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Risk factors for pediatric emergence delirium: a systematic review
Kazuyoshi Aoyama1,2,3,4, Machiko Furuta5, Lieven Ameye6
1Department of Anesthesia and Pain Medicine, The Hospital for Sick Children (SickKids), Toronto, ON, Canada. kazu.aoyama@utoronto.ca.
Insights
Emergence delirium (ED) in children is common after anesthesia. This review identified younger age, agitated induction, and sevoflurane as key risk factors for pediatric ED.
Area of Science:
- Anesthesiology
- Pediatric Medicine
- Critical Care
Background:
- Emergence delirium (ED) affects about 25% of pediatric patients post-anesthesia.
- ED is linked to patient and staff injuries, highlighting the need for predictive tools.
- Current risk prediction models for pediatric ED lack usability.
Purpose of the Study:
- To systematically review and identify published risk factors for pediatric emergence delirium.
- To address the lack of usable risk prediction models for ED in children.
Main Methods:
- Systematic literature search of prospective observational studies and clinical trials up to January 11, 2023.
- Inclusion of studies on pediatric patients (<18 years) undergoing general anesthesia, measuring preoperative/intraoperative risk factors for ED.
- Qualitative evaluation of risk factors synthesized with levels of evidence (strong, moderate, inconclusive, lack of evidence).
Main Results:
- Thirty-one studies involving 6,068 patients were analyzed, with a median ED incidence of 32%.
- Strong evidence identified younger age and agitated/excited induction behavior as risk factors.
- Moderate evidence linked sevoflurane use to an increased risk of pediatric ED.
Conclusions:
- Despite limitations in quantitative synthesis, this review qualitatively identified three significant risk factors for pediatric ED.
- Younger age, agitated induction, and sevoflurane are robustly evidenced risk factors.
- Further research may focus on developing usable risk prediction models based on these findings.
Purpose:
Emergence delirium (ED) impacts approximately 25% of pediatric patients undergoing general anesthesia and is associated with with concerning consequences, including injury to patients and health care personnel. Risk prediction models with good usability for pediatric ED are lacking. We aimed to identify published risk factors in this systematic review.
Methods:
We conducted a systematic literature search of prospective observational studies and clinical trials through eight major databases from inception to 11 January 2023. We included prospective studies published in English that examined the pediatric population (< 18 yr old) undergoing general anesthesia for any surgical or imaging procedure, that measured the risk factor(s) for ED preoperatively/intraoperatively, and that reported the incidence of ED. We excluded studies investigating therapeutic or prophylactic interventions of ED. We assessed the quality of eligible articles according to a modified version of the Scottish Intercollegiate Guidelines Network quality checklists and rated them as high, acceptable, or low quality. Risk factors discovered were qualitatively evaluated and synthesized with the following levels of evidence: strong evidence, moderate evidence, inconclusive evidence, or lack of evidence.
Results:
Thirty-one studies, comprising a total of 6,068 patients, met the inclusion criteria. The median incidence of ED was 32%. Twelve studies were rated as high quality, 15 as acceptable quality, and the remaining four as low quality. Younger age and agitated/excited induction behaviour with strong evidence, followed by sevoflurane with moderate evidence, were identified as risk factors for pediatric ED. Quantitative synthesis was not feasible as there were no more than two studies that explored the same risk factor with the same cut-off.
Conclusion:
Although quantitative analyses were not feasible, the current systematic review qualitatively identified three risk factors for pediatric ED with robust evidence.
Study Registration:
PROSPERO ( CRD42020192221 ); first submitted 18 June 2020.
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