managing pediatric emergence delirium little tykes...
TRANSCRIPT
Little Tykes Terror:M
anaging Pediatric Emergence D
elirium
Leianne O. K
noll Krajew
ski, CR
NA
, DN
P
Pediatric Emergence D
elirium
Pediatric Emergence D
eliriumPediatric Em
ergence Delirium
Pediatric Emergence D
eliriumO
utline
•D
efinition
•Incidence
•R
isk Factors
•Etiology
•Prevention
•Identification
•M
anagement
Emergence D
elirium: D
efinition
•D
elirium is a com
plex psychiatric syndrome that includes
perceptual disturbances, hallucinations and psychom
otor agitation.
•“A
disturbance in a child’s awareness of and attention to
his or her environment w
ith disorientation and perceptual alterations including hypersensitivity to stim
uli and hyperactive motor behavior in the im
mediate
post-anesthesia period.”
Am
erican Psychiatric Association (2000)
Sikich and Lerman, A
nesthesiology (2004)
Definition? C
lear as MU
D
•The term
“delirium” is often replaced w
ith the descriptive term
s “agitation” or “excitation” as it is not feasible to fully evaluate a young child’s psycho- logical state during em
ergence
•EA
(Emergence agitation) is a state of m
ild restlessness and m
ental distress that, unlike delirium, does not
always suggest a significant change in behavior
Choen, et al (2001)
Galford (1992)
More M
ud….
•A
gitation can indicate any number of sources, including
pain, physiological comprom
ise or anxiety.
•D
elirium m
ay be confused with agitation, but it m
ay also be a cause of agitation.
Voepel-Lew
is, et al (2004)
Emergence D
elirium
•U
sually within the first 30 m
inutes of recovery from
general anesthesia
•B
rief (10-15 minutes)
•Self-lim
ited and resolves spontaneously
•H
owever, 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 m
edication.
•First described by Eckenhoff, et al in 1961
•Pediatric: G
enerally ranged 10-50% but m
ay be as high as 80%
•A
dult: 3-4%
Vlaikovic, et al (2007)
Lepouse, et al (2006)
Does it m
atter?
•R
isk of harming surgical repair
•R
isk of harming self
•R
isk of harming caregivers (nurse, parent)
•R
isk of pulling out IV’s, drains, tubes, catheters,
dressings
•IT’S STR
ESSFUL, N
OT ID
EAL A
ND
IT MA
TTERS! W
E CA
N
DO
BETTER
!
What’s the big deal?
•M
ore nursing resources required
•M
ay require physical or pharmacological restraint (w
ith potential side effects)
•M
ay prolong recovery room stay
•M
ay delay hospital discharge
•Parents/nurses/providers less satisfied w
ith quality of surgical/anesthetic experience
RISK
FAC
TOR
S
•Patient related
•Surgery related
•A
nesthesia related
Risk Factors: Patient related
•A
ge
•A
nxiety
•Preoperative
•Postoperative
•Patient
•Parent
•Tem
perament
Risk Factors: A
ge
•G
enerally, younger children are more likely to show
altered behavior upon recovery from
anesthesia
•M
ore comm
on in younger children (preschool vs. school age)
•2-5 year-olds thought to be m
ost vulnerable to becom
ing easily confused and frightened by unfamiliar
experiences/surroundings
Voepel-Lew
is, et al (2003)V
laikovic, et al (2007)
Risk Factors: Patient
•M
ultiple studies show the likelihood of patient
preoperative anxiety increasing the risk of postoperative em
ergence delirium
•Pre-op anxiety in children m
ay depend primarily on their
stages of development.
•Previous hospital experience
Aono, et al (1999)
Kain, et al (2004)
Banchs, et al (2014)
Risk Factors: A
ge
•Infants: less likely to experience separation anxiety
•1-3 y/o: experience separation anxiety but respond positively to distraction and com
forting measures
•4-5 y/o: seek explanations and desire control of their enviornm
ent
•O
lder children 7-12 y/o: desire more independence and
want to be involved in decision m
aking processes.
