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Incidence of Emergence Delirium in the Pediatric PACU: Prospective Observational Trial.

ABSTRACT: Emergence delirium (ED) is a postoperative complication in pediatric anesthesia characterized by perception and psychomotor disorder and has a negative impact on morbidity in the form of maladaptive behavior, which can last weeks after anesthesia. Patients with developed ED present with psychomotor anxiety, agitation, and are at higher risk of unintentional extraction of an intravenous cannula, self-harm and nausea and vomiting. The described incidence of ED varies between 25-80%, with a higher prevalence among children younger than 6 years of age. We aimed to determine the incidence of ED in pediatric patients (>1 month) after general anesthesia in the post-anesthesia care unit (PACU), using Paediatric Anaesthesia Emergence Delirium (PAED) score, Watcha score and Richmond agitation and sedation scale (RASS). The incidence of ED was the highest in the PAED score with cutoff ≥10 points (89.0%, n = 1088). When using PAED score >12 points, ED incidence was 19.3% (n = 236). The lowest incidence was described by Watcha and RASS scores, 18.8% (n = 230) vs. 18.1% (n = 221), respectively. The threshold for PAED ≥10 points seems to give false-positive results, whereas the threshold >12 points is more accurate. RASS scale, although intended primarily for estimation of the depth of sedation, seems to have a good predictive value for ED.

SUBMITTER: Klabusayova E

PROVIDER: S-EPMC9600633 | biostudies-literature | 2022 Oct

REPOSITORIES: biostudies-literature

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Incidence of Emergence Delirium in the Pediatric PACU: Prospective Observational Trial.

Klabusayová Eva E Musilová Tereza T Fabián Dominik D Skříšovská Tamara T Vafek Václav V Kosinová Martina M Ťoukálková Michaela M Vrtková Adéla A Klučka Jozef J Štourač Petr P

Children (Basel, Switzerland) 20221021 10

Emergence delirium (ED) is a postoperative complication in pediatric anesthesia characterized by perception and psychomotor disorder and has a negative impact on morbidity in the form of maladaptive behavior, which can last weeks after anesthesia. Patients with developed ED present with psychomotor anxiety, agitation, and are at higher risk of unintentional extraction of an intravenous cannula, self-harm and nausea and vomiting. The described incidence of ED varies between 25−80%, with a higher ...[more]

PMID: 36291527

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Project description:BackgroundPost-stroke delirium (PSD) is a modifiable predictor for worse outcome in stroke. Knowledge of its risk factors would facilitate clinical management of affected patients, but recently updated national guidelines consider available evidence insufficient.AimsThe study aimed to establish risk factors for PSD incidence and duration using high-frequency screening.MethodsWe prospectively investigated patients with ischemic stroke admitted within 24 h. Patients were screened twice daily for the presence of PSD throughout the treatment period. Sociodemographic, treatment-related, and neuroimaging characteristics were evaluated as predictors of either PSD incidence (odds ratios (OR)) or duration (PSD days/unit of the predictor, b), using logistic and linear regression models, respectively.ResultsPSD occurred in 55/141 patients (age = 73.8 ± 10.4 years, 61 female, National Institutes of Health Stroke Scale (NIHSS) = 6.4 ± 6.5). Age (odds ratio (OR) = 1.06 (95% confidence interval (CI): 1.02-1.10), b = 0.08 (95% CI = 0.04-0.13)), and male gender (b = 0.99 (95% CI = 0.05-1.93)) were significant non-modifiable risk factors. In a multivariable model adjusted for age and gender, presence of pain (OR mvar = 1.75 (95% CI = 1.12-2.74)), urinary catheter (OR mvar = 3.16 (95% CI = 1.10-9.14)) and post-stroke infection (PSI; OR mvar = 4.43 (95% CI = 1.09-18.01)) were predictors of PSD incidence. PSD duration was impacted by presence of pain (b mvar = 0.49 (95% CI = 0.19-0.81)), urinary catheter (b mvar = 1.03 (95% CI = 0.01-2.07)), intravenous line (b mvar = 0.36 (95% CI = 0.16-0.57)), and PSI (b mvar = 1.60 (95% CI = 0.42-2.78)). PSD (OR = 3.53 (95% CI = 1.48-5.57)) and PSI (OR = 5.29 (95% CI = 2.92-7.66)) independently predicted inferior NIHSS at discharge. Insular and basal ganglia lesions increased the PSD risk about four- to eight-fold.Discussion/conclusionThis study identified modifiable risk factors, the management of which might reduce the negative impact PSD has on outcome.

