Face, Legs, Activity, Cry, Consolability scale
Face
0. No particular expression/smile, eye contact and interest in surroundings
1. Occasional grimace or frown, withdrawn, disinterested, worried look to face, eyebrows lowered, eyes partially closed, cheeks raised, mouth pursed
2. Frequent to constant frown, clenched jaw, quivering chin, deep furrows on forehead, eyes closed, mouth opened, deep lines around nose/lips
Legs
0. Normal position or relaxed
1. Uneasy, restless, tense, increased tone, rigidity, intermittent flexion/extension of limbs
2. Kicking or legs drawn up, hypertonicity, exaggerated flexion/extension of limbs, tremors
Activity
0. Lying quietly, normal position, moves easily and freely
1. Squirming, shifting back and forth, tense, hesitant to move, guarding, pressure on body part
2. Arched, rigid, or jerking, fixed position, rocking, side to side head movement, rubbing of body part
Cry
0. No cry/moan (awake or asleep)
1. Moans or whimpers, occasional cries, sighs, occasional complaint
2. Crying steadily, screams, sobs, moans, grunts, frequent complaints
Consolability
0. Calm, content, relaxed, does not require consoling
1. Reassured by occasional touching, hugging or ‘talking to’ distractible
2. Difficult to console or comfort
Locatelli et al. divided the PAED scales in a delirium-specific score (ED1 – ‘Eye contact’ and ‘Awareness of the surroundings’ and ‘Purposeful actions’) and in nonspecific delirium score (ED2 – ‘Restlessness’ and ‘Inconsolability’). In their study, ED1 (≥9 points in ‘Eye contact’ and ‘Awareness of the surroundings’ and ‘Purposeful actions’) was highly correlated with ED episodes in young children undergoing sub-umbilical surgery with effective caudal block. Moreover, the incidence of ED1 recognized ED cases (sensitivity 93 %) and non-ED cases (specificity 94 %). In contrast, ED2 correctly identified non-ED cases (specificity 95 %), but was not reliable in identifying ED cases (sensitivity 34 %) [46].
The descriptors used in some EA scales and in the PAED scale may overlap with those used by pain evaluation tools like the Face, Legs, Activity, Cry, Consolability (FLACC) scale (Table 22.2) [48]. The FLACC scale is a reliable observational score to assess pain in young children. It was validated to assess postoperative pain in fully awake children, observing the child over 5 min and recording the worse behaviour of each item [51].
Not at all | Just a little | Quite a bit | Very much | Extremely | |
|---|---|---|---|---|---|
Child makes eye contact with the caregiver | 4 | 3 | 2 | 1 | 0 |
Child’s actions are purposeful | 4 | 3 | 2 | 1 | 0 |
Child is aware of his/her surroundings | 4 | 3 | 2 | 1 | 0 |
Child is restless | 0 | 1 | 2 | 3 | 4 |
Child is inconsolable | 0 | 1 | 2 | 3 | 4 |
The PAED scale and the FLACC scales overlap three criteria: ‘Inconsolability’, ‘Purposeful actions’ and ‘Restlessness’. High scores on restlessness and inconsolability items, even associated with low scores on ED-specific items, may produce a false-positive diagnosis of ED [48]. On the other hand, if evaluated with FLACC scale, facial expression in combination with inconsolability and motor restlessness may diagnose pain instead of ED.
The categories ‘No eye contact’ and ‘No awareness of surroundings’ are unique to the PAED scale and considered as the most important items for ED identification [46, 48, 56]. The association of ‘No eye contact’ and ‘No awareness of surroundings’ is strongly correlated to ED episodes with 99 % sensitivity and 63 % specificity during the first 15 min after awakening. The association of ‘Abnormal facial expression’, ‘Crying’ and ‘Inconsolability’ demonstrates 93 % sensitivity and 82 % specificity to detect pain during the early postoperative period [28].
22.5 Prevention and Treatment
The treatment of e-PONB should be ideally preventive. Pharmacologic and non-pharmacologic strategies are largely investigated.
22.5.1 Non-pharmacologic Approach
The strong correlation between preoperative anxiety and postoperative behavioural supported the use of pharmacological and non-pharmacological preventive strategies. Different strategies to decrease preoperative anxiety have been proposed. They include decrease sensory stimuli during induction of anaesthesia, distraction and hypnosis, clown therapy, children and parents preparation with movies, videos or interactive book [72]. The efficacy of parental presence during induction in reducing anxiety in children is still controversial [30, 36, 44, 49]. The perioperative information and distraction reduce the perioperative anxiety, salivary cortisol concentrations and postoperative morphine consumption in children [70].
Kain et al. evaluated the ADVANCE strategy (anxiety-reduction, distraction, video modelling and education, adding parents, no excessive reassurance, coaching and exposure/shaping) for family preparation [38]. Informed parents are involved in the distraction of their own child before and during the induction of anaesthesia. This programme decreases preoperative anxiety of children and the incidence of ED. Moreover, it was more effective than premedication with midazolam on ED prevention [18].
Recently, Seiden et al. compared the tablet-based interactive distraction (TBID) method with midazolam premedication in children undergoing ambulatory surgery. TBID method reduced perioperative anxiety, incidence of ED and the discharge time and increased parental satisfaction [55].
