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
Disclosures

No relevant financial relationships

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
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
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
1. Cote C, A Practice of Anesthesia for Infants and Children 6e
2. Voepel-Lewis et al., Anesth Analg 2003; 96:1625-30
3. Lee CJ et al., Korean J Anesthesiol 2010; 59:75-81
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
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
Emergence Delirium:
What is the impact?
Post-operative behavioral changes
• Increased general anxiety
• Problems with separation
• Sleep disturbances
• Bedwetting
• Temper tantrums
• Eating disturbances
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
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
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

ED Assessment Tools:
CRAVERO SCALE
Behavior Score
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
 ED Assessment Tools:
PAED SCALE
Just a Quite a Very
Behavior Not at all little bit much Extremely

Eye contact 4 3 2 1 0

Purposeful
actions 4 3 2 1 0

Aware of 4 3 2 1 0
surroundings
Restless 0 1 2 3 4

Inconsolable 0 1 2 3 4

Scores > 12: very sensitive and specific for ED

1. Bajwa SA et al., Ped Anesth 2010; 20:704-711
Question:
What can we do as
anesthesiologists to reduce the
incidence of emergence
delirium?
Answers:
1) Identify risk factors
2) Determine best anesthetic
approach to decrease the
incidence of ED in high risk
cases
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
1. Cote, A Practice of Anesthesia for Infants and Children 6e
2. Kain et al. Anesth Analg 2004; 99:1648–1654
3. Voepel-Lewis et al., Anesth Analg 2003; 96:1625-30
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
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
• Peri-op analgesia emergence
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

1. Dahmani et al, BJA, 2010; 104:216-23

2. Kanaya et al, J Anesth 2014; 28:4-11
3. Van Hoff et al, Pediatric Anesthesia, 2015; 25:668-76
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

1. Pickard et al, BJA, 2014; 112:982-90

2. Dahmani et al, BJA, 2010; 104:216-23
3. Zhu et al, PLoS ONE 2015; 10(4): e0123728
4. Zhang et al., PLoS ONE 2014; 16:e99718
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 et al., Paediatr Anesth 2004; 14:477-482

2. Abu-Shawan I and Chowdary K. Pediatric Anesthesia 2007; 14:846-50
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

1. Kim et al., Ped Anesth 2017; 27:885-892

2. Dahmani et al., BJA 2010; 104:216-223
3. Shi et al., Plos One 2015 10:e0135244
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

1. Dahmani et al., BJA 2010; 104:216-223

2. Cho et al., Anesthesiology 2014; 2010:1354-61
3. Kim et al., Ped Anesth 2017; 27:885-892
Reducing ED:
What Doesn’t Work?
• Gabapentin
• Magnesium
• Melatonin
• 5-HT3 Antagonists
• Acupuncture
• Ketorolac

1. Dahmani et al., BJA 2010; 104:216-223

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?
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
Question:
What can we do as
anesthesiologists to treat
emergence delirium in the
recovery room?
Answers:
1. Rule out other causes of agitation in
the recovery room
2. Reassure parents
3. Educate PACU nurses
4. Pharmacologic treatment
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)
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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

30
Emergence Delirium:
Treatment
If emergence delirium persists in the
PACU consider IV bolus of either:
• Dexmedetomidine (0.2-0.4 mcg/kg)
• Propofol (1-2 mg/kg)

Remember to have emergency airway

equipment available at the bedside

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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
References:
References:

1. 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 2007 17: 846–850
2. Bajwa SA, Costi D, Cyna AM. A comparison of emergence delirium scales following general anesthesia in children.
Pediatric Anesthesia 2010; 20:704-711
3. 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: 1354-61
4. Cote, C, Jerrold L, Anderson Brian (2013) A Practice of Anesthesia for Infants and Children 6e. Philadelphia, PA.
Saunders
5. 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
6. Dahmani S, Delivet H, Hilly J. Emergence delirium in children: an update. Curr Opin Anesthesiol 2014; 27: 309–
315.
7. Kararmaz A, Kaya S, Turhanoglu S, Ozyilmaz MA. Oral ketamine premedication can prevent emergence agitation
in children after desflurane anaesthesia. Paediatr Anesth 2004; 14:477-482
8. Kain ZN, Caldwell-Andrews AA, Maranets I, et al. Preoperative anxiety and emergence delirium and
postoperative maladaptive behaviours. Anesth Analg 2004; 99:1648–1654
9. 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
10.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
11.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
References:
References (cont.):

12. Lee CJ et al. The effect of Propofol on emergence agitation in children receiving sevoflurane for
adenotonsillectomy. Korean J Anesthesiol 2010:59:75-81
13. 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;
14. 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 2015 10:e0135244
15. 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
16. Vlajkovic G, Sindjelic R. Emergence delirium in children: many questions, few answers. Anesthesia & Analgesia
2007; 104:84-91
17. Voepel-Lewis T, Malviya S, Tait AR. A Prospective Cohort Study of Emergence Agitation in the Pediatric
Postanesthesia Care Unit. Anesth Analg 2003; 96:1625-30
18. 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
19. 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): e0123728

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