Pediatric Anesthesia 2010 20: 704–711 doi:10.1111/j.1460-9592.2010.03328.

A comparison of emergence delirium scales

following general anesthesia in children
S A M I R A A . B A J W A F R C A , D A V ID C O S T I F A N Z C A A N D
ALLAN M. CYNA DRCOG, DIP.CLIN.HYP, FRCA
Department of Paediatric Anaesthesia, Women’s and Children’s Hospital, Adelaide, SA,
Australia

Section Editor: Dr Jerrold Lerman

Summary
Background: Emergence delirium (ED) is of increasing interest since
the introduction of short-acting volatiles such as sevoflurane.
Methods: We compared the Pediatric Anesthesia Emergence
Delirium (PAED), Watcha and Cravero scales for assessing the
presence of ED in 117 of 118 consecutive children <18 years
recovering from general anesthesia. The primary measure was the
worst score for ED as assessed on each scale and for each patient
during their PACU stay. An experienced anesthetist observer also
made a subjective assessment of the presence of ED.
Results: A PAED score of ‡10 detected ED in 37 children (32%), while
the Watcha detected 30 (26%) and Cravero 41 (35%). Twenty-five
patients (21%) fulfilled criteria for ED in all three scales as did all eight
patients assessed by the experienced pediatric anesthetist observer.
Median PAED scores (interquartile ranges) for patients assessed as
having ED or not respectively were for Watcha, 12 (11,14), 7 (4,8); for
Cravero, 11 (9,13), 7 (4,8); and for the experienced anesthetist observer,
14.5 (13.5,16.5), 7 (6,10).
Conclusions: All three scales correlated reasonably well with each
other but have individual limitations in their potential to assess
whether ED is present. In the absence of developing an improved
research tool to assess ED, a PAED score >12 appears to provide
greater sensitivity and specificity than a PAED score ‡10. However,
the Watcha scale is a simpler tool to use in clinical practice and
may have a higher overall sensitivity and specificity than the other
scales.

Keywords: emergence delirium; general anesthesia; sevoflurane;

children

Correspondence to: Dr Allan M Cyna, Consultant Anaesthetist, Department of Paediatric Anaesthesia, Women’s and Children’s Hospital, 72
King William Road, Adelaide, SA 5006, Australia (email allan.cyna@health.sa.gov.au).

