managing pediatric emergence delirium little tykes...

Little Tykes Terror:M

anaging Pediatric Emergence D

elirium

Leianne O. K

noll Krajew

ski, CR

NA

, DN

P

Pediatric Emergence D

elirium


eliriumPediatric Em

ergence Delirium


eliriumO

utline

•D

efinition

•Incidence

•R

isk Factors

•Etiology

•Prevention

•Identification

•M

anagement

Emergence D

elirium: D

efinition

•D

elirium is a com

plex psychiatric syndrome that includes

perceptual disturbances, hallucinations and psychom

otor agitation.

•“A

disturbance in a child’s awareness of and attention to

his or her environment w

ith disorientation and perceptual alterations including hypersensitivity to stim

uli and hyperactive motor behavior in the im

mediate

post-anesthesia period.”

Am

erican Psychiatric Association (2000)

Sikich and Lerman, A

nesthesiology (2004)

Definition? C

lear as MU

D

•The term

“delirium” is often replaced w

ith the descriptive term

s “agitation” or “excitation” as it is not feasible to fully evaluate a young child’s psychological state during em

ergence

•EA

(Emergence agitation) is a state of m

ild restlessness and m

ental distress that, unlike delirium, does not

always suggest a significant change in behavior

Choen, et al (2001)

Galford (1992)

More M

ud….

•A

gitation can indicate any number of sources, including

pain, physiological comprom

ise or anxiety.

•D

elirium m

ay be confused with agitation, but it m

ay also be a cause of agitation.

Voepel-Lew

is, et al (2004)

Emergence D

elirium

•U

sually within the first 30 m

inutes of recovery from

general anesthesia

•B

rief (10-15 minutes)

•Self-lim

ited and resolves spontaneously

•H

owever, 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 m

edication.

•First described by Eckenhoff, et al in 1961

•Pediatric: G

enerally ranged 10-50% but m

ay be as high as 80%

•A

dult: 3-4%

Vlaikovic, et al (2007)

Lepouse, et al (2006)

Does it m

atter?

•R

isk of harming surgical repair

•R

isk of harming self

•R

isk of harming caregivers (nurse, parent)

•R

isk of pulling out IV’s, drains, tubes, catheters,

dressings

•IT’S STR

ESSFUL, N

OT ID

EAL A

ND

IT MA

TTERS! W

E CA

N

DO

BETTER

!

What’s the big deal?

•M

ore nursing resources required

•M

ay require physical or pharmacological restraint (w

ith potential side effects)

•M

ay prolong recovery room stay

•M

ay delay hospital discharge

•Parents/nurses/providers less satisfied w

ith quality of surgical/anesthetic experience

RISK

FAC

TOR

S

•Patient related

•Surgery related

•A

nesthesia related

Risk Factors: Patient related

•A

ge

•A

nxiety

•Preoperative

•Postoperative

•Patient

•Parent

•Tem

perament

Risk Factors: A

ge

•G

enerally, younger children are more likely to show

altered behavior upon recovery from

anesthesia

•M

ore comm

on in younger children (preschool vs. school age)

•2-5 year-olds thought to be m

ost vulnerable to becom

ing easily confused and frightened by unfamiliar

experiences/surroundings

Voepel-Lew

is, et al (2003)V

laikovic, et al (2007)

Risk Factors: Patient

•M

ultiple studies show the likelihood of patient

preoperative anxiety increasing the risk of postoperative em

ergence delirium

•Pre-op anxiety in children m

ay depend primarily on their

stages of development.

•Previous hospital experience

Aono, et al (1999)

Kain, et al (2004)

Banchs, et al (2014)

Risk Factors: A

ge

•Infants: less likely to experience separation anxiety

•1-3 y/o: experience separation anxiety but respond positively to distraction and com

forting measures

•4-5 y/o: seek explanations and desire control of their enviornm

ent

•O

lder children 7-12 y/o: desire more independence and

want to be involved in decision m

aking processes.

