British Journal of Anaesthesia, 118 (3): 335–43 (2017)

doi: 10.1093/bja/aew477
Review Article

Paediatric emergence delirium: a comprehensive

review and interpretation of the literature
K. P. Mason
Harvard Medical School, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s
Hospital, 300 Longwood Avenue, Boston, MA 02115, USA

Corresponding author. E-mail: keira.mason@childrens.harvard.edu

Abstract
There remain unanswered questions and implications related to emergence delirium in children. Although we know that
there are some predisposing factors to emergence delirium, we still are unable to predict accurately those who are at great-
est risk. Emergence delirium should be considered as a ‘vital sign’, which should be followed and documented in every child
in the postanaesthesia recovery period. Standardized screening tools should be adopted for paediatric emergence delirium.

Key words: anaesthesia; emergence agitation; emergence delirium; maladaptive behaviour; paediatrics

As early as 1960 and 1961, Smessaert and colleagues1 and
Eckenhoff and colleagues,2 respectively, described behaviour
observed in the recovery period. In an effort to understand ‘emer-
gence excitement’, Eckenhoff and colleagues2 reviewed 14 436 pro-
spectively collected patient records. Emergence excitement was
defined as crying, sobbing, thrashing about, and disoriented. The
highest incidences of excitement were correlated with the ‘youth
of the patient, the excellence of his health, barbiturate and scopol-
amine pre-anaesthetic medication, cyclopropane or ether anaes-
thesia and operative procedures associated with pain or emotional
stress’. Forty years later, we still struggle to identify, prevent, and
treat emergence delirium (ED). This review will consider the evolu-
tion of emergence agitation (EA) and ED, from their initial identifi-
cation in the 1960s to the current and future implications of their
identification, treatment, and prognostic value (Fig. 1).
Identification of emergence delirium
In 2002, a prospective evaluation of children (10 months to 6 yr of
age), found up to a 30% incidence of inconsolable crying or severe
restlessness within the first 10 min of awake children arriving in
the postanaesthesia recovery room.3 In 2003, Voepel-Lewis and
colleagues4 reported an 18% incidence of EA in children 3–7 yr of
age, lasting an average of 14 min but up to 45 min. Fifty-two per
cent required pharmacological intervention. Emergence agitation
was characterized by non-purposeful movement, restlessness,
thrashing, incoherence, inconsolability, and unresponsiveness.
Otolaryngology procedures, time to awakening, and isoflurane
were considered to be independent risk factors.
Frequently, delirium and agitation are used interchangeably
in the literature. The challenge to proper treatment is to separ-
ate EA, ED, pain, and the patient’s baseline behavioural tenden-
cies when labelling a child’s behaviour as EA or ED.
As recently as 2011, we still strive to identify the behaviours
associated with ED. In children 18 months to 6 yr of age, those
with ED were more likely to display non-purposefulness, eyes
averted, staring, or closed, and non-responsivity. Associated be-
haviours included irrelevant language, activity, and vocaliza-
tion.5 Early postoperative negative behaviour after general
anaesthesia has been identified in up to 80%.6 Distinguishing

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335
 336 | Mason

• Levy identifies postoperative behavior problems in children with no history of behavior issues
1945 (12)

• Eckenhoff correlates unsatisfactory anesthesia induction with manifestation of negative

1953 postoperative behavior (13)

1960, • Smessaert and Eckenhoff describe postanesthetic excitement (1,2)

1961,

• Vernon publishers Changes in Children’s Behavior After Hospitalization (14)

1966

• Sevoflurane introduced in Japan

1990

• Post operative agitation first described with Sevoflurane in Japan and suggested to be of higher
1991 incidence than with halothane (20)

• FDA approves Sevoflurane in United States

1995

• Welborn and Lerman in United States report emergence agitation with Sevoflurane and
1996 compare to other volatile agents (18,19)

• Cole defines up to 30% incidence of inconsolable crying or restlessness in post anesthesia

2002 recovery period (3)

• Voepel-Lewis describes 18% incidence of emergence agitation in children 3–7 years old which
2003 can last an average of 14 minutes (4)

• The PAED scale presented for children greater than 2 years age (8)
2004

• Kain describes increased incidence ED, post op anxiety and sleep disturbances for up to 14 days
2006 postoperatively in those with increased level of preoperative anxiety (16)

• A meta-analysis decribes decreased incidence of emergence agitation when alpha 2 agonists

2010 are administered with volatile agents (50)

• Somaini presents observational data to distinguish acute pain from emergence delirium (78)
2016
• Schieveld advocates for unified standardized screening tool for delirium, from pediatrics to
geratrics (75)

Fig 1 Historical time line of noteworthy events for emergency agitation and delirium.

