Transcript Emergence Delirium

Pediatric Emergence Delirium
Pediatric Emergence Delirium
Pediatric Emergence Delirium
Pediatric Emergence Delirium
Outline
 Definition
 Incidence
 Risk Factors
 Etiology
 Prevention
 Identification
 Management
Emergence Delirium: Definition
 Delirium is a complex psychiatric syndrome that
includes perceptual disturbances, hallucinations and
psychomotor agitation.
 “A disturbance in a child’s awareness of and
attention to his or her environment with
disorientation and perceptual alterations including
hypersensitivity to stimuli and hyperactive motor
behavior in the immediate post-anesthesia period.”
American Psychiatric Association (2000)
Sikich and Lerman, Anesthesiology (2004)
Definition? Clear as MUD
 The term “delirium” is often replaced with the
descriptive terms “agitation” or “excitation” as it is
not feasible to fully evaluate a young child’s psychological state during emergence
 EA (Emergence agitation) is a state of mild
restlessness and mental distress that, unlike
delirium, does not always suggest a significant
change in behavior
Choen, et al (2001)
Galford (1992)
More Mud….
 Agitation can indicate any number of sources,
including pain, physiological compromise or anxiety.
 Delirium may be confused with agitation, but it may
also be a cause of agitation.
Voepel-Lewis, et al (2004)
Emergence Delirium
 Usually within the first 30 minutes of recovery from
general anesthesia
 Brief (10-15 minutes)
 Self-limited and resolves spontaneously
 However, agitation and regressive behavior that
lasted up to 2 days were also described in the
literature.
How often does this happen?
Incidence
 The incidence of EA/ED largely depends on
definition, age, anesthetic technique, surgical
procedure and application of adjunct medication.
 First described by Eckenhoff, et al in 1961
 Pediatric: Generally ranged 10-50% but may be as
high as 80%
 Adult: 3-4%
Vlaikovic, et al (2007)
Lepouse, et al (2006)
Does it matter?
 Risk of harming surgical repair
 Risk of harming self
 Risk of harming caregivers (nurse, parent)
 Risk of pulling out IV’s, drains, tubes, catheters,
dressings
 IT’S STRESSFUL, NOT IDEAL AND IT MATTERS! WE
CAN DO BETTER!
What’s the big deal?
 More nursing resources required
 May require physical or pharmacological restraint
(with potential side effects)
 May prolong recovery room stay
 May delay hospital discharge
 Parents/nurses/providers less satisfied with quality
of surgical/anesthetic experience
RISK FACTORS
 Patient related
 Surgery related
 Anesthesia related
Risk Factors: Patient related
 Age
 Anxiety




Preoperative
Postoperative
Patient
Parent
 Temperament
Risk Factors: Age
 Generally, younger children are more likely to show
altered behavior upon recovery from anesthesia
 More common in younger children (preschool vs.
school age)
 2-5 year-olds thought to be most vulnerable to
becoming easily confused and frightened by
unfamiliar experiences/surroundings
Voepel-Lewis, et al (2003)
Vlaikovic, et al (2007)
Risk Factors: Patient
 Multiple studies show the likelihood of patient
preoperative anxiety increasing the risk of
postoperative emergence delirium
 Pre-op anxiety in children may depend primarily on
their stages of development.
 Previous hospital experience
Aono, et al (1999)
Kain, et al (2004)
Banchs, et al (2014)
Risk Factors: Age
 Infants: less likely to experience separation anxiety
 1-3 y/o: experience separation anxiety but respond
positively to distraction and comforting measures
 4-5 y/o: seek explanations and desire control of their
enviornment
 Older children 7-12 y/o: desire more independence
and want to be involved in decision making
processes.
 Adolescents fear losing face and are concerned with
their inability to cope
McGraw, (1994)
Risk Factors: Parent Anxiety
 Pre-op PARENT anxiety also increases risk of post-op
emergence delirium
 The higher the level of maternal salivary amylase,
the more severe the child’s pre-op anxiety AND the
more severe the post-op emergence delirium
Kain, et al (2004)
Arai , et al (2008)
Risk Factors: Parent Anxiety
 Maternal heart variability just before surgery
significantly correlated with emergence behavior of
children undergoing general anesthesia
 Intense preoperative anxiety in children AND their
parents has been associated with increased
likelihood of restless recovery from anesthesia
Arai, et al (2008)
Aono, et al (1999)
Kain, et al (2004)
Risk Factors: Temperament
 Children who are more emotional, impulsive, less
social and less adaptable to environmental changes
are at higher risk for emergence delirium
 It is likely that there is some substrate innate to each
child that will elicit, to a larger or lesser extent, a
fearful response to outside stimuli, depending on
the interaction between the child and the
environment
Voepel-Lewis, et al (2003)
Kain, et al (2004)
Risk Factors: Temperament
 This reactivity, which describes the “excitability,
responsivity, or arousability” of the child, might be
the underlying substrate from which both
preoperative anxiety and ED arise.