704  2010 Blackwell Publishing Ltd

 COMPARISON OF EMERGENCE DELIRIUM SCALES
Introduction
Emergence delirium (ED) is a topic of increasing
interest since the introduction of the newer short-
acting volatiles such as sevoflurane and desflurane
(1–3). Behavioral changes following general anes-
thesia in children have been described in the
literature using a variety of descriptive terms. These
include ED, emergence agitation (EA) postanesthetic
excitation and postoperative delirium (1). ED is
probably the most frequently used term to describe
these postanesthetic behavioral changes. Unfor-
tunately, there is currently no consensus regarding
a clear definition (3). One definition of ED describes
it as: ‘a mental disturbance during the recovery from
general anesthesia consisting of; hallucinations,
delusions and confusion manifested by moaning,
restlessness, involuntary physical activity, and
thrashing about in the bed’ (4). This short-lived
behavioral disturbance may cause distress to both,
the child, parents and staff looking after the patient,
and lead to dissatisfaction with the anesthetic. In
addition, this behavior can dislodge cannulae, dress-
ings, drains and catheters. Rates of ED vary in the
literature from 10% to 80% depending on the
definition and scale used to measure it (3). There
are several scales and their variants that are reported
to measure ED (3,5). These are usually three, four or
five category scales, visual analog scales or the
Pediatric Anesthesia Emergence Delirium (PAED)
scale (5). The PAED scale and a four-point scale
described by Watcha (6) and minor variants of it (7)
are the most commonly used scales to assess ED.
Since its description in 2004, the PAED scale has
been used in at least nine studies (8–16). The Watcha
scale (6,17–21) and its variants (7,8,22–26) have been
used in at least 13 studies. Cravero has also
described a five-point scale to assess ED (27). If
one was to design a study to investigate the presence
or absence of ED, it would be unclear how to use the
PAED scale as it fails to provide clear guidance as to
the optimal score where ED is likely to be present.
The authors of the PAED scale do provide sensitivity
and specificity data for a score ‡10 but suggest that
‘further attempts to determine a cut off point are
needed’ (5). There is only limited research compar-
ing different scales for assessing the presence of ED
(8). We therefore aimed to observe a cohort of
children recovering from general anesthesia and
 2010 Blackwell Publishing Ltd, Pediatric Anesthesia, 20, 704–711
705
compare three measures of ED with each other and
with the assessment of an experienced pediatric
anesthetist observer.
Methods
Following Local Regional Ethics Committee
approval, we prospectively studied 118 children in
our PACU during their recovery from general
anesthesia. All premedicated and unpremedicated
patients up to the age of 18 years were included in
this study, irrespective of whether anesthesia was
required for surgery or a radiological examination.
The study was conducted on a consecutive cohort of
patients in February 2009, who were recovering from
anesthesia at the main theater suite’s PACU of the
largest tertiary referral center for pediatric surgery in
South Australia. Oral paracetamol, 20 mgÆkg)1, is
administered routinely prior to surgery as part of
our analgesic protocol unless having a radiological
procedure or an upper gastro-intestinal (GI) endos-
copy. All the children included in our study were
recovered as per usual practice in our institution and
as is our routine, no parent attended their child in
the PACU except when required to console a child in
extreme distress.
All children were observed by one researcher who
was an experienced pediatric anesthetist (SAB) who
had no previous experience of the scales being
studied. The observations were recorded at three
time points: on initial arrival of the patient in the
PACU, the worst score over the initial 10 min
and the worst score over the subsequent 10 min.
Tables 1–3 show the three different scales used: the
20-point PAED scale (5), Watcha’s four-point scale
(6) and Cravero’s five-point EA scale (27).
The PAED scale is shown in Table 1 and has five
items scored from 0 to 4 (with reverse scoring where
applicable). The scores are summed to obtain a total
score with a range of 0–20. We elected to use a cutoff
of ‡10 on the PAED scale to describe ED as this was
the only level where sensitivity data were reported
by Sikich and Lerman (5). The Watcha Scale is a
four-point scale as shown in Table 2 and defines ED
at a level of 3 or 4 at any time (6). The Cravero Scale
shown in Table 3 is a five-point scale (27). The
definition for ED in this scale was reached if level 4
or 5 was evident and present for at least 3 min.
Bearing in mind a previously reported description of
7 06 S.A. BAJWA ET AL.

Table 1
Not at Just a Quite a Very The Pediatric Anesthesia Emer-
Point Description all little bit much Extremely gence Delirium scale
1 The child makes eye contact with the caregiver 4 3 2 1 0
2 The child’s actions are purposeful 4 3 2 1 0
3 The child is aware of his ⁄ her surroundings 4 3 2 1 0
4 The child is restless 0 1 2 3 4
5 The child is inconsolable 0 1 2 3 4