•A

dolescents fear losing face and are concerned with

their inability to cope

McG

raw, (1994)

Risk Factors: Parent A

nxiety

•Pre-op PA

REN

T anxiety also increases risk of post-op em

ergence delirium

•The higher the level of m

aternal salivary amylase, the

more severe the child’s pre-op anxiety A

ND

the more

severe the post-op emergence delirium

Kain, et al (2004)

Arai , et al (2008)

Risk Factors: Parent A

nxiety

•M

aternal heart variability just before surgery significantly correlated w

ith emergence behavior of

children undergoing general anesthesia

•Intense preoperative anxiety in children A

ND

their parents has been associated w

ith increased likelihood of restless recovery from

anesthesia

Arai, et al (2008)

Aono, et al (1999)

Kain, et al (2004)

Risk Factors: Tem

perament

•C

hildren who are m

ore emotional, im

pulsive, less social and less adaptable to environm

ental changes are at higher risk for em

ergence delirium

•It is likely that there is som

e substrate innate to each child that w

ill elicit, to a larger or lesser extent, a fearful response to outside stim

uli, depending on the interaction betw

een the child and the environment

Voepel-Lew

is, et al (2003)K

ain, et al (2004)

Risk Factors: Tem

perament

•This reactivity, w

hich describes the “excitability, responsivity, or arousability” of the child, m

ight be the underlying substrate from

which both preoperative

anxiety and ED arise.

•Patient related factors are an im

portant source of variability for ED

and are the most difficult to control.

Kain, et al (2004)

Rothbart, et al (2000)

Risk Factors: Tem

perament

•R

ecent 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

•EN

T

•Tonsils, adenoids, thyroid, m

iddle ear

•O

phthalmology

•Strabism

us

Voepel-Lew

is, et al (2003)

Etiology

•Pain

•Intrinsic characteristics of anesthesia

•R

apid awakening

•A

nxiety

•Surgery type

•Psychologically im

mature

•Tem

perament

•U

nfamiliar environm

ent

•G

enetic predisposition

Etiology (continued)

•Pain

•M

ost confounding variable secondary to overlapping clinical picture w

ith ED

•D

ifficult to distinguish between pain and ED

•Inadequate pain relief m

ay cause agitation especially in short procedures w

here peak effect of analgesics may be

delayed until after wake up


•Intrinsic characteristics of anesthesia

•Postanesthesia agitation has been described not only w

ith sevoflurane and desflurane, but also w

ith isoflurane and lesser w

ith halothane (no longer used)

•C

hildren who received sevoflurane/isoflurane for the

induction/maintenance of anesthesia w

ere twice as likely

to develop EA w

hen compared w

ith children who had any

other anesthetic regimen

•C

hildren who received total intravenous anesthesia (TIV

A)-

no documented cases of ED

Voepel-Lew

is et al (2003)


•R

apid awakening

•postulated that rapid aw

akening after the use of the insoluble anesthetics m

ay initiate EA/ED

by worsening

a child’s underlying sense of apprehension when

finding them self in an unfam

iliar environment

however…

…

•D

elaying emergence by a slow

, stepwise decrease in

the concentration of inspired sevoflurane at the end of surgery did N

OT reduce the incidence of EA

Picard, et al (2000)O

h, et al (2005)


•Tem

perament/unfam

iliar environment

•O

lder children and adults usually become oriented rapidly

•Preschool-aged children, w

ho are less able to cope with

environmental stresses, tend to becom

e agitated and delirious

Vlajkovic et al (2007)

Prevention

•G

iven that the EA/ED

etiology is still unknown, a clear-

cut strategy for its prevention has not been developed

•M

any conflicting studies on preventative pharm

acological measures

•D

ifficult to study considering confounding variables and inability to do random

ized double blind study accurately

Prevention

•A

ll aimed at decreasing preoperative anxiety.