 Patient related factors are an important source of
variability for ED and are the most difficult to
control.
Kain, et al (2004)
Rothbart, et al (2000)
Risk Factors: Temperament
 Recent evidence suggests that cultural differences
including:
 Language
 Ethnicity
 …Contribute to changes in behavior especially
behavior during the recovery period.
Fortier, et al (2013)
Risk Factors: Surgery
 Types of Surgery
 Speculation that surgery involving the head leads
patients into feelings of suffocation thus increased
incidence of ED- Not clinically proven
 ENT
 Tonsils, adenoids, thyroid, middle ear
 Ophthalmology
 Strabismus
Voepel-Lewis, et al (2003)
Etiology
 Pain
 Intrinsic characteristics of anesthesia
 Rapid awakening
 Anxiety
 Surgery type
 Psychologically immature
 Temperament
 Unfamiliar environment
 Genetic predisposition
Etiology (continued)
 Pain
 Most confounding variable secondary to overlapping
clinical picture with ED
 Difficult to distinguish between pain and ED
 Inadequate pain relief may cause agitation especially in
short procedures where peak effect of analgesics may
be delayed until after wake up
Etiology (continued)
 Intrinsic characteristics of anesthesia
 Postanesthesia agitation has been described not only
with sevoflurane and desflurane, but also with isoflurane and lesser with halothane (no longer used)
 Children who received sevoflurane/isoflurane for the
induction/maintenance of anesthesia were twice as
likely to develop EA when compared with children who
had any other anesthetic regimen
 Children who received total intravenous anesthesia
(TIVA)- no documented cases of ED
Voepel-Lewis et al (2003)
Etiology (continued)
 Rapid awakening
 postulated that rapid awakening after the use of
the insoluble anesthetics may initiate EA/ED by
worsening a child’s underlying sense of
apprehension when finding them self in an
unfamiliar environment however……
 Delaying emergence by a slow, stepwise decrease
in the concentration of inspired sevoflurane at the
end of surgery did NOT reduce the incidence of EA
Picard, et al (2000)
Oh, et al (2005)
Etiology (continued)
 Temperament/unfamiliar environment
 Older children and adults usually become oriented
rapidly
 Preschool-aged children, who are less able to cope
with environmental stresses, tend to become agitated
and delirious
Vlajkovic et al (2007)
Prevention
 Given that the EA/ED etiology is still unknown, a
clear-cut strategy for its prevention has not been
developed
 Many conflicting studies on preventative
pharmacological measures
 Difficult to study considering confounding variables
and inability to do randomized double blind study
accurately
Prevention
 All aimed at decreasing preoperative anxiety.
 Preoperative Preparation Programs
 Parental Presence Induction of Anesthesia (PPIA)
 Sedative premedication
 Distraction techniques
Prevention
 Preoperative Preparation Programs
 Preoperative booklets or DVD sent to home prior to
surgery
 Child Life Specialist or Child Educator being present
during admission to educate parents and child in age
appropriate manner
 Use of anesthesia mask
 Practice “blowing up the balloon” or anesthesia ventilation
bag
Prevention: Preparation
 A novel preoperative preparation program is the ADVANCE
family centered behavioral preparation program which is an
acronym for
 Anxiety-reduction
 Distraction
 Video modeling and education
 Adding parents
 No excessive reassurance,
 Coaching
 Exposure shaping
Kain, et al (2007)
Prevention: Preparation
ADVANCE Program
 Effectiveness on pre-op anxiety and post-op was
compared with PPIA alone, oral midazolam and control
groups
 Findings:
 Pre-op Anxiety in the ADVANCE group significantly less than
all other groups
 Less anxiety during induction in ADVANCE group than PPIA
and control group
 Incidence of ED and analgesic requirement less in ADVANCE
group
 Discharge times for children in the ADVANCE group were
less
 Obstacle: large operational costs
Kain, et al (2007)
Prevention
 Parental Presence Induction of Anesthesia (PPIA)
 Very common practice in Europe, less common in US
 While 58% of US anesthesia providers agreed with
PPIA only 5% of cases where parents allowed in OR
 84% of British anesthesia providers allowed PPIA in
more than 75% of cases
 Their belief that PPIA decreased children's anxiety,
increased their cooperation and benefited both the
parent and anesthesia provider
Bowie (1993)
Johnson (2012)
Prevention PPIA cont
 Prospective randomized study, N=88, 2-7y/o, GA for
MRI
 Parents present group: reunited before emergence vs.