•A
dolescents fear losing face and are concerned with
their inability to cope
McG
raw, (1994)
Risk Factors: Parent A
nxiety
•Pre-op PA
REN
T anxiety also increases risk of post-op em
ergence delirium
•The higher the level of m
aternal salivary amylase, the
more severe the child’s pre-op anxiety A
ND
the more
severe the post-op emergence delirium
Kain, et al (2004)
Arai , et al (2008)
Risk Factors: Parent A
nxiety
•M
aternal heart variability just before surgery significantly correlated w
ith emergence behavior of
children undergoing general anesthesia
•Intense preoperative anxiety in children A
ND
their parents has been associated w
ith increased likelihood of restless recovery from
anesthesia
Arai, et al (2008)
Aono, et al (1999)
Kain, et al (2004)
Risk Factors: Tem
perament
•C
hildren who are m
ore emotional, im
pulsive, less social and less adaptable to environm
ental changes are at higher risk for em
ergence delirium
•It is likely that there is som
e substrate innate to each child that w
ill elicit, to a larger or lesser extent, a fearful response to outside stim
uli, depending on the interaction betw
een the child and the environment
Voepel-Lew
is, et al (2003)K
ain, et al (2004)
Risk Factors: Tem
perament
•This reactivity, w
hich describes the “excitability, responsivity, or arousability” of the child, m
ight be the underlying substrate from
which both preoperative
anxiety and ED arise.
•Patient related factors are an im
portant source of variability for ED
and are the most difficult to control.
Kain, et al (2004)
Rothbart, et al (2000)
Risk Factors: Tem
perament
•R
ecent 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
•EN
T
•Tonsils, adenoids, thyroid, m
iddle ear
•O
phthalmology
•Strabism
us
Voepel-Lew
is, et al (2003)
Etiology
•Pain
•Intrinsic characteristics of anesthesia
•R
apid awakening
•A
nxiety
•Surgery type
•Psychologically im
mature
•Tem
perament
•U
nfamiliar environm
ent
•G
enetic predisposition
Etiology (continued)
•Pain
•M
ost confounding variable secondary to overlapping clinical picture w
ith ED
•D
ifficult to distinguish between pain and ED
•Inadequate pain relief m
ay cause agitation especially in short procedures w
here peak effect of analgesics may be
delayed until after wake up
Etiology (continued)
•Intrinsic characteristics of anesthesia
•Postanesthesia agitation has been described not only w
ith sevoflurane and desflurane, but also w
ith isoflu- rane and lesser w
ith halothane (no longer used)
•C
hildren who received sevoflurane/isoflurane for the
induction/maintenance of anesthesia w
ere twice as likely
to develop EA w
hen compared w
ith children who had any
other anesthetic regimen
•C
hildren who received total intravenous anesthesia (TIV
A)-
no documented cases of ED
Voepel-Lew
is et al (2003)
Etiology (continued)
•R
apid awakening
•postulated that rapid aw
akening after the use of the insoluble anesthetics m
ay initiate EA/ED
by worsening
a child’s underlying sense of apprehension when
finding them self in an unfam
iliar environment
however…
…
•D
elaying emergence by a slow
, stepwise decrease in
the concentration of inspired sevoflurane at the end of surgery did N
OT reduce the incidence of EA
Picard, et al (2000)O
h, et al (2005)
Etiology (continued)
•Tem
perament/unfam
iliar environment
•O
lder children and adults usually become oriented rapidly
•Preschool-aged children, w
ho are less able to cope with
environmental stresses, tend to becom
e agitated and delirious
Vlajkovic et al (2007)
Prevention
•G
iven that the EA/ED
etiology is still unknown, a clear-
cut strategy for its prevention has not been developed
•M
any conflicting studies on preventative pharm
acological measures
•D
ifficult to study considering confounding variables and inability to do random
ized double blind study accurately
Prevention
•A
ll aimed at decreasing preoperative anxiety.
