Emergence Delirium in Pediatric Anesthesia

Emergence delirium (ED) is a complex of perceptual disturbances and psychomotor agitation that occurs most commonly in preschool-aged children in the early postanesthetic period. The incidence of ED varies between 10 and 80% in children and is perceived as a troublesome clinical situation by 42% of pediatric anesthesiologists. Although these events are often short lived, they increase the risk of self-injury and delayed discharge, require additional nursing staff and can increase medical care costs, all of which are causes for concern. The prevalence of ED has increased with the introduction and growing use of sevoflurane and desflurane, two low-solubility inhalational anesthetics. These agents promote early arousal post anesthetic, which contributes to ED. Physiological factors, pharmacological factors, the type of procedure, the anesthetic agent administered, painful stimuli, and various patient factors can all contribute to ED and thus need to be considered. Recent literature debates the cause-effect relationship between ED and pain, suggesting that they often occur concurrently but are sometimes independent findings. The consistent relation between ED and sevoflurane-based anesthesia has guided many studies to investigate its incidence compared with using other anesthetic techniques or various adjuncts. The risk of ED is lowest when propofol is used as a single-agent anesthetic compared with sevoflurane-based anesthetics. Adjunctive agents can be rated in the following order of most effective to least effective interventions: dexmedetomidine, fentanyl, ketamine, clonidine, and propofol bolus at the end of sevoflurane-based anesthesia. This review summarizes the factors that may predict ED and provides an intervention algorithm to guide effective prevention and treatment.