Emergence delirium can be a frustrating and stressful situation for everybody involved, including the patients’ families and the nurses. A scenario might unfold as follows: A 5-year-old patient with a history of mild attention deficit and hyperactivity disorder has come to your operating room for an emergency esophago gastroduodenoscopy (EGD) to rule out ingestion of a foreign body. The patient is given a midazolam premedication which helps some with the induction. The endoscopist finds nothing in the esophagus or stomach. You wake the child up from the sevoflurane anesthetic and, on the way to the postanesthesia care unit (PACU), he begins crying and thrashing. He catches the PACU nurse on the lip with the back of his head. There is blood. This doesn’t look good for you. He is crying and moaning. You can’t seem to get his attention even though his eyes are open. Mom comes in and says she has never seen him like this. She starts to cry because her child doesn’t recognize her. The nurse looks at you and whispers, “You better do something to make this better!”

Emergence Delirium (ED), also frequently called emergence agitation, is a diagnosis of exclusion. A disoriented patient who is incognizant of his or her surroundings and of previously familiar individuals and objects and who is generally inconsolable and uncooperative is diagnosed as having ED, absent another diagnosis. Behavior ranges from incoherence and moaning, to thrashing, agitation, and paranoia or hallucinations. While usually self-limited (<1 hour in duration), ED can lead to many undesirable consequences, such as an inability to monitor the patient, disconnected intravenous (IV) lines, and significant physical trauma to the patient or caregivers (or both).

Hypoxia, inadequate analgesia, hypoglycemia, severe hypercarbia, increased intracranial pressure, nausea, and bladder distention are all factors to consider prior to settling on ED as the diagnosis for a pediatric patient’s disorientation and agitation.

The incidence of ED is estimated to range from 5% to 55% and is higher in children who are 2 to 5 years of age than in younger and older children. One of the problems in recognizing and treating the disease has been the lack of a reliable and valid instrument for measuring ED in children. Previously, this precluded comparisons between trials and raised serious questions about the reliability and validity of research results. The development and evaluation
of the Pediatric Anesthesia Emergence Delirium (PAED) Scale in 2004 will enable researchers to characterize ED in children accurately and to compare treatment options in future studies.

Various mechanisms have been postulated to cause ED; a definitive causality has yet to be identified. Volatile anesthetics (halothane, isoflurane, sevoflurane, and desflurane) are associated with an incidence of ED as high as 50%. Sevoflurane and desflurane have been extensively studied. Their low blood-gas-solubility quotient with rapid emergence has been theorized to lead to a higher incidence of ED. Numerous studies have yielded conflicting data but suggest that sevoflurane may be associated with a higher incidence of ED than desflurane. Ketamine, droperidol, atropine, and scopolamine also are associated with ED. Propofol, when used for maintenance of anesthesia, is associated with a very low incidence of ED.