Table 1 Paediatric Anaesthesia Emergence Delirium scale.8
Items 1, 2, and 3 are reverse scored as follows: 4¼not at all;
3¼just a little; 2¼quite a bit; 1¼very much; and 0¼extremely.
Items 4 and 5 are scored as follows: 0¼not at all; 1¼just a little;
2¼quite a bit; 3¼very much; and 4¼extremely. The scores of
each item were summed to obtain a total Paediatric
Anaesthesia Emergence Delirium (PAED) scale score. The de-
gree of emergence delirium increased directly with the total
score
PAED scale
1. The child makes eye contact with the caregiver
2. The child’s actions are purposeful
3. The child is aware of his/her surroundings
4. The child is restless
5. The child is inconsolable
between these negative behaviours, most importantly pain
and ED, can be challenging. The Face, Legs, Activity, Cry,
Consolability (FLACC) scale and the Paediatr Anaesth Emergence
Delirium (PAED) scale have been applied in efforts to differenti-
ate between ED and pain in children 2–6 yr of age after ton-
silecctomy, adenoidectomy, or both. Inconsolability and
restlessness were not reliable enough to differentiate between
the two in the early postoperative period.7 Rather, the presence
of no eye contact, no purposeful action, and no awareness of sur-
roundings was found to correlate significantly with ED.
There are many scales that have been proposed to identify
ED. The limitations of most scales are that they have not been
psychometrically tested and that they follow emotional distress
and psychomotor agitation as surrogate markers of delirium.
The PAED scale, developed in 2004 for children >2 yr of age, has
been psychometrically evaluated and is used most commonly
(Table 1).8
This scale has limitations, which include the subjective nature
of some of the assessments, inter-rater variability, a high false-
positive rate, and qualifying behaviours that overlap with other
negative postoperative diagnosis (pain). The diagnosis of delirium
is a DSM (Diagnostic and Statistical Manual) IV and V condition;5 9
10
it is defined as disturbance in a child’s awareness of and atten-
tion to his/her environment with disorientation and perceptual al-
terations including hypersensitivity to stimuli and hyperactive
motor behaviour in the immediate postanaesthesia period.11
Implications of emergence delirium
Although those children who exhibit ED have episodes of short
duration, there are indications that there may be effects that
linger beyond the recovery period, In 1945, Levy12 noted that
some children exhibited postoperative behavioural problems
that had not existed beforehand. Eckenhoff,13 in 1953, noted a
correlation between unsatisfactory anaesthesia inductions and
the manifestation of negative postoperative behaviour. In 1966,
Vernon and colleagues14 published ‘Changes in children’s be-
haviour after hospitalization’, identifying anxiety (regression,
separation, sleep), eating disturbances, aggression, and apathy.
Although the effects of hospitalization, not necessarily inclu-
sive of surgery, have been described as early as the 1960s, the ef-
fect of ED on postoperative behaviour became of heightened
interest a decade ago. Children with ED were at 1.43 times
greater risk of having maladaptive behavioural change.15
Paediatric emergence delirium | 337
Table 2 Post Hospital Behaviour Questionnaire (PHBQ).14
Reproduced with permission.
PHBQ
Items
I: 4. Does your child need a pacifier?
5. Does your child seem to be afraid of leaving the house
with you?
6. Is your child uninterested i n what goes on around
him (or her)?
8. Does your child bite his (or her) finger nails?
12. Does your child seem to avoid or be afraid of new
things?
13. Does your child have difficulty making up his (or her)
mind?
22. Is your child irregular in his (or her) bowel
movements?
28. Does your child suck his (or her) fingers or thumbs?
II: 9. Does your child get upset when you leave him (or her)
alone for a few minutes?