•Preoperative Preparation Program

s

•Parental Presence Induction of A

nesthesia (PPIA)

•Sedative prem

edication

•D

istraction techniques

Prevention

•Preoperative Preparation Program

s

•Preoperative booklets or D

VD

sent to home prior to

surgery

•C

hild Life Specialist or Child Educator being present during

admission to educate parents and child in age appropriate

manner •

Use of anesthesia m

ask

•Practice “blow

ing up the balloon” or anesthesia ventilation bag

Prevention: Preparation

•A

novel preoperative preparation program is the A

DV

AN

CE fam

ily centered behavioral preparation program

which is an acronym

for

•A

nxiety-reduction

•D

istraction

•V

ideo modeling and education

•A

dding parents

•N

o excessive reassurance,

•C

oaching

•Exposure shaping

Kain, et al (2007)

Prevention: Preparation

AD

VA

NC

E Program•

Effectiveness on pre-op anxiety and post-op was com

pared w

ith PPIA alone, oral m

idazolam and control groups

•Findings: •

Pre-op Anxiety in the A

DV

AN

CE group significantly less than all

other groups

•Less anxiety during induction in A

DV

AN

CE group than PPIA

and control group

•Incidence of ED

and analgesic requirement less in A

DV

AN

CE

group

•D

ischarge times for children in the A

DV

AN

CE group w

ere less

•O

bstacle: large operational costs

Kain, et al (2007)

Prevention

•Parental Presence Induction of A

nesthesia (PPIA)

•V

ery comm

on practice in Europe, less comm

on in US

•W

hile 58% of U

S anesthesia providers agreed with PPIA

only 5%

of cases where parents allow

ed in OR

•84%

of British anesthesia providers allow

ed PPIA in m

ore than 75%

of cases

•Their belief that PPIA

decreased children's anxiety, increased their cooperation and benefited both the parent and anesthesia provider

Bow

ie (1993)Johnson (2012)

Prevention PPIA cont

•Prospective random

ized study, N=88, 2-7y/o, G

A for M

RI

•Parents present group: reunited before em

ergence vs. Parents absent group: reunited per routing practice

•Parental presence at em

ergence did NO

T decrease incidence or duration of agitation

•Significant psychosocial benefits to the parents: present at the “right tim

e” and felt “helpful” to their child

•O

ne study N=60, 1-3y/o, m

inor plastic surgery•

PPIA vs M

idazolam 0.5 m

g/kg vs. Midazolam

AN

D PPIA

•Less ED

seen with com

bination midazolam

AN

D PPIA

Arai (2007)

Burke (2009)

If I can’t prevent, then what?

•D

iagnose or Identify

•A

ssessment tools

•R

eliability and validity of tools

•M

anage

•Pharm

acological

•Environm

ental

Identification: Assessm

ent

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 tw

o main respects

•Scale content

•Psychom

etric evaluation

•These finding lead to the developm

ent of Pediatric A

nesthesia Emergence D

elirium (PA

ED)

Sikich (2004)

Date of dow

nload: 9/9/2015C

opyright © 2015 A

merican S

ociety of Anesthesiologists. A

ll rights reserved.

From: D

evelopment and Psychom

etric Evaluation of the Pediatric Anesthesia Em

ergence Delirium

ScaleA

nesthesiology. 2004;100(5):1138-1145. Identify

•2010 com

parison of these 3 emergence delirium

scales

•Findings include:

•A

ll three scales correlate reasonably well w

ith each other

•Each have individual lim

itations

•A

ll patients in this study assessed by the experienced pediatric anesthetist observer has having ED

scored highly on all three scales

PAED

ScalePA

ED SC

ALE

•Pros:

•PA

ED Scale strong evidence of m

easurement reliability and

validity.

•Internal consistency of 0.89 w

ith delirium characteristics

of Diagnostic and Statistical M

anual of Mental D

isorders (D

SM IV

)

•H

igh sensitivity and specificity when scores w

here equal or greater than 10

•C

ons:

•Possibly cum

bersome to use in busy clinical setting

Cravero Scale

Cravero Scale

•Pros:

•A

dvantage of simplicity

•C

ons:

•A

uthors subsequently changed definition of items used

•Item

4 (crying) is nonspecific to ED and show

s distress that could be related to pain, hunger or parental separation

•N

ot scientifically validated

•Pro or C

on:

•H

as “sleep” item com

ponent

•A

rgument is not necessary com

ponent for agitation/delirium

Watcha Scale

Watcha Scale

•Pro:•

Watcha scale has higher correlation than C

ravero with

respect to the PAED

scale

•PA

ED score >12 and W

atcha scale have maxim

al sensitivity and high specificity in detecting ED

•Ease of use

•C

ons: •

No evidence of validation

•M

inimal research using just W

atcha scale is effective for determ

ining ED

•C

annot rule out other causes for high ratings, pain, anxiety etc.