Project description:IntroductionPostoperative delirium can be a serious consequence of major surgery, associated with longer hospital stays, readmission, cognitive and functional deterioration and mortality. Delirium is an acute, reversible disorder characterised by fluctuating course, inattention, disorganised thinking and altered level of consciousness. Delirium occurring in the hours immediately following anaesthesia and delirium occurring in the postoperative period of 1-5 days have been described as distinct clinical entities. This protocol describes an observational study with the aim of determining if delirium in the first hour following tracheal tube removal is a predictor of delirium in the 5 subsequent postoperative days. Improved understanding regarding the development of postoperative delirium would improve patient care and allow more effective implementation of delirium prevention measures.Methods and analysisPatients enrolled to the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomised controlled trial will be eligible for this substudy. A validated delirium assessment method, the 3-min Diagnostic Confusion Assessment Method and the Richmond Agitation and Sedation Scale will be used to assess 100 patients for delirium at 30 min and 60 min following tracheal tube removal. Patients will also be assessed for delirium over postoperative days 1-5 using three validated methods, the Confusion Assessment Method (CAM), CAM for the Intensive Care Unit and structured chart review. Logistic regression analysis will then be performed to test whether immediately postoperative delirium independently predicts subsequent postoperative delirium.Ethics and disseminationThis observational substudy of ENGAGES has been approved by the ethics board of Washington University School of Medicine. Enrolment began in June 2016 and will continue until June 2017. Dissemination plans include presentations at scientific conferences and scientific publications.Trial registration numberNCT02241655.

Project description:BackgroundFactors that may increase the risk for delirium and the firm knowledge around mechanism for delirium in noninvasive ventilation (NIV) patients is lacking. We investigated the incidence, characteristics, and outcomes of delirium in NIV patients.MethodsA prospective observational study was performed in an intensive care unit (ICU) of a teaching hospital. Patients in whom NIV was used as a first-line intervention were enrolled. During NIV intervention, delirium was screened using the Confusion Assessment Method for the ICU each day. The association between delirium and poor outcomes (e.g., NIV failure, ICU and hospital mortality) was investigated using forward stepwise multivariate logistic regression analyses.ResultsWe enrolled 1083 patients. Of these, 196 patients (18.1%) experienced delirium during NIV intervention. Patients with delirium had higher NIV failure rates (37.8% vs. 21.0%, p < 0.01), higher ICU mortality (33.2% vs. 14.3%, p < 0.01), and higher hospital mortality (37.2% vs. 17.0%, p < 0.01) than subjects without delirium. They also had a longer duration of NIV (median 6.3 vs. 3.7 days, p < 0.01), and stayed longer in the ICU (median 9.0 vs. 6.0 days, p < 0.01) and the hospital (median 14.5 vs. 11.0 days, p < 0.01). These results were confirmed in COPD and non-COPD cohorts. According to subtype, compared to hyperactive delirium patients, hypoactive and mixed delirium patients spent more days and many more days on NIV (median 3.4 vs. 6.5 vs. 10.1 days, p < 0.01). Similar outcomes were found for length of stay in the ICU and hospital. However, NIV failure, ICU mortality, and hospital mortality did not differ among the three subtypes.ConclusionsDelirium is associated with increases in poor outcomes (NIV failure, ICU mortality, and hospital mortality) and the use of medical resources (duration of NIV, and lengths of stay in the ICU and hospital). Regarding subtype, hypoactive and mixed delirium are associated with higher, and much higher, consumption of medical resources, respectively, compared to hyperactive delirium.

