Emergence Delirium in Perioperative Pediatric Care: A Review of Current Evidence and New Directions

Urits, Ivan; Peck, Jacquelin; Giacomazzi, Stephen; Patel, Riki; Wolf, John E.; Mathew, Denzil P.; Schwartz, Ruben; Kassem, Hisham; Urman, Richard D.; Kaye, Alan D.; Viswanath, Omar

doi:10.1007/s12325-020-01317-x

Cited by 39 publications

(27 citation statements)

References 48 publications

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“…The high incidence and extensive harm of EA in children have brought many troubles to clinical practice. Various drugs have been investigated to prevent EA in pediatric patients (2). Earlier network meta-analyses (85,86) suggested that DEX may be the most effective drug to prevent EA in children.…”

Section: Discussionmentioning

confidence: 99%

“…The negative behavioral symptoms of EA include combative movements, excitability, thrashing, disorientation, and inconsolable crying. Although these events are often short-lived, they increase the risk of selfinjury and delayed discharge from the PACU, require added nursing care, and increase medical costs (2). EA incidence varies from 10% to 80% in children, and 42% of pediatric anesthesiologists consider it a troublesome clinical situation (3,4).…”

Section: Introductionmentioning

confidence: 99%

“…Various drugs have been investigated to prevent EA in pediatric patients, including dexmedetomidine (DEX), midazolam, propofol, opioids, ketamine, and ketofol (2). Among these drugs, DEX, a highly selective α2adrenoreceptor agonist, is the most prevalent drug used in pediatric anesthesia due to its sedative, analgesic, amnesic, anxiolytic, and sympatholytic properties with minimal respiratory depression (5).…”

Section: Introductionmentioning

confidence: 99%

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Effect of different administration and dosage of dexmedetomidine in the reduction of emergence agitation in children: a meta-analysis of randomized controlled trials with sequential trial analysis

Xu¹,

Bai²,

Shi³

et al. 2021

Transl Pediatr

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Background: Beneficial effects of dexmedetomidine (DEX) against emergence agitation (EA) in children remain controversial. We performed a more comprehensive meta-analysis to evaluate the protective effect of different administration routes, timing, patterns, and doses of DEX on EA in children. Methods:The randomized controlled trials about DEX preventing EA in children were searched in PubMed, Cochrane Library, Embase, and Web of Sciences up to October 7, 2020. The traditional meta-analysis and subgroup analysis were performed to study the influence of DEX on EA in children. The sequential trial analysis (TSA) further analyzed the pooled results to evaluate meta-analyses' robustness. Grading of recommendation, assessment, development, and evaluation (GRADE) was used to assess evidence quality.Results: Sixty-seven studies with 5,688 pediatric patients were included. DEX significantly decreased EA in children compared to placebo [RR 0.29, 95% confidence intervals (CI): 0.25-0.34] and midazolam (RR 0.34, 95% CI: 0.25-0.45), with firm evidence from TSA. Notably, using DEX significantly reduced severe EA incidence (RR 0.23, 95% CI: 0.16-0.32), with firm evidence by TSA and high quality of GRADE. Pre-specified subgroup analyses revealed firm and high-quality evidence for a reduction of EA, only if the perineural route administers DEX (RR 0.24, 95% CI: 0.14-0.41), as premedication (RR 0.27, 95% CI: 0.20-0.36), as continuous dosage (RR 0.25, 95% CI: 0.18-0.33), at high dose (RR 0.24, 95% CI: 0.18-0.31). The pooled results also showed that DEX reduced the incidence of PONV compared to placebo (RR 0.43, 95% CI: 0.33-0.55). Evidence for DEX's influence on other secondary outcomes (emergence time, time in PACU, rescue analgesia, hypotension, and bradycardia) is insufficient to draw any conclusion.Conclusions: Our findings confirm the beneficial effects of DEX on EA, severe EA, and PONV in children. There was firm and high-quality evidence for the efficacy of DEX in preventing EA in children when perineural routes administered DEX, as premedication, as continuous dosage, and at a high dose. The best dose, route, patterns, and timing of DEX and influence on other outcomes call for further studies.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Effect of different administration and dosage of dexmedetomidine in the reduction of emergence agitation in children: a meta-analysis of randomized controlled trials with sequential trial analysis

Xu¹,

Bai²,

Shi³

et al. 2021

Transl Pediatr

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“…It also minimizes postoperative side effects, especially emergence delirium, nausea, and vomiting. [ 19 , 20 ] In our patient, TIVA was used to preserve HPV function and avoid adverse effects of inhalational anesthetics. Studies also have suggested that the BIS index, a computer-processed electroencephalography score that ranges from 0 (no electroencephalography activity) to 100 (fully awake), can predict responses to noxious stimulation during TIVA.…”

Section: Discussionmentioning

confidence: 99%

Airway management during left-sided gastrobronchial fistula repair after esophagectomy for esophageal carcinoma

