Emergence delirium

Other names| Agitated emergence, emergence agitation, emergence excitement, postanesthetic excitement
Specialty| Anesthesia
Symptoms| Auditory and Visual Hallucinations; uncontrollable screaming, crying, panic attacks; and uncontrollable body movements
Usual onset| ranges from immediately on awakening to weeks later
Duration| few minutes to months

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.

## Contents

* 1 Children
* 2 Elderly
* 3 Epidemiology
* 4 References
* 5 Further reading
* 6 External links

## 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". http://www.asa2012.com/PDFs_abstracts/davidson.pdf.
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.
3. ↑ Traube, C.; Silver, G.; Kearney, J.; Patel, A.; Atkinson, T. M.; Yoon, M. J.; Halpert, S.; Augenstein, J. et al. (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. PMID 24145848.
4. ↑ 4.0 4.1 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. https://journals.lww.com/anesthesia-analgesia/pages/articleviewer.aspx?year=2007&issue=01000&article=00018&type=Fulltext.
5. ↑ Lo, S. S.; Sobol, J. B.; Mallavaram, N.; Carson, M.; Chang, C.; Grieve, P. G.; Emerson, R. G.; Stark, R. I. et al. (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.
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. https://journals.lww.com/anesthesia-analgesia/Fulltext/1996/11000/Comparison_of_Emergence_and_Recovery.5.aspx.
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. 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. 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. et al. (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. PMID 36939716.
10. ↑ Mason, LJ (2004). "Pitfalls of Pediatric Anesthesia: Emergence Delirium". Richmond, Virginia: Society for Pediatric Anestheisa. http://www.pedsanesthesia.org/meetings/2004winter/pdfs/mason_Pitfalls.pdf.
11. ↑ Card, E.; Tomes, C.; Lee, C.; Wood, J.; Nelson, D.; Graves, A.; Shintani, A.; Ely, E.W. et al. (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. PMID 25540068.

## Further reading

* "Emergence delirium in children: many questions, few answers". Anesth. Analg. 104 (1): 84–91. Jan 2007. doi:10.1213/01.ane.0000250914.91881.a8. PMID 17179249. http://www.anesthesia-analgesia.org/content/104/1/84.long.
* "Emergence delirium in adults in the post-anaesthesia care unit". Br. J. Anaesth. 96 (6): 747–53. Jun 2006. doi:10.1093/bja/ael094. PMID 16670111.

## External links

Classification|

* ICD-10: F13.4
* ICD-9-CM: 292.81

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* v
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Anesthesia and anesthesiology

Types|

* General
* Sedation
* Twilight anesthesia
* Local
* Topical
* Intercostal nerve block
* Neuraxial blockade
* Spinal
* Epidural
* Dental
* Inferior alveolar nerve

Techniques|

* Airway management
* Anesthesia provision in the US
* Arterial catheter
* Bronchoscopy
* Capnography
* Dogliotti's principle
* Drug-induced amnesia
* Intraoperative neurophysiological monitoring
* Nerve block
* Penthrox inhaler
* Tracheal intubation

Scientific principles|

* Blood–gas partition coefficient
* Concentration effect
* Fink effect
* Minimum alveolar concentration
* Second gas effect

Measurements|

* ASA physical status classification system
* Baricity
* Bispectral index
* Entropy monitoring
* Fick principle
* Goldman index
* Guedel's classification
* Mallampati score
* Neuromuscular monitoring
* Thyromental distance

Instruments|

* Anaesthetic machine
* Anesthesia cart
* Boyle's machine
* Gas cylinder
* Laryngeal mask airway
* Laryngeal tube
* Medical monitor
* Odom's indicator
* Relative analgesia machine
* Vaporiser
* Double-lumen endotracheal tube
* Endobronchial blocker

Complications|

* Emergence delirium
* Allergic reactions
* Anesthesia awareness
* Local anesthetic toxicity
* Malignant hyperthermia
* Perioperative mortality
* Postanesthetic shivering
* Postoperative nausea and vomiting
* Postoperative residual curarization

Subspecialties|

* Cardiothoracic
* Critical emergency medicine
* Geriatric
* Intensive care medicine
* Obstetric
* Oral sedation dentistry
* Pain medicine

Professions|

* Anesthesiologist
* Anesthesiologist assistant
* Nurse anesthetist
* Operating department practitioners
* Certified Anesthesia Technician
* Certified Anesthesia Technologist
* Anaesthetic technician
* Physicians' assistant (anaesthesia)

History|

* ACE mixture
* Helsinki Declaration for Patient Safety in Anaesthesiology
* History of general anesthesia
* History of neuraxial anesthesia
* History of tracheal intubation

Organizations|

* American Association of Nurse Anesthetists
* American Society of Anesthesia Technologists & Technicians
* American Society of Anesthesiologists
* Anaesthesia Trauma and Critical Care
* Association of Anaesthetists of Great Britain and Ireland
* Royal College of Anaesthetists
* Association of Veterinary Anaesthetists
* Australian and New Zealand College of Anaesthetists
* Australian Society of Anaesthetists
* International Anesthesia Research Society

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