17. Does your child seem to get upset when someone
mentions doctors or hospitals?
18. Does your child follow you everywhere around the
house?
19. Does your child spend time trying to get or hold your
attention?
21. Does your child have bad dreams at night or wake up
and cry?
III: 1. Does your child make a fuss about going to bed at night?
20. Is your child afraid of the dark?
23. Does your child have trouble getting to sleep at night?
IV: 2. Does your child make a fuss about eating?
Behavioural changes were assessed using the Post Hospital
Behaviour Questionnaire (PHBQ), created in the 1960s and still a
gold standard for posthospital behaviour assessment
(Table 2).14 An increased level of patient preoperative anxiety
has been associated with an increase in the incidence of ED and
up to 14 days of postoperative anxiety and sleep disturbances.16
Maladaptive behaviour at up to 1 week after surgery is un-
affected by choice of halothane vs sevoflurane.17
Major contributors to emergence delirium
In order to have a better understanding of emergence delirium,
it is important to be able to critically review the published litera-
ture and have a comprehensive understanding of those factors
that have been implicated as contributors to ED. A MEDLINE
search was queried from 1946 to October 1, 2016 for keywords
‘pediatric’, ‘paediatric’, ‘emergence delirium’, or ‘emergence agi-
tation’. All publications were reviewed and considered, with
emphasis on the past 10 yr, although commonly cited and rele-
vant older publications were included. Pertinent papers identi-
fied in the references of the searched articles were also
reviewed and included, if relevant. A detailed dissection of the
degree of association between the cited factors will be exam-
ined. Of interest, observations published >60 yr ago have at
their core still held true.13 As EA has often been and still is used
interchangeably in reference to ED, I will also use them inter-
changeably, citing EA or ED according to the mode of citation in
 338 | Mason
Table 3 Proposed contributors to emergence delirium
Proposed contributors to emergence delirium
Volatile anaesthetics
Type of surgery
Patient age
Parental anxiety
Patient anxiety
Patient pre-existing behaviour
Patient and parent interaction with health-care providers
the primary publication. The sections below review the import-
ant findings in the literature related to the proposed contribu-
tions to emergence delirium (Table 3).
Volatile anaesthetics
Although inhalation anaesthesia has been delivered to children
for >150 yr, it was not associated with EA until the 1960s, with
cyclopropane and ether.2 The first account of EA in the USA was
in 1996,18 19 1 yr after sevoflurane achieved US Food and Drug
Administration approval. In Japan, however, sevoflurane-related
agitation was reported as early as 1991, 1 yr after its introduction
in Japan.20 Isoflurane, halothane, sevoflurane, and desflurane
have all been recognized as contributors to ED and EA, with the
suggestion that sevoflurane has the greatest propensity.21–27
Surgery type
Eckenhoff and colleagues,2 in 1961, cited tonsil, thyroid, and cir-
cumcision surgeries as having a higher incidence of emergence
agitation. Forty years later, a higher incidence of EA is reported
after ophthalmology and otorhinolaryngology procedures.4
Age
In 1961, up to a 13% incidence of Eckenhoff’s ‘postanesthetic ex-
citement’ was reported in children age 3–9 yr, and 9% cited for
those 10–19 yr.2 A younger age has been associated with a
greater risk of preoperative anxiety28 and a higher incidence of
ED.8 A prospective cohort study described up to an 18% inci-
dence of EA in those 3–7 yr of age.4
Parental anxiety
Although a direct correlation between parental anxiety and ED
has not been examined specifically, a child’s increased pre-
operative anxiety level is correlated with an increased risk of
ED. A high level of parental anxiety and parents who are ‘high