•Preoperative Preparation Program
s
•Parental Presence Induction of A
nesthesia (PPIA)
•Sedative prem
edication
•D
istraction techniques
Prevention
•Preoperative Preparation Program
s
•Preoperative booklets or D
VD
sent to home prior to
surgery
•C
hild Life Specialist or Child Educator being present during
admission to educate parents and child in age appropriate
manner •
Use of anesthesia m
ask
•Practice “blow
ing up the balloon” or anesthesia ventilation bag
Prevention: Preparation
•A
novel preoperative preparation program is the A
DV
AN
CE fam
ily centered behavioral preparation program
which is an acronym
for
•A
nxiety-reduction
•D
istraction
•V
ideo modeling and education
•A
dding parents
•N
o excessive reassurance,
•C
oaching
•Exposure shaping
Kain, et al (2007)
Prevention: Preparation
AD
VA
NC
E Program•
Effectiveness on pre-op anxiety and post-op was com
pared w
ith PPIA alone, oral m
idazolam and control groups
•Findings: •
Pre-op Anxiety in the A
DV
AN
CE group significantly less than all
other groups
•Less anxiety during induction in A
DV
AN
CE group than PPIA
and control group
•Incidence of ED
and analgesic requirement less in A
DV
AN
CE
group
•D
ischarge times for children in the A
DV
AN
CE group w
ere less
•O
bstacle: large operational costs
Kain, et al (2007)
Prevention
•Parental Presence Induction of A
nesthesia (PPIA)
•V
ery comm
on practice in Europe, less comm
on in US
•W
hile 58% of U
S anesthesia providers agreed with PPIA
only 5%
of cases where parents allow
ed in OR
•84%
of British anesthesia providers allow
ed PPIA in m
ore than 75%
of cases
•Their belief that PPIA
decreased children's anxiety, increased their cooperation and benefited both the parent and anesthesia provider
Bow
ie (1993)Johnson (2012)
Prevention PPIA cont
•Prospective random
ized study, N=88, 2-7y/o, G
A for M
RI
•Parents present group: reunited before em
ergence vs. Parents absent group: reunited per routing practice
•Parental presence at em
ergence did NO
T decrease incidence or duration of agitation
•Significant psychosocial benefits to the parents: present at the “right tim
e” and felt “helpful” to their child
•O
ne study N=60, 1-3y/o, m
inor plastic surgery•
PPIA vs M
idazolam 0.5 m
g/kg vs. Midazolam
AN
D PPIA
•Less ED
seen with com
bination midazolam
AN
D PPIA
Arai (2007)
Burke (2009)
If I can’t prevent, then what?
•D
iagnose or Identify
•A
ssessment tools
•R
eliability and validity of tools
•M
anage
•Pharm
acological
•Environm
ental
Identification: Assessm
ent
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 tw
o main respects
•Scale content
•Psychom
etric evaluation
•These finding lead to the developm
ent of Pediatric A
nesthesia Emergence D
elirium (PA
ED)
Sikich (2004)
Date of dow
nload: 9/9/2015C
opyright © 2015 A
merican S
ociety of Anesthesiologists. A
ll rights reserved.
From: D
evelopment and Psychom
etric Evaluation of the Pediatric Anesthesia Em
ergence Delirium
ScaleA
nesthesiology. 2004;100(5):1138-1145. Identify
•2010 com
parison of these 3 emergence delirium
scales
•Findings include:
•A
ll three scales correlate reasonably well w
ith each other
•Each have individual lim
itations
•A
ll patients in this study assessed by the experienced pediatric anesthetist observer has having ED
scored highly on all three scales
PAED
ScalePA
ED SC
ALE
•Pros:
•PA
ED Scale strong evidence of m
easurement reliability and
validity.
