FRCA Notes

Emergence Delirium

Resources

  • A self-limiting (15 - 30mins) delirium which occurs immediately post-operatively
  • Typically in those 2-4yrs old, with a highly variable incidence
  • Characterised by non-purposeful restlessness and inconsolability, often accompanied by thrashing, screaming, prolonged crying and disorientation
Negative sequelae of emergence delirium
Distressing for parents, and staff
Patient can cause harm to themselves
Inability to monitor them
Accidental removal of lines, catheters
Decreased parental satisfaction with healthcare
Slows discharge from recovery
Post-operative behavioural problems e.g.
anxiety, regression, eating disturbance, aggression or apathy for up to 4 weeks
Long term sequelae include nightmares and nocturnal enuresis

  • Patient age:
    • <10yrs; 13-18%
    • >10yrs; 9%
  • Pre-operative patient anxiety
  • Higher parental anxiety
  • Upset during gas induction
  • Use of volatile-only anaesthesia
    • Higher rates with sevoflurane (26-38%) than with IV agents e.g. propofol/TIVA (0%)
  • Short procedures
  • Rapid wakening

Volatile anaesthetics

  • The sevoflurane - GABAA receptor interaction demonstrates:
    • High concentration = receptor potentiation
    • Low concentration = receptor inhibition
  • Higher incidence with sevoflurane (26-38%) than with halothane (16%)

Pre-operative

  • Possibly benzodiazepine premedication by reducing anxiety, but may lead to unpredictable or paradoxical effects
  • Melatonin premedication may be as effective

Intra/post-operative

  • Reduce anxiety at induction e.g. parental presence, distraction techniques
  • Avoid volatile maintenance in those at risk
  • Use propofol, either:
    • Alongside gas induction ± prior to extubation
    • As TIVA if previous emergence delirium
  • Adequate analgesia e.g. fentanyl
  • Extubate deep if appropriate

Other drugs for prevention