monitors’ in the face of stress create a higher level of preopera-
tive anxiety in the child.28 ‘High monitors’ are generally
described as those who are highly sensitive to perceived threats
and who tend to amplify them. Extrapolating from the data, I
would suggest that decreasing parental anxiety and making ef-
forts to improve their coping approach in the pre-, peri- and
postoperative period could all be helpful strategies to decrease
anxiety and ultimately the incidence of ED.
Patient anxiety
Anxious children (5–12 yr old) who present for tonsilectomy and
adenoidectomy without preoperative anxiolytics are at elevated
risk (9.7% incidence) of developing ED compared with those
without anxiety (1.5% incidence).16 A child’s degree of preopera-
tive anxiety is correlated with their risk of exhibiting ED. A higher
score on the modified Yale Preoperative Anxiety Scale (mYPAS)
posed an increased risk of ED; specifically, for every additional
10-point increment, the risk of ED increased by 10%.15
Pre-existing behaviours
A child’s temperament, sociability, and cognitive skills are
related to his level of preoperative anxiety.28 As anxiety is a risk
factor for ED, those who exhibit certain behaviour and tempera-
ment will be at greater risk for preoperative anxiety.
Interactions with health-care providers
Careful examination of interactions between parents, their chil-
dren, and health-care providers, using real-time evaluation and a
five-point scoring system called the Perioperative Adult Child
Behavioural Interaction Scale (PACBIS), reveals that negative inter-
actions and coping are correlated with a higher incidence of EA.29
Likewise, negative behaviour on induction (2–12 yr) increases the
risk of ED and subsequent maladaptive behaviour (Fig. 2).30
Strategies to decrease emergence delirium
Having identified the possible contributors to ED, the challenge
lies in determining how to modify the perioperative experience
in order to decrease the incidence of ED. Strategies for improv-
ing outcomes range from non-pharmacological techniques,
such as behaviour management and distraction techniques, to
modification of the delivery of anaesthesia (choice of medica-
tions, techniques, and delivery methods). Each strategy will be
reviewed and evaluated (Table 4).
Behaviour management techniques to decrease
preoperative anxiolysis
Decreasing anxiety after surgery, regardless of technique (be-
havioural or pharmacological), has been shown in prospective
trials to have equal effects on decreasing ED in those 2–7 yr of
age. Specifically, parental presence at inhalation induction vs a
cartoon video or a combination of the two had equal effects on
decreasing anxiety on induction and equal effects on decreasing
ED.31 Watching cartoons, video goggles, or hand-held video
games have been shown to decrease anxiety in some patients
as effectively as those who received oral midazolam as pre-
medication.32–34 In some situations, pharmacological anxiolysis
may be preferable to a parent being present at induction.28
A family-centred approach, ADVANCE, aims at Anxiety re-
duction, Distraction on the day of surgery, Video modelling and
education before the day of the operation, Adding parents to the
child’s surgical experience, No excessive reassurance, Coaching
of parents by staff, and Exposure/shaping of the child via mask
practice. After a 30 min average time commitment of the health-
care staff via videotape, pamphlets, and a kit for practising mask
induction, the children exhibited less ED than those with mida-
zolam premedication or parent-present induction.35
Choice of volatile agent and depth of anaesthesia
Volatile agents have been implicated in EA and ED, although
there is no strong support, in this author’s opinion, for one vola-
tile agent rather than another. A meta-analysis in 2008 pre-
sented 23 studies (children 3 months to 12 yr old) and reported
 Paediatric emergence delirium | 339