Project description:Background: Emergence delirium in children following strabismus surgery is a distressing and potentially dangerous condition and is likely attributable to visual disturbances, pain, and anesthetic gases. We explored whether a single intraoperative dose of methadone could reduce emergence delirium. Methods: Our study was an institutional review board-approved prospective, controlled, before-and-after investigation. Inclusion criteria were age <18 years and American Society of Anesthesiologists (ASA) classification 1 or 2. Patients were excluded for obesity, documented sleep apnea, significant neurologic disease, or inpatient status. Control group patients were recruited sequentially, and the anesthetic was performed per preference. The study group was recruited similarly and received an intravenous dose of methadone 0.15 mg/kg at induction. The primary outcome was peak score on the Pediatric Anesthesia Emergence Delirium (PAED) scale. Secondary outcomes included time to anesthetic emergence, postoperative pain scores, postanesthesia care unit (PACU) length of stay, and postdischarge respiratory complications. Results: Forty-nine control group and 55 study group patients were recruited. No significant differences were found between groups for age, sex, weight, ASA classification, or duration of surgery. The control group received more preoperative midazolam, intraoperative fentanyl, and intraoperative ketorolac. Compared to the control group, the study group had 42% and 85% reductions in peak and severe PAED scale scores, respectively, in the PACU and required less rescue pain medications. Anesthetic emergence time and length of stay were not different between the groups. No significant postoperative complications occurred. Conclusion: Emergence delirium following outpatient pediatric strabismus surgery was substantially mitigated by the use of intraoperative methadone without affecting PACU throughput. No significant complications occurred. Further study is warranted to corroborate routine use of this drug for emergence delirium.

Project description:BackgroundSevoflurane anesthesia is widely used in pediatric ambulatory surgery. However, emergency agitation (EA) and emergency delirium (ED), as major complications following sevoflurane anesthesia in children, pose risks to surgery and prognosis. Identifying the high risk of EA/ED, especially anesthesia exposure and the depth of anesthesia, may allow preemptive treatment.MethodsA total of 137 patients were prospectively enrolled in this single-center observational cohort study to assess the incidence of EA or ED. Multivariable logistic regression analyses were used to test the association between volatile anesthesia exposure and depth with EA or ED. The Richmond Agitation and Sedation Scale (RASS), Pediatric Anesthesia Emergence Delirium Scale (PAED) and Face, Legs, Activity, Cry, and Consolability (FLACC) behavioural pain scale was used to assess the severity of EA or ED severity and pain. Bispectral index (BIS) to monitor the depth of anesthesia, as well as TimeLOW-BIS/TimeANES %, EtSevo (%) and EtSevo-time AUC were included in the multivariate logistic regression model as independent variables to analyze their association with EA or ED.ResultsThe overall prevalence of EA and ED was 73/137 (53.3%) and 75/137 (54.7%) respectively, where 48/137 (35.0%), 19/137 (13.9%), and 6/137 (4.4%) had mild, moderate, and severe EA. When the recovery period was lengthened, the prevalence of ED and extent of FLACC decreased and finally normalized within 30 min in recovered period. Multivariable logistic regression demonstrated that intraoperative agitation [2.84 (1.08, 7.47) p = 0.034], peak FLACC [2.56 (1.70, 3.85) p < 0.001] and adverse event (respiratory complications) [0.03 (0.00, 0.29) p = 0.003] were independently associated with higher odds of EA. Taking EtSevo-time AUC ≤ 2,000 as a reference, the incidence of EA were [15.84 (2.15, 116.98) p = 0.002] times and 16.59 (2.42, 113.83) p = 0.009] times for EtSevo-time AUC 2,500-3,000 and EtSevo-time AUC > 3,000, respectively. Peak FLACC [3.46 (2.13, 5.62) p < 0.001] and intraoperative agitation [5.61 (1.99, 15.86) p = 0.001] were independently associated with higher odds of developing ED. EtSevo (%), intraoperative BIS value and the percentage of the duration of anesthesia at different depths of anesthesia (BIS ≤ 40, BIS ≤ 30, BIS ≤ 20) were not associated with EA and ED.ConclusionsFor pediatrics undergoing ambulatory surgery where sevoflurane anesthesia was administered, EA was associated with surgical time, peak FLACC, respiratory complications, and "EtSevo-time AUC" with a dose-response relationship; ED was associated with peak FLACC and intraoperative agitation.

Dataset Information

Incidence of Emergence Delirium in the Pediatric PACU: Prospective Observational Trial.

Publications

Incidence of Emergence Delirium in the Pediatric PACU: Prospective Observational Trial.

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