An Observational Study of Emergence and Hypoactive Delirium After Anesthesia

The restless recovery from anesthesia is a relevant clinical problem that can be present in up to 80% of surgical cases. The incidence varies with age, anesthetic agents, type of surgery, and definition of the children behavior.

Unsettle behavior after anesthesia is associated with patient injury, damage to incision sites, exacerbated parental anxiety, increased nursing workload and cost of the healthcare system. Moreover, agitated children are seven times more likely to have new-onset separation anxiety, apathy, eating and sleeping problems.

The term early postoperative negative behavior (e-PONB) includes different unsettle behaviors after awakening and differentiates early phase from later postoperative behavioral changes. The more relevant components of e-PONB have been identified as pain and Emergence Delirium (ED).

ED a mental disturbance during the recovery from general anesthesia consisting in hallucinations, delusions and confusion manifested by moaning, restlessness, involuntary physical activity, and thrashing in bed. ED occurs within the first 20 min of recovery from anesthesia and often lasts 5-15 minutes and is self-limited.

The five-item Pediatric Anesthesia Emergence Delirium (PAED) scale is the gold standard to assess ED in the pediatric population. However, the diagnosis of ED may be affected by the concurrent presence postsurgical pain. A recent investigation found that only three of the five items of the PAED are delirium-specific ('Eye contact, 'Awareness of the surroundings', 'Purposeful actions'), whereas the other two ('Restlessness' and 'Inconsolability') are noted. As a consequence, if the child has 'no eye contact' and is 'no aware of surroundings,' emergence delirium should be suspected. On the contrary, a child showing 'Abnormal facial expression,' 'Crying' and being 'Inconsolable,' likely suffers of pain. The ED I and II score have been defined as the sum of the first 3-item (eye contact, purposeful movement, and awareness of surrounding) and the last 2-item scores (restlessness and inconsolability) of the PAED scale, respectively.