Postoperative behavior changes

* = High anxiety
5 * = Low anxiety

4
*
3
*
2

POD# 1 POD# 2 POD# 3 POD# 7 POD# 14

Fig 2 The number of new-onset maladaptive behaviours throughout a 2 week postoperative period as exhibited by groups of children with high and low pre-
operative anxiety. *Statistical significance; P<0.05, reproduced with permission.36

propofol resulted in less EA vs sevoflurane in children <15 yr of

Table 4 Strategies to decrease emergence delirium age.40 This meta-analysis was limited in interpretation by mul-
tiple confounding factors [no standardized scoring system, the
Strategies to decrease emergence delirium administration of analgesics (narcotics and non-narcotics), re-
gional anaesthesia, adjuvant medications, and a range of surgi-
1. Behaviour management
2. Choice of volatile anaesthetic cal procedures]. Confounders also existed in the TIVA trial that
3. Choice of anaesthetic technique demonstrated less ED after a propofol–remifentanil anaesthetic
4. Choice of medications compared with a sevoflurane anaesthetic in healthy children
a. Benzodiazepine (2–6 yr) for strabismus surgery. Although the TIVA group ex-
b. Opioid hibited less ED, they also exhibited less pain.41 Propofol as a
c. a2-Agonist maintenance anaesthetic, however, has been shown to decrease
d. Gabapentin EA after sevoflurane inductions.42 43
e. Melatonin The time to emergence has been proposed as a contributor
f. Propofol to EA/ED. A prospective cohort study of 521 children aged 3–7 yr
g. Ketamine concluded that a shortened time to awakening (emergence) was
h. Magnesium
an independent risk factor for EA.4 This was corroborated in
5. Acupuncture
2004, with the development and introduction of the PAED scale.8
6. Regional anaesthesia
If a short emergence is a risk for EA, it has been suggested that a
7. pain control
delayed emergence may decrease EA. A prospective randomized
controlled trial of children (1–12 yr of age) undergoing magnetic
resonance imaging with a laryngeal mask airway with sevoflur-
ane, showed a decreased incidence of EA when sevoflurane was
more EA with sevoflurane (vs halothane), a finding similar to that transitioned to propofol 3 mg kg1 (via divided bolus) before
shown for non-painful procedures.22 25 A randomized controlled emergence. A slow washout with nitrous oxide after a sevoflur-
trial of children 2–8 yr of age demonstrated that depth of anaes- ane anaesthetic has also been shown to decrease EA.44 A con-
thesia (measured by bispectral index values) were not correlated founding report, however, showed no difference in EA when a
with the incidence of General anaesthesia (measured by the PAED standardized anaesthetic technique was used to compare
scale).37 Other studies have found no difference between sevoflur- abrupt with gradual sevoflurane emergence in children (1–7 yr)
ane and halothane.17 38 39 Rather, the administration of ketorolac after urological ambulatory procedures.45
or paracetamol can be effective in diminishing EA.26 38
Choice of medications
Choice of anesthetic technique-GA,TIVA, Induction/
Benzodiazepines
Emergence, Regional
The administration of benzodiazepines has largely been done in
Total i.v. anaesthesia (TIVA) vs a general anaesthetic with vola- the preoperative/pre-induction period in efforts to decrease
tile inhalation agent have been compared to determine whether anxiety. Midazolam is not an effective anxiolytic for all children.
there is a difference in the incidence of EA or ED. A meta- In a study of young children, 14.1% did not respond to oral mida-
analysis in 2014 compared 14 studies and demonstrated that zolam and instead displayed extreme distress.46 There are no
 340 | Mason
substantive data to suggest that midazolam, diazepam, or cloni-
dine decreases the incidence of ED associated with volatile
anaesthetics.23 37 47–49 50 A recent meta-analysis of 37 papers
with sevoflurane, desflurane, or both indicates that midazolam
has no preventative role.51
Although benzodiazepines may not decrease ED, their ability
to decrease preoperative anxiety and negative, maladaptive be-
haviours for up to 7 days warrants strong consideration of their
use, particularly in the at-risk patient.52
Choice of narcotic
Narcotics have not been definitively shown to decrease EA or
ED. Intraoperative fentanyl i.v. (2.5 lg kg1) did not decrease the
incidence of EA exhibited after desflurane or sevoflurane for
tonsillectomy, adendectomy, or both.27
a2-Agonists
Used in conjunction with volatile anaesthetics, a2-agonists, re-
gardless of when administered (pre- or intraoperative) have been
found to decrease the incidence and degree of EA and ED.51 As a
premedication, dexmedetomidine at 1 or 2 lg kg1 intranasally
decreased ED in a prospective, randomized, double-blind placebo-
controlled trial53 and may be superior to clonidine (4 lg kg1 intra-
nasal) in decreasing incidence and severity of EA.54
Dexmedetomidine i.v. (bolus, continuous infusion, or both)
has been shown to decrease the EA after a volatile anaes-