Parents absent group: reunited per routing practice
 Parental presence at emergence did NOT decrease incidence
or duration of agitation
 Significant psychosocial benefits to the parents: present at
the “right time” and felt “helpful” to their child
 One study N=60, 1-3y/o, minor plastic surgery
 PPIA vs Midazolam 0.5 mg/kg vs. Midazolam AND PPIA
 Less ED seen with combination midazolam AND PPIA
Arai (2007)
Burke (2009)
If I can’t prevent, then what?
 Diagnose or Identify
 Assessment tools
 Reliability and validity of tools
 Manage
 Pharmacological
 Environmental
Identification: Assessment
Tools
 16 rating scales and 2 visual analog scales that
measure agitation have been used to measure ED in
young children
 These scales are deficient in two main respects
 Scale content
 Psychometric evaluation
 These finding lead to the development of Pediatric
Anesthesia Emergence Delirium (PAED)
Sikich (2004)
From: Development and Psychometric Evaluation of the Pediatric Anesthesia Emergence Delirium Scale
Anesthesiology. 2004;100(5):1138-1145.
Date of download: 9/9/2015
Copyright © 2015 American Society of Anesthesiologists. All rights reserved.
Identify
 2010 comparison of these 3 emergence delirium
scales
 Findings include:
 All three scales correlate reasonably well with each
other
 Each have individual limitations
 All patients in this study assessed by the experienced
pediatric anesthetist observer has having ED scored
highly on all three scales
PAED Scale
PAED SCALE
 Pros:
 PAED Scale strong evidence of measurement reliability
and validity.
 Internal consistency of 0.89 with delirium
characteristics of Diagnostic and Statistical Manual of
Mental Disorders (DSM IV)
 High sensitivity and specificity when scores where
equal or greater than 10
 Cons:
 Possibly cumbersome to use in busy clinical setting
Cravero Scale
Cravero Scale
 Pros:
 Advantage of simplicity
 Cons:
 Authors subsequently changed definition of items used
 Item 4 (crying) is nonspecific to ED and shows distress that
could be related to pain, hunger or parental separation
 Not scientifically validated
 Pro or Con:
 Has “sleep” item component
 Argument is not necessary component for agitation/delirium
Watcha Scale
Watcha Scale
 Pro:
 Watcha scale has higher correlation than Cravero with
respect to the PAED scale
 PAED score >12 and Watcha scale have maximal
sensitivity and high specificity in detecting ED
 Ease of use
 Cons:
 No evidence of validation
 Minimal research using just Watcha scale is effective
for determining ED
 Cannot rule out other causes for high ratings, pain,
anxiety etc.
Diagnosis
 Rule out other factors: begin with basics
 Hypoxemia: using adhesive sat probe vs. clip on
 Dehydration: case dependent, fluid status, urine
output, surgical blood loss
 Hypotension: fluid status, medication related etc.
 Hypoglycemia: patient dependent
 Anxiety
 Narcotic side effects: itching, urinary retention etc.
 Pain: case dependent, procedure, VS, anesthetic
technique, intra op medications
Diagnosis
 Critical Thinking is a necessary component to
diagnosing ED
 Ruling out other causative factors in combinations
with….
 Use of diagnostic tools
 DIAGNOSIS IS ED……NOW WHAT?
MANAGEMENT
 Decision to treat ED in PACU is often influenced by the
severity and duration of symptoms.
 Likely to treat pharmacologically when concerns of safety
of the child, disruption of surgical site or accidental
removal of lines or drains
 Two strategies:
 Non Pharmacologic
 Pharmacologic
Management
 Non-pharmacologic
 Allow child to wake up in their own time
(preventative)
 Decrease stimulation
 Consider foregoing EKG lead (per anesthesia or
department policy)
 Dark and quiet environment
 Soothing verbal reassurance and orientation if
appropriate
Management
 Non-pharmacologic (continued)
 Allowing familiar objects (blanket, stuffed animal)
 Parental reuniting- if appropriate
 Soothing music or iPad cartoons
 Physical restraint- may “wrap” in warm blankets in lieu
of restraints
Management
 Pharmacologic- used as preventative and for
management.
 Fentanyl
 Morphine
 Midazolam
 Dexmedetomidine
 Clonidine
 Ketorolac
 Propofol
Prevention/Management
Vlajkovic et al (2007 )
Management
 Large meta-analysis 2010
 37 articles, 3172 patients
 Midazolam, propofol, ketamine, A2 antagonists, fentanyl,
5HT3 inhibitors
 Primary outcomes: incidence of emergence agitation
 Results in brief:
 Midazolam, and 5HT3 inhibitors not found to have
protective effect against EA/ED
 Propofol, ketamine, A2 agonists, fentanyl and preop
analgesia were all found to have a preventative effect.
