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Emergence delirium in children: functional explanation and
possible treatments
Andrew Davidson
Royal Children’s Hospital, Melbourne
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Outline
• Defining emergence delirium
• Sleep and parasomnias
• A possible mechanism for emergence delirium
• Preventing and managing emergence delirium
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What is emergence delirium?
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• Preschool child, uneventful volatile anaesthetic, block seemed to be working, left the child unconscious in PACU
• Start to hear the screaming as you collect your next case
• Child awoke suddenly, crying and screaming incoherently, trying to get off trolley, not looking at the nurses, has pulled off dressings and pulled out the IV, inconsolable, being restrained
• Parents arrive but child pushes them away, they say “he’s behaving like he is not my child”
• 20 minutes later child slows down, goes to sleep, awakens quietly 5 minutes later
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• Preschool child, uneventful volatile anaesthetic, block seemed to be working, left the child unconscious in PACU
• Start to hear the screaming as you collect your next case
• Child awoke and shortly afterwards is crying and screaming “ouch” “mummy”, looking angrily at nurses, has pulled off dressings and pulled out the IV, briefly consolable, being restrained
• Parents arrive and child reaches for them
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• Preschool child, uneventful volatile anaesthetic, block seemed to be working, left the child unconscious in PACU
• Child opens eyes briefly, starts moaning, rolls over repeatedly tangling lines but not dislodged, nurses ask what’s wrong and tell the child to lie still, but only get moaning and incoherent response
• Parents arrive and child does not acknowledge their presence
• After 5-10 minutes child goes back to sleep
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How to measure emergence delirium?
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Scores used to measure ED
• PAED
• Watcha
• Cravero
• KEDS
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Cravero
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Watcha
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PAED
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Delirium
• Reduced awareness of environment - non responsive
• Altered cognition, perceptual disturbance -disoriented
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Item Description Yes No
Awake Child has eyes open or is vocalisingScale not
appropriate
Purposeful
Child displays purposeful movement, e.g. reaching for a caregiver, eating, drinking. Agitated behaviours may be purposeful, e.g. kicking and thrashing when forced to take medication
Responsive
Child is responsive to stimuli, interacting with people or objects in his/her environment. May be verbal or non-verbal, e.g. following instructions, responding to questions appropriately, pushing away/drinking from a bottle placed to his/her mouth
Eyes openChild’s eyes are open. If eyes are closed, answer “No” to this item and “N/A” for Stare and Avert gaze.
StareChild is staring blankly, not directing his/her gaze meaningfully
Yes No N/A
Avert gazeChild’s gaze is directed to the right/left, with no obvious object of attention; not directing gaze meaningfully
Yes No N/A
KEDS
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Item Yes No
AwakeScale not
appropriate
Purposeful
Responsive
Eyes open
Stare Yes NoN/A
Avert gaze Yes No
X
X
X
XX
XX
X
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Agitation Delirium
Crying, screaming
Thrashing, punching
No eye contact
Non responsive
Disoriented
X
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Cravero
Agitation
Agitation
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Watcha
Agitation
Agitation
Delirium
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PAED
Delirium
Agitation
DeliriumDelirium
Delirium
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• Preschool child, uneventful volatile anaesthetic, block seemed to be working, left the child unconscious in PACU
• Start to hear the screaming as you collect your next case
• Child awoke suddenly, crying and screaming incoherently, trying to get off trolley, not looking at the nurses, has pulled off dressings and pulled out the IV, inconsolable, being restrained
• Parents arrive but child pushes them away, they say “he’s behaving like he is not my child”
• 20 minutes later child slows down, goes to sleep, awakens quietly 5 minutes later
Delirium with agitation
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• Preschool child, uneventful volatile anaesthetic, block seemed to be working, left the child unconscious in PACU
• Start to hear the screaming as you collect your next case
• Child awoke and shortly afterwards is crying and screaming “ouch” “mummy”, looking angrily at nurses, has pulled off dressings and pulled out the IV, briefly consolable, being restrained
• Parents arrive and child reaches for them
Agitation
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• Preschool child, uneventful volatile anaesthetic, block seemed to be working, left the child unconscious in PACU
• Child opens eyes briefly, starts moaning, rolls over repeatedly tangling lines but not dislodged, nurses ask what’s wrong and tell the child to lie still, but only get moaning and incoherent response
• Parents arrive and child does not acknowledge their presence
• After 5-10 minutes child goes back to sleep
Delirium
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Normal sleep and parasomnias
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Normal sleep
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Parasomnias
• Occur in children
• Arousal from deep NREM sleep
• Continuum of behaviour without conscious awareness
Confusional arousal – little motor or autonomic features
Somnambulism – complex motor
Sleep terror – fear and autonomic features, variable motor
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Night terror
• Children often scream and are very frightened and confused
• They thrash around violently and are often not aware of their surroundings
• May be unable to talk to, comfort, or fully wake up the child
• The child may be sweating, hyperventilating and tachycardic with dilated pupils
• May last 10 - 20 minutes, then the child goes back to sleep
• Looks very similar to emergence delirium with agitation
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EEG and emergence delirium
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• 64 Channel EEG during anaesthesia and recovery
• Sevoflurane anaesthesia +/- caudal and/or fentanyl
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Awake
• Frontal low voltage beta, Posterior Dominant Rhythm (alpha)
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Anaesthetised
• Diffuse slow (delta) with some frontal alpha
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Pre-arousal, indeterminate EEG
Anaesthetised, slow wave EEG
Gas off
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Indeterminate state
• Diffuse mixed alpha and beta
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Indeterminate state
• Diffuse mixed alpha and beta – gradual lower voltage and modulation
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Pre-arousal, indeterminate EEG
Anaesthetised, slow wave EEG
Delirium with agitation
Delirium without agitation
Calm awake Drowsy
1631
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Sleep spindles
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K complexes
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K complexes & hypnopompic hypersynchrony
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Pre-arousal, indeterminate EEG
Anaesthetised, slow wave EEG
Delirium with agitation
Delirium without agitation
Calm awake Drowsy
1631
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EEG during delirium
• No specific EEG patterns
• Diffuse theta, no “sleep transients”
• Diffuse theta with PDR alpha and frontal beta
• Diffuse theta and frontal alpha
• Mixed “awake” and “asleep” features
• Some similarity to night terror
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Delirium
• Diffuse theta with frontal EMG and no transients
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EEG after propofol
• No delirium
• All had sleep like transients before awakening
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Mechanism?
• Anaesthetics work via multiple mechanisms
• Mechanism is different depending on drug and concentration
• Some act via sleep-like mechanisms
• Perhaps these are less likely to produce delirium?
• Delirium occurs when the brain “wakes up” in a disorganised way
• Why do children get agitation with delirium? Maybe they are more anxious and unable to adapt
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Prevention and management
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At risk
• Preschool age
• Sevoflurane or desflurane
• Male
• ENT surgery?
• Pain?
• Pre-op anxiety?
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Prevention
• Propofol• Infusion
• Bolus at end
• Alpha 2 agonsists
• Analgesia
• Dexamethasone
• Ketamine
• Gabapentin
• Less evidence: midazolam
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Prevention – non pharmacologic
• Pre-op preparation – little evidence
• Let them wake up without being disturbed?
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Management
• Little evidence
• Identify and treat any causes for agitation• Pain, fear, cold, hunger, full bladder
• Propofol
• Midazolam?
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Summary
• Emergence agitation
• Emergence delirium
• Emergence delirium with agitation
• May be related to parasomnias
• May be linked to emergence that doesn’t enagage sleep path ways
• Propofol most effective
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Thank you