thetic.24 55–58 Dexmedetomidine infusions appear to be more ef-
fective than narcotic. A prospective, randomized trial
demonstrated that dexmedetomidine (2 lg kg1 i.v. bolus fol-
lowed by 0.7 lg kg1 h1) was more effective than a single dose
of fentanyl 1 lg kg1 i.v. in decreasing EA in children with ob-
structive sleep apnoea undergoing tonsillectomy or adenoidec-
tomy with sevoflurane.59 Intraoperative dexmedetomidine 0.3
lg kg1 i.v. may be more effective than propofol 1 mg kg1 i.v. in
decreasing EA after adenotonsillectomy with sevoflurane.60 In a
double-blind trial, intraoperative clonidine 2 lg kg1 i.v.
decreased the incidence and severity of EA in children who
received sevoflurane and a penile block for circumcision.61
Gabapentin
Gabapentin given as an oral premedication (15 mg kg1)
decreased the severity of EA in healthy children (3–12 yr) after a
sevoflurane anaesthetic for adenotonsillectomy.62
Melatonin
Preoperative oral administration of melatonin (0.2 or 0.4
mg kg1), despite it having no effect on preoperative anxiety,
has been shown to have greater benefits than midazolam
0.5 mg orally in decreasing incidence of emergence delirium. A
dose-dependent effect was found. The incidence of ED was
25.6% with midazolam and 8.3 and 5.4% with melatonin 0.2 and
0.4 mg kg1, respectively.63
Propofol
The perioperative administration of propofol i.v. has not been
definitively shown to be effective in decreasing ED after a vola-
tile anaesthetic.23 42 64 Although a recent meta-analysis demon-
strated that intraoperative propofol (1–3 mg kg1) decreased EA
in children, there were multiple confounders (midazolam, para-
cetamol, ketorolac, thiopental, morphine, fentanyl, sevoflurane,
desflurane, and painful and non-painful procedures)65 which, in
this author’s opinion, make the interpretation of the benefits of
intraoperative propofol inadmissible.
Ketamine
Premedication with ketamine 1 mg kg1 i.v. may decrease the inci-
dence of early EA (first 20 min) more effectively than midazolam
0.1 mg kg1 i.v.66 Premedication with ketamine (6 mg kg1 orally
30 min before induction) has also been effective in decreasing EA
from 56 to 18% after desflurane for adenotonsillectomy.67
Intraoperative ketamine (1 mg kg1 i.v. followed by a 1 mg kg1 h1
infusion) may be equally effective as dexmedetomidine (1 lg kg1
i.v. followed by 1 lg kg1 h1 infusion) in preventing EA after stra-
bismus surgery with sevoflurane.68
Magnesium
Magnesium sulphate may decrease the incidence and severity of
EA. A randomized, controlled, double-blind study concluded that
postinduction magnesium sulphate (30 mg kg1 i.v. followed by
10 mg kg1 h1) decreased the incidence and severity of EA after
sevoflurane for adenotonsillectomy. There was no difference in
pain scores between the magnesium and control group, suggest-
ing that the effect was attributed to the magnesium.69
Acupuncture
A prospective, randomized, double-blind controlled study dem-
onstrated that intraoperative electrical stimulation of the heart
7 acupuncture site in healthy children (1.5–8 yr) resulted in
decreased ED after a variety of ambulatory surgeries.70
Regional anaesthesia
Although regional anaesthesia may decrease pain and narcotic
requirement in the postoperative period, there is no definitive
evidence to suggest that, in combination with sevoflurane, it de-
creases EA/ED.38 71 The effect of caudal blocks on EA is con-
founded by their analgesic effect. A prospective randomized,
double-blind study of children (1–6 yr) showed that ilioinguinal/
iliohypogastric blocks did not decrease ED after a sevoflurane
anaesthetic, despite equal pain relief between those with and
without blocks.72
Minimize pain
It is important to ensure that there is adequate analgesia, as
pain behaviour can be misinterpreted as EA or ED (some of the
pain behaviours overlap with those behaviours that are identi-
fied using the PAED scale, for example).
Controlling for pain, there is a suggestion that fentanyl
can decrease EA. Using an up–down method with fentanyl
(1.25–4.2 lg kg1 i.v.) for adenoidectomy with desflurane, al-
though different doses conferred equal analgesia in recovery,
the dose of fentanyl 2.5 lg kg1 i.v. decreased EA.73
Thoughts for the future
Whether there are long-term or permanent effects of ED has yet
to be studied. Long-term effects beyond 14 days have not been
examined. To date, maladaptive behaviour up to 2 weeks after
surgery has been identified. Delirium in the intensive care unit
and postoperative delirium in the elderly, however, can have
more grave implications and consequences. Poorer outcomes,
increased health-care costs, and even cognitive dysfunction,
have all been attributed to delirium in these patient popula-
tions. In children, however, ED has not been carefully examined
for longer-term consequences. The patient’s pre-existing tem-
perament, anxiety, and coping behaviour are important factors
in predicting emergence delirium. The anaesthetic technique