BJA (2010)
Management
 Research has found PACU nurses have first utilized
pain management orders such as fentanyl
 If assertive treatment is necessary…
 Single bolus of propofol 0.5-1 mg/kg IV
 Fentanyl 1-2.5 mcg/kg IV
 Dexmedetomidine 0.5 mcg/kg IV
Has been successful in decreasing the severity and
duration of ED episode.
Banchs (2014)
Emergence Delirium:
Conclusion
 ED is common and self limiting
 ED is usually brief, but pharmacological management
may be required
 Potentially harmful to patient and caregivers
 Challenging to manage
 Good post-op pain control is crucial
Emergence Delirium
Conclusion
 Pre-op sedation is probably helpful for anxious
patients
 NO evidence that if left untreated ED had long-term
sequelae in children
 More research is necessary to find better anesthetic
agents, diagnostic tools and preventative measures.
We like Happy Tykes
References
American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. 4th ed. Arlington, VA: American Psychiatric Publishing, 2000.
Aono J, Mamiya K, Manabe M. Preoperative anxiety is associated with a high
incidence of problematic behavior on emergence after halothane anesthesia in
boys. Acta Anaesthesiol Scand 1999;43:542–4.
Bajwa S, Costi, D, Cyna, A, A comparison of emergence delirium scales following
general anesthesia in children. Pediatric Anesthesia 2010;20:704-11
Bowie, JR. Parents in the operating room? Anesthesiology 1993:78:1192-3
Cohen IT, Hannallah RS, Hummer KA. The incidence of emergence agitation
associated with desflurane anesthesia in children is reduced by fentanil. Anesth
Analg 2001;93:88–91.
References
Cravero J, Surgenor S, Whalen K. Emergence agitation in paediatric patients after
sevoflurane anesthesia and no surgery: a comparison with halothane. Paediatr
Anaesth 2000;10: 419 –24.
Eckenhoff JE, Kneale DH, Dripps RD. The incidence and etiol- ogy of postanesthetic
excitement. A clinical survey. Anesthesiology 1961;22:667–73.
Fortier MA, Tan ET, Mayes LC, et al. Ethnicity and parental report of postoperative
behavioral changes in children. Paediatr Anesthe 2013;23:422-8
Galford RE. Problems in anesthesiology: approach to diagnosis. Boston, MA: Little,
Brown & Company, 1992:341–3.
References
Johnson, YJ, Nickerson M, Quezado ZM. An unforeseen peril of parental presence
during induction of anesthesia. Anesth Analg 2012;115:1371-4
Kain ZN, Caldwell-Andrews AA, Mayes LC, et al. Family-centered preparation for
surgery improves perioperative outcomes in children. Anesthesiology
2007;106:65 74
Kain ZN, Caldwell-Andrews AA, Maranets I, et al. Preoperative anxiety and
emergence delirium and postoperative maladaptive behaviors. Anesth Analg
2004;99:1648–54.
Kulka PJ, Bressem M, Tryba M. Clonidine prevents sevoflurane- induced agitation
in children. Anesth Analg 2001;93:335–8.
References
Lepouse et al. BJA 2006: 96(6):747-753
McGraw T. Preparing children for the operating room: psychological issues. Can J
Anesth 1994;41:1094-103
Oh AY, Seo KS, Kim SD, et al. Delayed emergence process does not result in a
lower incidence of emergence agitation after sevoflurane anesthesia in
children. Acta Anaesthesiol Scand 2005;49:297–9.
Picard V, Dumont L, Pellegrini M. Quality of recovery in children: sevoflurane
versus propofol. Acta Anaesthesiol Scand 2000;44:307–10.
Przybylo HJ, Martini DR, Mazurek AJ, et al. Assessing behaviour in children
emerging from anesthesia: can we apply psychiatric diagnostic techniques?
Paediatr Anaesth 2003;13: 609 –16.
References
Rothbart MK, Ahadi SA, Evans DE. Temperament and personality: origins and
outcomes. J Pers Soc Psychol 2000;78:122–35
Sikich, N, Lermann J. Development and psychometric evaluation of the Pediatric
Anesthesia Emergence Delirium Scale. Anesthesiology 2004; 11: 1138-1145
Vlajkovic & Sindjelic, Anesth Analg 2007: 104(1):84-91
Voepel-Lewis T, Burke C. Differentiating pain and delirium is only part of assessing
the agitated child. J Perianesth Nurs 2004;19:298 –9.
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.