Emergence delirium

Emergence delirium is a condition in which emergence from general anesthesia is accompanied by psychomotor agitation. Some see a relation to pavor nocturnus[1] while others see a relation to the excitement stage of anesthesia.

Emergence delirium
Other namesAgitated emergence, emergence agitation, emergence excitement, postanesthetic excitement
SpecialtyAnesthesia
SymptomsAuditory and Visual Hallucinations; uncontrollable screaming, crying, panic attacks; and uncontrollable body movements
Usual onsetranges from immediately on awakening to weeks later
Durationfew minutes to months

Children

The Pediatric Anesthetic Emergence Delirium (PAED) scale or the Cornell Assessment of Pediatric Delirium may be used to measure the severity of this condition in children.[2][3] In this patient population, emergence delirium is typically identified within the first 30 minutes of recovery from anesthesia. It terminates within five to fifteen minutes with spontaneous resolution.[4]

Emergence delirium occurs with similar frequency after anesthesia with desflurane and isoflurane.[5] It has been hypothesized that rapid awakening from these inhaled anesthetics may worsen the child's natural apprehension upon suddenly finding him/herself in an unfamiliar environment.[6]

ED in children has been associated with the type of surgery, anesthesia, and the use of adjunct medication, but the identification of its underlying cause remains elusive.[4]

Elderly

Elderly people are more likely to experience confusion or problems with thinking following surgery, which can occur up to several days postoperatively. These cognitive problems can last for weeks or months, and can affect the patients’ ability to plan, focus, remember, or undertake activities of daily living. A review of intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery showed little or no difference in postoperative delirium according to the type of anaesthetic maintenance agents from five studies (321 participants). The authors of this review were uncertain whether maintenance of anaesthesia with propofol-based total intravenous anaesthesia (TIVA) or with inhalational agents can affect incidences of postoperative delirium.[7] Emergence delirium has been associated long-term changes neurocognitive dysfunction after cardiac surgery.[8]

A cohort study which included 560 adults aged 70 years and older for a period of 6 years revealed that delirium represents the most common post-operative complication and is associated with long-term cognitive decline and increased incidence of dementia.[9]

Epidemiology

The overall incidence of emergence delirium is 5.3%, with a significantly greater incidence (12–13%) in children. The incidence of emergence delirium after halothane, isoflurane, sevoflurane or desflurane ranges from 2–55%.[10] Most emergence delirium in the literature describes agitated emergence. Unless a delirium detection tool is used, it is difficult to distinguish if the agitated emergence from anesthesia was from delirium or pain or fear, etc. A research study of 400 adult patients emerging from general anesthesia in the PACU were assessed for delirium using the Confusion Assessment Method for the ICU (CAM-ICU) found rates of emergence delirium of 31% at PACU admission with rates declining to 8% by 1 hour.[11]

References
  1. "Archived copy" (PDF). www.asa2012.com. Archived from the original (PDF) on 25 January 2020. Retrieved 13 January 2022.{{cite web}}: CS1 maint: archived copy as title (link)
  2. Sikich, N; Lerman, J (2004). "Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale". Anesthesiology. 100 (5): 1138–45. doi:10.1097/00000542-200405000-00015. PMID 15114210. S2CID 25599011.
  3. Traube, C.; Silver, G.; Kearney, J.; Patel, A.; Atkinson, T. M.; Yoon, M. J.; Halpert, S.; Augenstein, J.; Sickles, L. E.; Li, C.; Greenwald, B. (2014). "Cornell Assessment of Pediatric Delirium: A valid, rapid, observational tool for screening delirium in the PICU". Critical Care Medicine. 42 (3): 656–663. doi:10.1097/CCM.0b013e3182a66b76. PMC 5527829. PMID 24145848.
  4. Vlajkovic, Gordana P.; Sindjelic, Radomir P. (2007). "Emergence Delirium in Children: Many Questions, Few Answers". Anesthesia & Analgesia. 104 (1): 84–91. doi:10.1213/01.ane.0000250914.91881.a8. PMID 17179249. S2CID 7315961.
  5. Lo, S. S.; Sobol, J. B.; Mallavaram, N.; Carson, M.; Chang, C.; Grieve, P. G.; Emerson, R. G.; Stark, R. I.; Sun, L. S. (2009). "Anesthetic-specific electroencephalographic patterns during emergence from sevoflurane and isoflurane in infants and children". Pediatric Anesthesia. 19 (12): 1157–1165. doi:10.1111/j.1460-9592.2009.03128.x. PMID 19708912. S2CID 23663252.
  6. Welborn, Leila G.; Hannallah, Raafat S.; Norden, Janet M.; Ruttimann, Urs E.; Callan, Clair M. (November 1996). "Comparison of Emergence and Recovery Characteristics of Sevoflurane, Desflurane, and Halothane in Pediatric Ambulatory Patients". Anesthesia & Analgesia. 83 (5): 917–920. doi:10.1213/00000539-199611000-00005. PMID 8895263.
  7. Miller, David; Lewis, Sharon R; Pritchard, Michael W; Schofield-Robinson, Oliver J; Shelton, Cliff L; Alderson, Phil; Smith, Andrew F (21 August 2018). "Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non‐cardiac surgery". Cochrane Database of Systematic Reviews. 2018 (8): CD012317. doi:10.1002/14651858.CD012317.pub2. PMC 6513211. PMID 30129968.
  8. Saczynski, J. S.; Marcantonio, E. R.; Quach, L.; Fong, T. G.; Gross, A.; Inouye, S. K.; Jones, R. N. (2012). "Cognitive Trajectories after Postoperative Delirium". The New England Journal of Medicine. 367 (1): 30–39. doi:10.1056/NEJMoa1112923. PMC 3433229. PMID 22762316.
  9. Kunicki, Zachary J.; Ngo, Long H.; Marcantonio, Edward R.; Tommet, Douglas; Feng, Yi; Fong, Tamara G.; Schmitt, Eva M.; Travison, Thomas G.; Jones, Richard N.; Inouye, Sharon K. (2023). "Six-Year Cognitive Trajectory in Older Adults Following Major Surgery and Delirium". JAMA Internal Medicine. 183 (5): 442–450. doi:10.1001/jamainternmed.2023.0144. PMC 10028541. PMID 36939716.
  10. Mason, LJ (2004). "Pitfalls of Pediatric Anesthesia: Emergence Delirium" (PDF). Richmond, Virginia: Society for Pediatric Anestheisa. Archived from the original (PDF) on 2016-03-27. Retrieved 2012-06-21.
  11. Card, E.; Tomes, C.; Lee, C.; Wood, J.; Nelson, D.; Graves, A.; Shintani, A.; Ely, E.W.; Hughes, C.; Pandharipande, P. (2015). "Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit". British Journal of Anaesthesia. 115 (3): 411–417. doi:10.1093/bja/aeu442. PMC 4533730. PMID 25540068.

Further reading
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