and agents administered (or not administered) are also import-
ant contributors.
Only a few studies have used BIS to guide anaesthetic manage-
ment in the paediatric studies being examined for ED. In adults,
however, the depth of anaesthesia extrapolated from intraopera-
tive BIS and EEG in some instances, predicts not only postopera-
tive delirium, but also morbidity and mortality.74 Prospective,
randomized trials are needed to determine whether intraoperative
BIS levels affect ED and subsequent maladaptive behaviour.
Summary
We must carefully design large studies to evaluate the risk fac-
tors for ED prospectively, eliminating as many confounders as
possible. In order to compare outcomes between studies, or
even to share data between research groups, it is essential that
everyone uses the same tools. Standardized screening and
evaluation tools should be adopted by all researchers of paediat-
ric ED.75–77 Emergence delirium should be considered a ‘vital
sign’, which should be followed and documented on every child
in the postanaesthesia recovery period. Currently, ED assess-
ment is not being performed consistently. Even in the paediatric
intensive care unit setting, where >20% may have delirium,78 a
majority of children are still not being screened for delirium.79
Currently, the PAED scale is the most widely used and vali-
dated means of identifying delirium. It is important to recognize,
however, that the PAED assigns scores based on exhibited behav-
iour. An important consideration, however, is that even at base-
line not all children can make eye contact, have purposeful
actions, show an awareness of surroundings, or maintain calm be-
haviour (all behaviours which are assessed and scored by the
PAED). Specifically, infants and those with behavioural, neuro-
logical, or developmental challenges may always score high on
some or all the qualifiers. Particularly in the stressful pre- or
postoperative period, any child may exhibit behaviours that do
not reflect his usual behaviour. For this reason, a baseline, preop-
erative PAED score should be assessed and documented on every
child. This preoperative score may be useful to provide a compara-
tive reference point in the recovery room, specifically in efforts to
decrease risk of false positives, particularly in those children for
whom it may be difficult to distinguish between pain, a variant of
baseline behaviour, general agitation, and delirium.
This author asserts that by adopting the PAED as a pre- and
postoperative assessment tool, scores should be documented as
soon as the child arrives in the recovery unit, in conjunction
with the routine initial intake vital signs. Upon any change in
behavioural status (or after an intervention to alleviate pain or
delirium), the PAED score should be reassessed. The PAED score
must always be evaluated in relationship to the pain score, with
vigilant attention to those patients who are not able to express
pain verbally (infants or those neurologically, developmentally,
or behaviourally challenged). Differentiating between pain and
delirium can be challenging, and frequently delirium may be
mistaken for pain behaviour. Although there is not yet a gold
standard to differentiate between the two, as their behaviour
may overlap, careful observation should be able to differentiate
acute pain from emergence delirium. Emergence delirium tends
to be accompanied by failure to make eye contact and a lack of
awareness of surroundings. Acute pain behaviour tends to ex-
hibit abnormal facial expression, crying, and inconsolability.80
Differentiating between the two entities is crucially important
to guide treatment. There are currently no validated ‘gold-
standard’ interventions for postoperative ED, as there have
Paediatric emergence delirium | 341
been no trials that have specifically aimed at evaluating or com-
paring treatment options. Currently, the best approach to miti-
gating ED should be founded in its prevention, rather than in its
treatment. In the postanaesthesia care unit, if in doubt whether
the exhibited behaviour is ED or acute pain, treatment should
err by treating for pain in conjunction with, in this author’s
opinion, a single dose of an a2-adrenergic agonist. A PAED score
should be documented before discharge from the recovery
room, and patients should remain until the PAED score reaches
their preoperative baseline.
In order to further the understanding of ED in children, it is
crucial that prospective studies of large enrolment are per-
formed, collecting data that are standardized with respect to
terminology and identification.77 Standardized data collection
will enable us to compare results across all spectra. Once we
agree on a unified approach to data identification and collec-
tion, we will then be better equipped to identify risk factors, pre-
ventative and therapeutic treatment outcomes, and to follow
both short- and long-term outcomes from ED.
Declaration of interest
None declared.
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Handling editor: Jonathan Hardman