•Internal consistency of 0.89 w
ith delirium characteristics
of Diagnostic and Statistical M
anual of Mental D
isorders (D
SM IV
)
•H
igh sensitivity and specificity when scores w
here equal or greater than 10
•C
ons:
•Possibly cum
bersome to use in busy clinical setting
Cravero Scale
Cravero Scale
•Pros:
•A
dvantage of simplicity
•C
ons:
•A
uthors subsequently changed definition of items used
•Item
4 (crying) is nonspecific to ED and show
s distress that could be related to pain, hunger or parental separation
•N
ot scientifically validated
•Pro or C
on:
•H
as “sleep” item com
ponent
•A
rgument is not necessary com
ponent for agitation/delirium
Watcha Scale
Watcha Scale
•Pro:•
Watcha scale has higher correlation than C
ravero with
respect to the PAED
scale
•PA
ED score >12 and W
atcha scale have maxim
al sensitivity and high specificity in detecting ED
•Ease of use
•C
ons: •
No evidence of validation
•M
inimal research using just W
atcha scale is effective for determ
ining ED
•C
annot rule out other causes for high ratings, pain, anxiety etc.
Diagnosis
•R
ule out other factors: begin with basics
•H
ypoxemia: using adhesive sat probe vs. clip on
•D
ehydration: case dependent, fluid status, urine output, surgical blood loss
•H
ypotension: fluid status, medication related etc.
•H
ypoglycemia: patient dependent
•A
nxiety
•N
arcotic side effects: itching, urinary retention etc.
•Pain: case dependent, procedure, V
S, anesthetic technique, intra op m
edications
Diagnosis
•C
ritical Thinking is a necessary component to diagnosing
ED
•R
uling out other causative factors in combinations
with…
.
•U
se of diagnostic tools
•D
IAG
NO
SIS IS ED…
…N
OW
WH
AT?
MA
NA
GEM
ENT
•D
ecision to treat ED in PA
CU
is often influenced by the severity and duration of sym
ptoms.
•Likely to treat pharm
acologically when concerns of safety of
the child, disruption of surgical site or accidental removal of
lines or drains
•Tw
o strategies:
•N
on Pharmacologic
•Pharm
acologic
Managem
ent
•N
on-pharmacologic
•A
llow child to w
ake up in their own tim
e (preventative)
•D
ecrease stimulation
•C
onsider foregoing EKG
lead (per anesthesia or departm
ent policy)
•D
ark and quiet environment
•Soothing verbal reassurance and orientation if appropriate
Managem
ent
•N
on-pharmacologic (continued)
•A
llowing fam
iliar objects (blanket, stuffed animal)
•Parental reuniting- if appropriate
•Soothing m
usic or iPad cartoons
•Physical restraint- m
ay “wrap” in w
arm blankets in lieu of
restraints
Managem
ent
•Pharm
acologic- used as preventative and for managem
ent.
•Fentanyl
•M
orphine
•M
idazolam
•D
exmedetom
idine
•C
lonidine
•K
etorolac
•Propofol
Prevention/Managem
ent
Vlajkovic et al (2007 )
Managem
ent
•Large m
eta-analysis 2010
•37 articles, 3172 patients
•M
idazolam, propofol, ketam
ine, A2 antagonists, fentanyl,
5HT3 inhibitors
•Prim
ary outcomes: incidence of em
ergence agitation
•R
esults in brief:•
Midazolam
, and 5HT3 inhibitors not found to have protective
effect against EA/ED
•Propofol, ketam
ine, A2 agonists, fentanyl and preop analgesia
were all found to have a preventative effect.
BJA
(2010)
Managem
ent
•R
esearch has found PAC
U nurses have first utilized pain
managem
ent orders such as fentanyl
•If assertive treatm
ent is necessary…
•Single bolus of propofol 0.5-1 m
g/kg IV
•Fentanyl 1-2.5 m
cg/kg IV
•D
exmedetom
idine 0.5 mcg/kg IV
Has been successful in decreasing the severity and duration of ED
episode.
Banchs (2014)
Emergence D
elirium:
Conclusion
•ED
is comm
on and self limiting
•ED
is usually brief, but pharmacological m
anagement
may be required
•Potentially harm
ful to patient and caregivers
•C
hallenging to manage
•G
ood post-op pain control is crucial
Emergence D
elirium
Conclusion
•Pre-op sedation is probably helpful for anxious patients
•N
O evidence that if left untreated ED
had long-term
sequelae in children
•M
ore research is necessary to find better anesthetic agents, diagnostic tools and preventative m
easures.
