pediatric emergence delirium outline definition incidence risk factors etiology prevention ...
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Little Tykes Terror:
Managing Pediatric Emergence Delirium
Leianne O. Knoll Krajewski, CRNA, DNP
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 psycho- logical 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 isoflu- rane 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 shapingKain, 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)
Date of download: 9/9/2015 Copyright © 2015 American Society of Anesthesiologists. All rights reserved.
From: Development and Psychometric Evaluation of the Pediatric Anesthesia Emergence Delirium ScaleAnesthesiology. 2004;100(5):1138-1145.
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
ReferencesAmerican Psychiatric Association. Diagnostic and statistical manual of
mental disorders. 4th ed. Arlington, VA: American Psychiatric Publishing, 2000.
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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
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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.
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References
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