Journal Reading: Emergence delirium in

Children

PGY 吳易儒

Purpose of Review

● Volatile agents (no evidence)● Recent Findings:

○ preventing pre-OP anxiety○ providing sufficient analgesia

○ intra-OP sedative agents: ketamine,

clonidine, dexmedetomidine,

gabapentine, midazolam, magnesium,

hydroxyzine, midazolam, dexamethasone

● Tx :○ propofol, opoid○ dexmedetomidine(prevent PONV)

Introduction

● Adult: postopreative agitation● Children: emergence delirium● No strong evidence of:

○ pathophysiology of ED○ the relation between ED and fast acting volatile agents

Cause of ED

Cause of ED

● post-operative pain● pharmacokinetics● pharmacodynamics of anesthetics agents

Cause of ED - post OP pain

● a study: 4 case with post-OP agitation (1 is children)● paranoid sensation● fear for anesthesiologists/surgeons● but occurs in non-painful procedures (Pediatric imaging)

Cause of ED - Pharmacokinetics/dynamics

● Clearance of volatile agents from CNS : different recovery rate of brain functions

● Late recovery of congitive function compared to audition and locomotion: cause confusion state

● Sevoflurane and desflurane use increase incidence of ED● Propofol, Sevoflurane or desflurane have preventive effect of ED● The resting state and dynamic state can not be activated simultaneously● Different cognitive control between children and adultes● ASA 2012 found similar in EEG patteren in children’s ED and night terrors

● resting state= resting functional connectivity network, when patients are asked to think

● dynamic state= executive control network, when patients are focusing on external environment

Clinical presentation and diagnostic criteria

Clinical presentations and diagnostic criteria

● ED incidence from 2-80% , different from○ agent○ preventive strategies○ validated tools○ different thresholds to score

Clinical presentations and diagnostic criteria

● Risk factors of ED:○ have emergence agitation○ preschool children(40% pre v.s. 11.5% school)○ male○ Sevolurane / desflurane use (v.s. isoflurane, halothane, iv agents)○ ENT surgery○ pre-OP anxiety

Clinical presentations and diagnostic criteria

● Vopel-Lewis (2003, Anesth Analg) : factors associated with ED○ activity, rhythmicity, approachability, adaptability, intensity, mood, per- sistence, distractibility

and sensitivity○ adaptability significantly associated with ED when facing anxicious

● Pre-OP anxiety is strong associated with ED

Clinical presentations and diagnostic criteria

● Classical predictors of pre-OP anxiety: ○ young age○ parental anxiety○ very few siblings○ poor sociability○ few social adaptative capability○ poor quality of previous medical experience○ lack of enrollment in a day care surgery○ low rating for activity

Clinical presentations and diagnostic criteria

● ED= emotional agitation state (confusion of recognizing surrounding environment)○ soon(14 +- 11mins) ~ 45mins○ no eye contact with surrounding person, inconsolable

● Paediatr Anaesth 2011, specific symptoms:(18m~ 6y)○ involuntary agitation with kicking○ absence of eye contact with caregivers or parents (with eyes staring or averting) ○ inconsolability and absence of awareness of the surroundings.

Clinical presentations and diagnostic criteria

● 2004, Sikich and Lerman: Pediatric Anesthesia Emergence Delirium (PAED) scale

● >10 , sensibility of 64% and a specificity of 86%

Clinical presentations and diagnostic criteria

● 2010, Anesth Analg, mal-adaptive behavior in post-OP stage○ sleep disturbances○ bed wetting○ temper tantrums○ attention seeking○ loneliness fear as well as high stress level for parents

Clinical presentations and diagnostic criteria

● Paediatr Anaesth 2010, risk factors of ED:○ younger age○ lower birth order○ an inhibited temperament○ pre-OP anxiety (in parents and children)○ noninclusion in a day care surgery program○ sevoflurane-based anesthesia○ post-OP pain

● no study can clearly support, but parents should be informed

Prevention of ED

Prevention of ED - Pharmacological

● Propofol as induction showed no efficiency in decreasing ED, related to its short half-life

● Premedicatio clonidine and melatonin decreased the incidence of ED compared with midazolam.

● Dexmedetomine end of surgery (0.3 mg/kg) / continuously better than ○ propofol bolus of 1 mg/kg at the end of surgery○ or contiouous ketamine○ although it may increase the duration of PACU○ but the effect of preventing ED and post operative N/V is recommended○ recently found as effective as ACT-codeine association in preventing ED (pain part)

Prevention of ED - Pharmacological

● Propofol given at the end of surgery or continuous during surgery● intraoperative fentanyl● ketamine (systemically/regional)● clonidine (systemically/regional) ● dexmedetomidine (systemically/regional); ● preoperative gabapentine ● intraoperative Mg infusion ● preoperative midazolam● intraoperative dexamethasone

Prevention of ED - Non-pharmacological

● Cochrane Database Syst Rev 2009, focus on decreasing the preoperative anxiety

● Strategies to decrease children and parents anxiety:○ quiet induction with decreased sensory stimuli○ music therapy,○ distraction and hypnosis,○ clown doctors acupressure,○ videotapes information movies before induction○ parents’ information

● Other study : parents present showed inconsistently results

Prevention of ED - Non-pharmacological

● Anesthesiology 2007, Kain: family-based preparation: ADVANCE strategy○ Anxiety-reduction,○ Distraction,○ Video modeling and education,○ Adding parents,○ No excessive reassurance安慰,○ Coaching,○ Exposure/shaping

● More effective than premedication midazolam

Treatment of ED

Treatment of ED

● Pharmacologic treatment : iv sedative agents○ midazolam 0.1 mg/kg [37]○ propofol 0.5 – 1 mg/kg [38]○ or opioid agents (iv fentanyl 1 – 2 mg/kg [39]○ Dexmedetomine showed better than propofol in prevention but never been studied in

treatment● All of these agents may delay discharge from PACU● Physicians are encouraged to use compounds as analgesia or PONV

preventive agents: sufentanil, dexmedetomidine, clonidine or ketamine.

Conclusion

Conclusion

● ED is common in ○ anesthetized preschool children○ especially sevoflurane use

● Preventive strategies:○ prevent pre-operative anxiety○ treating post-OP pain○ propofol at end of OP○ intra-OP dexmedetomidine and dexamethasone○ parents should be informed possible post-OP maladaptive behaviors

Thanks for your attention.