Emergence Delirium with Transient Associative Agnosia and Expressive Aphasia Reversed by Flumazenil in a Pediatric Patient

Abstract

Multiple factors may contribute to the development of emergence delirium in a child. We present the case of a healthy 12-year-old girl who received preoperative midazolam with the desired anxiolytic effect, underwent a brief general anesthetic, and then exhibited postoperative delirium, consisting of a transient associative agnosia and expressive aphasia. Administration of flumazenil led to immediate and lasting resolution of her symptoms. We hypothesize that γ-aminobutyric acid type A receptor-mediated effects, most likely related to an atypical offset of midazolam, are an important subset of emergence delirium that is amenable to pharmacologic therapy with flumazenil.

Effects of γ-Aminobutyric Acid Type A Receptor Modulation by Flumazenil on Emergence from General Anesthesia

“…Taken in the context of our previous work with flumazenil in patients with hypersomnia 10 and clinical case reports of flumazenil in reversing emergence delirium 50 , our results suggest that flumazenil has a more complex relationship with GABA A Rs than pure antagonism. Our results are consistent with clinical studies that suggest flumazenil can reverse anesthesia even in the absence of benzodiazepines 35 .…”

Risperidone in a child with untractable emergency delirium: a case report

“…Emergence delirium (ED) is defined as "a cluster of disturbing behaviors that can occur in the early post-anesthetic period" [1], and is a very common pediatric disturbance with an incidence ranging from 10% to 80% [23]. ED is characterized by non-purposeful restlessness, agitation, crying, disorientation, and paranoid ideation [123].…”

“…ED is characterized by non-purposeful restlessness, agitation, crying, disorientation, and paranoid ideation [123]. The Pediatric Anesthesia Emergence Delirium (PAED) scale, which scores ED based on eye contact, purposeful actions, awareness, restlessness, and consolability, has been validated to evaluate the incidence and severity of ED [3].…”

“…If pediatric patients show ED-like behaviors in the PACU, the staff will usually administer sedative or opioid agents to calm them [14]. However, many of the clinical symptoms of ED are similar to those of paradoxical midazolam reactions [256]. Therefore, flumazenil has also been used to treat postoperative ED associated with midazolam exposure [2].…”

“…However, many of the clinical symptoms of ED are similar to those of paradoxical midazolam reactions [256]. Therefore, flumazenil has also been used to treat postoperative ED associated with midazolam exposure [2]. In this case study, the patient experienced uncontrolled ED even after clinicians used classical treatments, such as sedative drugs, opioids, and flumazenil.…”