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Avoiding Pediatric Emergence Delirium

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Jason Cole

on 18 May 2014

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Transcript of Avoiding Pediatric Emergence Delirium

Comparison of the Effects of 0.03 and 0.05mg/kg Midazolam with Placebo on Prevention of Emergence Agitation in Children Having Strabismus Surgery (Anesthesiologogy, 2014)
As a result of this activity the learner will be able to :
The effect of fentanyl and clonidine on early postoperative
negative behavior in children: a double-blind placebo
controlled trial (Bartone et.al., 2014)
Published in Pediatric Anesthesia, 2014
First study to look at simultaneous effects of pharmacological interventions on EA,ED and Pain
ePONB= catchall for EA,ED and Pain
Methods: 90 children, subumbilical surgery supplimented with regional anesthesia, all premed oral midaz, parent present mask induction (local infiltration of ropivacaine on skin)
randomized and DB, placebo controlled
3 groups recieved either clonidine 2mcg/kg, fent 2mcg/kg, or saline prior to incision
primary outcomes: EA, ED, Pain
ED defined as a state of acute confusion accomp. by cognitive impairment (PAED scale >12)
EA assoc with pain and preop anxiety (Cravero scale >4)
Pain (CHIPPS score >4)
"Postop phenomenon characterized by aberrant cognitive and psychomotor behavior which can place the patient and health care personnel at risk"

Also defined as "a mental disturbance during the recovery from general anesthesia consisting of hallucinations, delusions, and confusion manifested by moaning, restlessness, involuntary physical activity, and thrashing about in the bed"

21% Clonidine group
18% placebo group
10% Fentanyl group
0% Fentanyl group
21% Clonidine
14% Placebo
no statistical difference between groups
12% Fentanyl group
0% Clonidine group
7% Placebo group
Meta Analysis
Jason Cole CRNA
Chris Palombo CRNA

Topics/Research to be presented
Definitions and assessment of EA, ED and Pain
Fentanyl vs Clonadine (Pediatric Anesthesia, 2014)
Dexmetotomadine (2014)
Subhypnotic Midazolam dosing (Anesthesiology, 2014)
Comparison of midazolam, propofol and Ketamine (Pediatric Anesthesia, 2010)
Meta Analysis exploring Various pharmacological prevention (BJA, 2010)
objectives: to determine whether subhypnotic dose of midaz, prop, or ketamine with fentanyl just prior to awakening would decrease ED without delaying awakening and discharge.
Methods: 120 unpremedicated children ages 1-7yo, ASA 1 & 2, 40 per group. mask induction sevo, LMA, sevo/remi maint. No placebo group d/t ethics. Fentanyl 0.5mcg/kg given at same time as each drug in each group just before DC sevo/remi. then obs. 5min for resp depr.. when adeq VT/RR, LMA out to PACU.
Doses: Midazolam 0.05mg/kg
Propofol 1mg/kg
Ketamine 0.25mg/kg
primary outcomes: Incidence and severity of EA, PAED scale measured at 5, 10 and 15 min., time to eye opening, and time to dishcarge from PACU

Emergence Agitation after cataract surgery in children: a comparison of midazolam, propofol, and ketamine.(Pediatric Anesthesia, 2010)
Emergence Delirium
"A mental disturbance during the recovery from GA consisting of hallucination, delusions, and confusion manifested by moaning, restlessness, involuntary physical activity, and thrashing about in the bed" (Stamper et. al.)

Highest incidence among children:
preop anxiety
emerge rapidly (sevo and des)
head and neck procedures

Why is it Bad?
Can place the patient, health care personnel at risk for injury (removal of drains, IVs, wound dehiscence)
linked to later development of sleeping anxiety and separation anxiety (Bartone et. al.)
Puts strain on staffing (often 1/1 RN needed)
stress on parents, staff and other patients
It had previously published (Anesth Intensive Care, 2011) that 0.05mg/kg IV reduces EA but prolongs emergence time
Randomized, DB, PC trail
90 children 1-13yo, strabismus surgery
0.03mg/kg vs 0.05mg/kg IV midaz vs saline given just before end of surgery
primary outcome: EA/ED measured using PAED scale
Fentanyl 2mcg/kg significantly reduced EA even with effective regional anesthesia

