Abstract
This chapter discusses the phenomenon of Emergence delirium/agitation that is fairly unique to children. The author reviews the pathophysiology, detection using the relevant scoring systems as well as treatment and prognosis of emergence delirium.
A five-year-old, otherwise healthy, boy arrives to the recovery room after his adenotonsillectomy. He is thrashing, incoherent, and inconsolable. You and the recovery room nurse are unable to obtain his vital signs.
What Is Emergence Delirium (ED)?
One clinically accepted definition of ED is the “dissociated state of consciousness in which the child is irritable, uncompromising, uncooperative, incoherent, and inconsolably crying, moaning, kicking, or thrashing” (Vlajkovic et al.) This definition lends itself to understanding that emergence disorders are a clinical spectrum, ranging from irritability (emergence agitation) to frank delirium (emergence delirium). ED may cause patient or provider injury, parental and staff distress, and parental dissatisfaction with care. The incidence varies between 10–80% in the published literature.
What Are the Risk Factors for ED, and How Is ED Measured?
Risk factors for ED include:
Children aged 6 months to 4 years
Preexisting anxious temperament
Parental anxiety
Children not in school/daycare
ED generally occurs within the first 30 minutes following anesthesia. ED seems to have a predilection for males and those children with enhanced preoperative anxiety. Proposed mechanisms include increased sympathetic nervous system activity as well as alternations in frontal lobe connectivity during the indeterminate stage of emergence. A variety of different measurement scales have been described, including the Pediatric Anesthesia Emergence Delirium (PAED) scale (Table 6.1), the Watcha scale (Table 6.2), and the Cravero scale (Table 6.3).
Table 6.1 Pediatric anesthesia emergence delirium scale (PAED)
| PAED scale for evaluation of emergence delirium | |||||
|---|---|---|---|---|---|
| Behavior | Not at all | Just a little | Quite a bit | Very much | Extremely |
| The child makes eye contact with the caregiver | 4 | 3 | 3 | 1 | 0 |
| The child’s actions are purposeful | 4 | 3 | 2 | 1 | 0 |
| The child is aware of his/her surroundings | 4 | 3 | 2 | 1 | 0 |
| The child is restless | 0 | 1 | 2 | 3 | 4 |
| The child is inconsolable | 0 | 1 | 2 | 3 | 4 |
Scores >10 and especially >12 strongly suggest emergence delirium.
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