We like H
appy Tykes
References
Am
erican Psychiatric Association. D
iagnostic and statistical manual of m
ental disorders. 4th ed. A
rlington, VA
: Am
erican Psychiatric Publishing, 2000.
Aono J, M
amiya K
, Manabe M
. Preoperative anxiety is associated with a high incidence of
problematic behavior on em
ergence after halothane anesthesia in boys. Acta
Anaesthesiol Scand 1999;43:542–4.
Bajw
a S, Costi, D
, Cyna, A
, A com
parison of emergence delirium
scales following general
anesthesia in children. Pediatric Anesthesia 2010;20:704-11
Bow
ie, JR. Parents in the operating room
? Anesthesiology 1993:78:1192-3
Cohen IT, H
annallah RS, H
umm
er KA
. The incidence of emergence agitation associated
with desflurane anesthesia in children is reduced by fentanil. A
nesth Analg 2001;93:
88–91.
References
Cravero J, Surgenor S, W
halen K. Em
ergence agitation in paediatric patients after sevoflurane anesthesia and no surgery: a com
parison with halothane. Paediatr
Anaesth 2000;10: 419 –24.
Eckenhoff JE, Kneale D
H, D
ripps RD
. The incidence and etiol- ogy of postanesthetic excitem
ent. A clinical survey. A
nesthesiology 1961;22:667–73.
Fortier MA
, Tan ET, Mayes LC
, et al. Ethnicity and parental report of postoperative behavioral changes in children. Paediatr A
nesthe 2013;23:422-8
Galford R
E. Problems in anesthesiology: approach to diagnosis. B
oston, MA
: Little, Brow
n &
Com
pany, 1992:341–3.
References
Johnson, YJ, Nickerson M
, Quezado ZM
. An unforeseen peril of parental presence during
induction of anesthesia. Anesth A
nalg 2012;115:1371-4
Kain ZN
, Caldw
ell-Andrew
s AA
, Mayes LC
, et al. Family-centered preparation for surgery
improves perioperative outcom
es in children. Anesthesiology 2007;106:65 74
Kain ZN
, Caldw
ell-Andrew
s AA
, Maranets I, et al. Preoperative anxiety and em
ergence delirium
and postoperative maladaptive behaviors. A
nesth Analg 2004;99:1648–54.
Kulka PJ, B
ressem M
, Tryba M. C
lonidine prevents sevoflurane- induced agitation in children. A
nesth Analg 2001;93:335–8.
References
Lepouse et al. BJA
2006: 96(6):747-753
McG
raw T. Preparing children for the operating room
: psychological issues. Can J A
nesth 1994;41:1094-103
Oh A
Y, Seo KS, K
im SD
, et al. Delayed em
ergence process does not result in a lower
incidence of emergence agitation after sevoflurane anesthesia in children. A
cta A
naesthesiol Scand 2005;49:297–9.
Picard V, D
umont L, Pellegrini M
. Quality of recovery in children: sevoflurane versus
propofol. Acta A
naesthesiol Scand 2000;44:307–10.
Przybylo HJ, M
artini DR
, Mazurek A
J, et al. Assessing behaviour in children em
erging from
anesthesia: can we apply psychiatric diagnostic techniques? Paediatr A
naesth 2003;13: 609 –16.
References
Rothbart M
K, A
hadi SA, Evans D
E. Temperam
ent and personality: origins and outcomes. J
Pers Soc Psychol 2000;78:122–35
Sikich, N, Lerm
ann J. Developm
ent and psychometric evaluation of the Pediatric
Anesthesia Em
ergence Delirium
Scale. Anesthesiology 2004; 11: 1138-1145
Vlajkovic &
Sindjelic, Anesth A
nalg 2007: 104(1):84-91
Voepel-Lew
is T, Burke C
. Differentiating pain and delirium
is only part of assessing the agitated child. J Perianesth N
urs 2004;19:298 –9.
Voepel-Lew
is T, Malviya S, Tait A
R. A
prospective cohort study of emergence agitation in
the pediatric postanesthesia care unit. Anesth A
nalg 2003;96:1625–30.