22.5.2 Pharmacologic Approach
22.5.2.1 Midazolam
Midazolam is the most common used drug to prevent and treat preoperative anxiolysis [34, 35]. However, the efficacy of midazolam on preventing e-PONB or its long-term sequels is controversial. Few studies supported the use of midazolam premedication to prevent EA [11, 12, 42, 43]. Other studies reported no effect on e-PONB [11, 12, 15, 18]. Recently, Chuo et al. showed that intravenous midazolam 0.03 mg/kg just before the end of surgery decreases the incidence of EA in children undergoing elective strabismus surgery. They suggested that premedication midazolam is unable to reduce e-PONB because its effect may not last enough in longer procedures [10].
22.5.2.2 Alpha2-Adrenergic Agonists
There is strong evidence that intravenous clonidine or dexmetomidine reduced the incidence of postoperative e-PONB (overall summary odds ratio 0.28, 95 % CI 0.19–0.40) [10]. It should be consider that most of these studies investigated EA, and not specifically ED, and no studies investigate the effect on long-term behaviour changes. The administration of alpha2-adrenergic agonists prolongs the time in recovery room, but this finding seems to be clinically irrelevant [54].
Mikawa et al. found that 4 mcg/kg clonidine premedication is more effective on reduce EA when compared with clonidine 2 mcg/kg, midazolam 0.5 mg/kg, diazepam 0.4 mg/kg or placebo [52]. Yao et al. demonstrated that intranasal dexmedetomidine premedication (1–2 mcg/kg) significantly reduces incidence and severity of ED in children aged 3–7 years undergoing general anaesthesia [71].
The mechanism of alpha2-adrenergic agonist on e-PONB is unclear. Some authors hypothized that clonidine reduces the noradrenaline content in adrenergic areas of the brain increased by all the inhaled anaesthetics [61].
22.5.2.3 Intravenous Anaesthesia with Propofol
The combination of a propofol infusion and nitrous oxide with an effective regional block or a low dose of opioid represents the best strategy for the prevention of e-PONB [5, 8]. Propofol, either as a single bolus at the end of surgery or as an infusion, has been shown to decrease the incidence of ED after sevoflurane anaesthesia [40, 41].
22.5.2.4 Pain Management
Inadequate pain control remains a potential contributor of e-PONB analgesia and is considered the first act to prevent negative behaviour changes after awakening [1, 2, 5, 11, 12, 39–41].
Caudal block and loco-regional anaesthesia had been showed to reduce the risk of EA [2, 39]. As well nonsteroidal anti-inflammatory drug administration decreases the incidence of e-PONB. Intraoperative fentanyl showed an overall decrease in risk of EA (RR 0.37, 95 % CI 0.27–0.50) (I 2 = 54 %) [26, 15]. The incidence of EA and pain but not ED can be reduced by fentanyl, but not clonidine, before surgery in children undergoing lower abdominal surgery with sevoflurane without affecting awakening and discharge from PACU. Whilst this strategy may reduce both EA and pain after awakening, it was also associated with a higher incidence of PONV the day after surgery [8].
The mechanisms of action of opioids on the prevention of e-PONB are unclear. Fentanyl inhibits neurons of the hypocretin-orexin system in the hypothalamus, which regulate arousal and maintenance of the awake state [45].
22.5.3 When and How to Treat e-PONB?
Clinicians should consider treating e-PONB according to the severity and duration of the symptoms and concerns over the safety of the child [5]. However, there is no evidence that if left untreated the ED episodes have any sequelae in young children.
Clinicians should consider two aims during e-PONB management: protect the child from self-injury and second provide a quiet setting where the child can recover. The parental presence in recovery room does not affect the incidence of ED. Heath providers in PACU should explain the phenomenon and reassure parents that ED is self-limiting and their child will return to his/her normal behaviour [5].
If clinicians consider treating e-PONB, they first need to define if the negative behaviour is the expression of ED, pain or both. If it is clearly an ED episodes (PAED score ≥10 or the association of ‘No eye contact’ and ‘No awareness of surroundings’), a small bolus of propofol (0.5–1 mg/kg) should be enough to control the child. If the origin of the distressing behaviours is difficult to understand, fentanyl (1–1.5 mcg/kg) should be the first option as it is possible to control pain and ED [17, 18].
22.6 Conclusion
e-PONB significantly affects the awakening of young children. The recognition of the different components of e-PONB is clinically relevant but remains a challenge, even for expert nurses and doctors. Prevention of preoperative anxiety, propofol anaesthesia, associated with adequate analgesia and an accurate assessment during early period after awakening remain the main tools for the prevention of e-PONB.
References
1.
2.
3.
4.
Bajwa SA, Costi D, Cyna AM (2010) A comparison of emergence delirium scales following general anesthesia in children. Pediatr Anesth 20:704–711CrossRef
Related posts:
Pain After Surgical Correction of Congenital Chest Wall Deformities
Perioperative Care of the Pediatric Neurosurgical Patient
Preoperative Preparation
Acute Pain Management and Prevention
Long-Term Consequences of Anesthesia (and Surgery) on the Infant Brain
Perioperative Care of Children with Cerebral Palsy and Behavioral Problems
Full access? Get Clinical Tree