Diagnosis

•R

ule out other factors: begin with basics

•H

ypoxemia: using adhesive sat probe vs. clip on

•D

ehydration: case dependent, fluid status, urine output, surgical blood loss

•H

ypotension: fluid status, medication related etc.

•H

ypoglycemia: patient dependent

•A

nxiety

•N

arcotic side effects: itching, urinary retention etc.

•Pain: case dependent, procedure, V

S, anesthetic technique, intra op m

edications

Diagnosis

•C

ritical Thinking is a necessary component to diagnosing

ED

•R

uling out other causative factors in combinations

with…

.

•U

se of diagnostic tools

•D

IAG

NO

SIS IS ED…

…N

OW

WH

AT?

MA

NA

GEM

ENT

•D

ecision to treat ED in PA

CU

is often influenced by the severity and duration of sym

ptoms.

•Likely to treat pharm

acologically when concerns of safety of

the child, disruption of surgical site or accidental removal of

lines or drains

•Tw

o strategies:

•N

on Pharmacologic

•Pharm

acologic

Managem

ent

•N

on-pharmacologic

•A

llow child to w

ake up in their own tim

e (preventative)

•D

ecrease stimulation

•C

onsider foregoing EKG

lead (per anesthesia or departm

ent policy)

•D

ark and quiet environment

•Soothing verbal reassurance and orientation if appropriate

Managem

ent

•N

on-pharmacologic (continued)

•A

llowing fam

iliar objects (blanket, stuffed animal)

•Parental reuniting- if appropriate

•Soothing m

usic or iPad cartoons

•Physical restraint- m

ay “wrap” in w

arm blankets in lieu of

restraints

Managem

ent

•Pharm

acologic- used as preventative and for managem

ent.

•Fentanyl

•M

orphine

•M

idazolam

•D

exmedetom

idine

•C

lonidine

•K

etorolac

•Propofol

Prevention/Managem

ent

Vlajkovic et al (2007 )

Managem

ent

•Large m

eta-analysis 2010

•37 articles, 3172 patients

•M

idazolam, propofol, ketam

ine, A2 antagonists, fentanyl,

5HT3 inhibitors

•Prim

ary outcomes: incidence of em

ergence agitation

•R

esults in brief:•

Midazolam

, and 5HT3 inhibitors not found to have protective

effect against EA/ED

•Propofol, ketam

ine, A2 agonists, fentanyl and preop analgesia

were all found to have a preventative effect.

BJA

(2010)

Managem

ent

•R

esearch has found PAC

U nurses have first utilized pain

managem

ent orders such as fentanyl

•If assertive treatm

ent is necessary…

•Single bolus of propofol 0.5-1 m

g/kg IV

•Fentanyl 1-2.5 m

cg/kg IV

•D

exmedetom

idine 0.5 mcg/kg IV

Has been successful in decreasing the severity and duration of ED

episode.

Banchs (2014)

Emergence D

elirium:

Conclusion

•ED

is comm

on and self limiting

•ED

is usually brief, but pharmacological m

anagement

may be required

•Potentially harm

ful to patient and caregivers

•C

hallenging to manage

•G

ood post-op pain control is crucial

Emergence D

elirium

Conclusion

•Pre-op sedation is probably helpful for anxious patients

•N

O evidence that if left untreated ED

had long-term

sequelae in children

•M

ore research is necessary to find better anesthetic agents, diagnostic tools and preventative m

easures.

We like H

appy Tykes

References

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erican Psychiatric Association. D

iagnostic and statistical manual of m

ental disorders. 4th ed. A

rlington, VA

: Am

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amiya K

, Manabe M

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problematic behavior on em

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a S, Costi, D

, Cyna, A

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Bow

ie, JR. Parents in the operating room

? Anesthesiology 1993:78:1192-3

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annallah RS, H

umm

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ressem M

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, et al. Delayed em

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