Fentanyl had no effect on ED

Fentanyl increased day one PONV

Clonidine 2mcg/kg had no effect on either EA, ED.
Pharmacological prevention of sevoflurane and desflurane related emergence agitation in children: a meta analysis of published studies (BJA, 2010)
Aim of study: Meta Analysis of studies on Pharmacological prevention of EA
37 articles, 3172 patients
Midazolam, Propofol, Ketamine, A2 antagonists, fentanyl, 5HT3 inhibitors
primary outcomes: incidence of emergence agitation
Results in brief:
Midazolam and 5HT3 inhibitors not found to have protective effect against EA
propofol, ketamine, A2 agonists, fentanyl and perop analgesia were all found to have a preventive effect
4 articles:
Results: Midazolam given as oral premed 30min before induction or after induction did not have a prophalactic effect against EA
4 articles
Found to prevent EA
A2 receptor Agonists:
10 articles
Included clonidine and dexmetatomadine given orally, caudal or IV
Found to be protective
5 articles
Intranasal route found to be protective against EA
IV route was not (not including 2014 study)
Early Postoperative negative behaivior
Emergence Agitation
Emergenge Delirium
asses and identifiy emergence delirium and agitation
understand the associated implications and risks
be familiar with current research on anesthetic techniques to decrease risk
Identify risks and benefits associated with each anesthetic technique
Restlessness associated wih preop anxiety, pain and other factors
Cravero scale >4
a state of confusion accompanied by cognitive impairment
self limiting
PAED scale >12
Preventing Pediatric Emergence Delirium
Conclusion: 0.03mg/kg IV just prior to end of surgery reduces EA without delaying emergence time
L. Bartone et. al.
CHIPPS scale
often lack of aggreement in definitions
Considerable overlap among the three
significantly more agitated children in the ketamine group (45%)when compared to the midaz group (20%) or the propofol group (15%). PAED scale showed significantly less EA in midaz and prop groups.
Time to discharge(avg 27-30min) was not significantly different amoung groups.
13 articles
Continuous, bolus after induction, or bolus at the end of anesthesia
All showed an overall protective effect against EA
Perioperative Analgesia including local anesthetics, caudal analgesia, and periperative IV local anesthetic
3 articles
found to be protective
5HT3 inhibitors:
(ondansatron and tropisatron)
2 articles
found to be ineffective
theory was that serotonin was involved in EA upon awakening
Stamper, M.J., Hawks, S.J., Taicher, B.M., Bonta, J., Brandon, D.H. (2014).AORN Journal
99,(4) 480-94.
Bortone, L., Bertolizio, G., Engelhardt, T., Frawley, G., Somaini, M., Ingelmo, P.M. (2014).
The effect of fentanyl and clonindine on early postoperative negative behavior in childrn: a double blind placebo eonntrolled trial. Pediatric Anesthesia 2/18/14. 1-6.
Cho, E.J., Yoon, S.Z., cho, J.E., Lee, H.W. (2014). Comparison of the Effects of 0.03 and
0.05mg/kg Midazolam with Placebo on Prevention of Emergence Agitation in Children Having Strabismus Surgery. Anesthesiology 5, 2014.
Chen, J., Li, W., Hu, X., Wang, D. (2010). Emergence agitation after cataract surgery in
children: a comparison of midazolam, propofol and ketamine. Pediatric Anesthesia 20:873-879.
Dahmani, S., Stany, I., Brasher, C., Lejeune, C., Bruneau, B., Wood, C. Nivoche, Y.,
Constant, I., Murat, I. (2010). Pharmacological prevention of sevoflurane and desflurane related emergence agitation in children: a meta-analysis of published studies. 104(2):216-223.
Kim, J., Kim, S., Lee, J., Kang, Y., Koo, B., (2014). Low-Dose dexmedotomidine reduces emergence agitation after desflurance Anaesthesia in children undergoing strabismus surgery. 55(2): 508-516.
Low-dose dexmedetomidine reduces emergence agitation after desflurane anesthesia in children undergoing strabismus surgery
Midazolam: For shorter procedures, PO dosing may be effective for prevention of ED, consider smaller dose for more rapid emergence.

Fentanyl: Effective for EPONB at
but consider risk of PONV, intranasal route a good option when no IV access

Ketamine: based on the presented research consider not giving for ED (any opinions?)

A2 agonists: highly effective choice at low dose for prevention of ED. Consider its longer Duration of action

Propofol: 1mg/kg effective choice for prevention of ED

-2014 Study of 96 children (1-5yrs) undergoing strabismus surgery were enrolled.

-Induction with propofol and maintained with desflurane.

-After induction, fentanyl (1mcg/kg) and then an ifusion of DEX at .
(Half received NS placebo)

-OPS, PAED, ad EA scores were documented q10min in the PACU

The mean values of all of these scales we all significantly lower in the DEX group at 0, 10, and 20 minutes (p<0.001)

-EA in in FD group was 12.8% vs. 74.5% in FN (p<0.001)

-Preliminary study shows decease EA just as effective with 2.5mcg/kg however with a significant delay in emergence
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