incidence of emergence agitation. [25] The incidence of
emergence agitation in group S was 66.7% (20/30) and in group R 23.3% (7/30),
Page 14 of 22
P <0.01 Table 13 Group S received no other medication(saline) while group R
received remifentanil 1 μg/kg/minute intraoperatively.
Table 13
The influence of remifentanil on emergence agitation may be that more profound
intraoperative suppression of pharyngeal and laryngeal reflexes during
adenotonsillectomy might reduce emergence agitation. However in this study,
there is no mention of administration of another analgesic and this technique may
be cumbersome and expensive in clinical practice.
5HT3 antagonist
It has also been shown that tropisetron, a 5HT3 antagonist, decreases emergence
agitation compared to placebo (32% vs 62%). However, the mechanism of action
is unclear as described by Lankinen et al.[35]
Non-pharmacologic tools
It is important to maintain a quiet environment for the child. If ED occurs, holding
the child and physical restraint may be necessary sometimes to protect the child.
A very effective method is reuniting with the parent or caregiver during awakening.
However, if an emergence delirium reaction occurs, it is best to remove and
counsel the parent on the child's condition as this is a distressing event to witness.
Acupuncture
Acupuncture therapy may be effective in diminishing both pain and emergence
agitation in children. In a prospective randomized controlled trial, Yuan-Chi et al
showed that acupuncture markedly reduces emergence agitation in children after
sevoflurane and nitrous oxide anaesthesia for bilateral myringotomy and
tympanostomy tube insertion without producing adverse events. [41] Table 14
Page 15 of 22
Table 14
RELATIONSHIP BETWEEN EMERGENCE DELIRIUM AND LONG-TERM
POSTOPERATIVE MALADAPTIVE BEHAVIOURS
Following discharge to home, another perioperative complication that has been
seen in up to 50% of children postoperatively is the development of negative
postoperative behavioural changes (NBC) [40].
These behaviours include generalized anxiety, nighttime crying, enuresis,
separation anxiety, and temper tantrums. Kain et al suggests that patients with
emergence delirium are seven times more likely to have new onset postoperative
maladaptive behavioural changes including eating problems, sleep disturbances,
separation anxiety and apathy.[36] He reported that 54% of all children undergoing
general anaesthesia exhibit negative behavioural responses 2 weeks after the
surgery and continues up to 6 months in 20% and up to one year in 7%.[36]
In another study he found no difference in behaviour between children exposed to
sevoflurane or halothane.[39] Faulk et al revealed no correlation between the length
of time under deep hypnosis defined as BIS<45 and the incidence of ED or
negative postoperative behavioural changes [37].
In a prospective randomized control trial involving 120 patients, Keany et al
showed that there was a significant decrease in the incidence over time with 58.3,
46.7 and 38.3% of all children exhibiting negative changes on postoperative days
1, 7 and 30, respectively (P < 0.03). [38] Children under the age of 4 years were
significantly more likely to develop postoperative negative behavioural
changes(NBC) than older children.
Page 16 of 22
Table 15 [38]
Fortier et al examined children’s anxiety across the perioperative setting. Anxiety
levels of 261 children aged 2–12 was rated prior to surgery, immediately after
surgery, and for 2 weeks at home following surgery using the modified Yale
preoperative anxiety scale (mYPAS) and the post hospitalization behavioural
questionnaire (PHBQ). The mYPAS is a structured, observational measure of
preoperative anxiety in children that has been validated and has demonstrated
good to excellent inter- and intraobserver reliability.
The PHBQ is a questionnaire measuring post hospitalization behavioural changes
in children and has acceptable validity and test–retest reliability. Questions
evaluate maladaptive behaviour patterns such as an increase in temper tantrums,
loss of appetite and sleep disturbances. It also appraises behavioural regression
including the loss of previously gained milestones (e.g. return to bedwetting). The
PHBQ consists of 27 items rated by parents relative to behaviour before surgery.
Child anxiety increased significantly prior to surgery, peaked at mask introduction,
and decreased in the immediate postoperative setting and over the 2 weeks at
home (P < 0.001). (Figure 1) It is important to remember that a hospital admission
for a child has many stressful events and emergence delirium is not a sole
contributor to the occurrence of negative postoperative behavioural changes.
Page 17 of 22
PREVENTION AND MANAGEMENT
As previously described in detail, numerous medications have been studied to
prevent or reduce emergence delirium in children. No one effective method has
been shown to be highly superior. It is very difficult to compare studies as each
uses different assessment tools, type of surgical procedure, or even anaesthetic
techniques. However, it is no doubt that a young anxious preschool child
undergoing a painful surgical procedure without adequate pain control will most
likely suffer from emergence delirium.
There is a relationship linking preoperative anxiety, emergence delirium, and
postoperative maladaptive behaviour changes. Children who are at high risk of
developing all of these clinical phenomena are younger, more emotional, more
impulsive, and less social.36] Parental anxiety is a significant predictor of
perioperative anxiety and thus has implications for treatment. [36] Children’s
temperament may also be a modifiable target. Emphasis is placed on identifying
ways to mitigate parental anxiety, such as developing preoperative preparation
programs directed at parents and patients.
It is vital for the anaesthetist to be aware of this phenomenon and to add
awareness to the recovery room staff. If a child has emergence delirium, the first
step is to secure the drip site for intravenous drug administration. The next step is
to call for help and to prevent injury to the child. The caregiver should be removed
and counselled if already present. Administer propofol in 5 to 10mg increments
and be prepared to support the child's ventilation with an ambubag, oxygen and
an oropharyngeal airway if apnoea occurs.
Page 18 of 22
CONCLUSION
In summary, ED remains a significant post anaesthetic problem that interferes
with the child’s recovery and challenges the anaesthetist and the recovery room
staff in terms of assessment and treatment. An understanding of potential risk
factors is important to appropriately differentiate and treat agitation in the
paediatric recovery unit. As studies are ongoing trying to discover the underlying
causes or trying to treat and prevent the occurrence of emergence delirium, it is
the role of the anaesthetist to recognize patients at risk, involve the parents
preoperatively as well as postoperatively and use adjuvant drugs as deemed
necessary.
Page 19 of 22
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