Wang¹,

Yuan²,

Wu³

2021

Medicine

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Rationale: Gastrobronchial fistula (GBF) is a rare but life-threatening complication of esophagectomy with gastric conduit reconstruction, and airway management during fistula repair is challenging. Here, we describe airway management in a patient undergoing left-sided GBF repair using video-assisted thoracoscopic surgery. Patient concerns: A 63-year-old man diagnosed with esophageal carcinoma underwent esophagectomy with reconstruction by gastric pull-up and tabularization of the gastric conduit. Subsequently, about 8 weeks later, the patient presented with repeated pneumonia and a 1-week history of cough with significant sputum, dysphagia, and repeated fever. Diagnosis: GBF, a rare postoperative complication, was located on the left main bronchus at 2 cm below the carina and was diagnosed based on findings from gastroscopy, flexible bronchoscopy, and thoracic computed tomography scan with contrast. Interventions: We performed left-sided one-lung ventilation (OLV) under total intravenous anesthesia instead of inhalational anesthetics. The left-sided OLV, with positive end-expiratory pressure (PEEP) and nasogastric tube decompression, generated positive pressure across the fistula. It prevented backflow into the left main bronchus. Total intravenous anesthesia preserved hypoxic pulmonary vasoconstriction and prevented adverse effects associated with inhalational anesthetics. A right-sided, double-lumen endotracheal tube was inserted after anesthesia induction, and surgical repair was performed through a right-sided video-assisted thoracoscopic surgery. Outcomes: Intraoperative hemodynamics remained relatively stable, except for brief tachycardia at 113 beats/min. Arterial blood gas analysis revealed pH 7.17 and PaO 2 89.1 mmHg upon 100% oxygenation, along with hypercapnia (PaCO 2 77.1 mmHg), indicating respiratory acidosis. During OLV, pulse oximetry remained higher than 92%. The defect in the left main bronchus was successfully sutured after dissecting the fistula between the left main bronchus and the gastric conduit, and subsequently, OLV resulted in ideal ventilation. Lessons: A left-sided GBF could lead to leakage from the OLV during surgery. Possible aspiration or alveolar hypoventilation due to this leakage is a major concern during airway management before surgical repair of the main bronchus.

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“…до батьків і медперсоналу [1]. Ці ознаки характеризують так званий синдром післяопераційної ажитації.…”

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Postoperative agitation syndrome in young children with perinatal damage to the central nervous system

Snisar¹,

Pavlysh²

2022

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One of the complications of the postoperative period in children is postanesthetic agitation, a significant emotional and uncontrollable worry, clouding of consciousness, feeling of anxiety and fear, inappropriate behavior, irritability, inconsolable crying, aggressive and negative attitude towards parents and medical staff. Postoperative agitation is very important for clinicians and hospitals, it has a risk of harming a patient, staying longer in the ward after anesthesia, and increasing the period of postoperative recovery. The frequency of postoperative agitation depends on age group. Most often agitation occurs in young children. There is evidence that agitation can also be due to the immature nervous system and a consequence of pathological conditions of the central nervous system (asthenoneurotic syndrome, encephalopathy, hyperactivity syndrome, perinatal posthypoxic and organic brain lesions, history of prematurity, epilepsy, psychophysical and speech delay, etc.). That is why the goal of our research was to study the patterns of clinical manifestations of postoperative agitation syndrome in children with prenatal damage to the central nervous system. The work was performed based on the analysis of the postoperative period in 109 young children: 59 patients with acquired hydrocephalus, who underwent ventriculoperitoneal shunting, and 50 children without neurological disorders in whom reconstructive surgeries were carried out. Depending on the type anesthetic management, each group was divided into two subgroups: children, who received inhalation anesthesia with sevoflurane, and those, who received total intravenous anesthesia using propofol. In the postoperative period, the behavior of children was assessed on a Pediatric Anesthesia Emergence Delirium scale 30 minutes after anesthesia was completed. Criterion for the development of agitation was the presence of excitement in a child with a score of ≥ 10 points. Study showed that young children with perinatal damage to the central nervous system and children whose anesthetic provision is carried out using sevoflurane are the most vulnerable to the development of agitation syndrome. Agitation in such children is more pronounced and longer. These cases require prediction, detection and active surveillance.

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Emergence Delirium in Perioperative Pediatric Care: A Review of Current Evidence and New Directions

Cited by 39 publications

References 48 publications

Effect of different administration and dosage of dexmedetomidine in the reduction of emergence agitation in children: a meta-analysis of randomized controlled trials with sequential trial analysis

Effect of different administration and dosage of dexmedetomidine in the reduction of emergence agitation in children: a meta-analysis of randomized controlled trials with sequential trial analysis

Airway management during left-sided gastrobronchial fistula repair after esophagectomy for esophageal carcinoma

Postoperative agitation syndrome in young children with perinatal damage to the central nervous system

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