Table 2
patient during their PACU stay. Spearman’s corre-
Watcha behavior scale for emergence delirium lations were calculated using maximum (worse)
scores for each of the scales over the three time
Level Description
points.
1 Calm
2 Crying, but can be consoled
3 Crying, cannot be consoled Results
4 Agitated and thrashing around
One patient was excluded from the analyses as
observational data had inadvertently been omitted
Table 3 from the data collection form. This left 117 of the 118
Cravero emergence agitation scale consecutive patients (99.2%) who completed the
Level Description
study. Paracetamol was given to all our study
patients except for 11 having nonoperative proce-
1 Obtunded with no response to stimulation dures or an upper GI endoscopy. One hundred and
2 Asleep but responsive to movement or stimulation
3 Awake and responsive eleven children (94.8%) were extubated while
4 Crying (for >3 min) deeply anesthetized and hence arrived asleep in
5 Thrashing behavior that requires restraint recovery.
Baseline demographics are shown in Table 4.
Table 5 shows our rates of ED as measured by the
the phenomenon of ED (4), the observer anesthetist
different scales. Figure 1 shows a diagrammatic
also made a subjective assessment, whether in her
representation of the number of patients assessed
experienced opinion, the patient had ED at any time
as having ED using each of the three scales. Table 6
during the PACU stay. At no point did the observer
shows sensitivity and specificity data according to
intervene or suggest treatment for ED. The order of
whether the PAED scale ‡10, Cravero scale or
documenting the scale items was PAED, Watcha and
then Cravero scales for each child. Data were Table 4
collected regarding the age, weight, gender of the Demographic data of children and their perioperative medication.
patient, premedication, nature of surgery and intra- Data presented as numbers of children (%) unless otherwise
stated
operative anesthesia and analgesia used. Parental
presence at the time of induction and any require- Demographics N = 117
ments for postoperative analgesia were also noted. Age in years, mean (SD) 5.6 (4.6)
The data were recorded in the PACU prospec- Weight in kg, mean (SD) 26.4 (19.6)
tively using a standardized data collection form Male ⁄ female 74 (63) ⁄ 43 (36)
Premedication with midazolam 8 (7)
without calculating any scores. Only after the com- Parental presence at induction 108 (92)
pletion of the data collection phase were the data No intraoperative analgesia 35 (30)
subsequently transcribed on to a Microsoft ExcelTM Intraoperative opioids 76 (65)
Intraoperative tramadol 19 (16)
spreadsheet for analyses. Descriptive statistics is
Tropisetron 70 (60)
reported together with sensitivity and specificity of Postoperative analgesia in PACU 8 (7)
the various ED scales with 95% confidence intervals i.e., fentanyl ⁄ morphine fentanyl = 3,
(CI). We took as our primary measure the worst morphine = 5
No surgery 11 (9)
score for ED as assessed on each scale and for each

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 COMPARISON OF EMERGENCE DELIRIUM SCALES 707

Table 5 addition, at this PAED score, the sensitivity of the

Numbers of patients (%) as measured by the PAEDS, Cravero and
Watcha scale increased to 0.93 and the specificity
Watcha scales
was 0.84. Table 7 shows the scores using PAED,
Numbers of patients Watcha and Cravero scales in the eight children
Scale used with emergence delirium (%)
subjectively assessed by the experienced observer
PAED ‡10 37 (32) anesthetist as having ED. Table 8 shows median
PAED >12 14 (12) PAED scores for patients assessed as having ED or
Cravero >3 41 (35)
Watcha >2 30 (26) not according to the Watcha scale, the Cravero scale
Experienced Observer 8 (7) and the experienced anesthetist. Figure 2 shows the
percentage and numbers of patients scoring positive
PAED, Pediatric Anesthesia Emergence Delirium.
for ED on the Watcha and Cravero scales according
to their score on the PAED scale. Spearman’s
correlation for PAED scale and the Watcha scale
was 0.67 (P < 0.001), and the correlation for PAED
and Cravero scales was 0.51 (P < 0.001). Figure 3
and Table 9 show ROC data for the observer and
PAED scale.

Figure 1
Diagrammatic representation of the number of patients diagnosed
with emergence delirium in each of the three scale: Cravero;
Watcha; and PAED > 10.
Watcha scale is designated the Gold Standard.
However, our experienced observer had optimal
sensitivity (100%) and specificity (94.5%) when a
PAED score >12 was used to determine ED. In
Discussion
This is the first study to compare three scales for
assessing ED in children recovering from general
anesthesia in the PACU. The key finding of our
study is that all three scales correlate reasonably well
with each other but have individual limitations in
their potential to assess whether ED is present or
not. Interestingly, all eight patients assessed by the
experienced pediatric anesthetist observer as having
ED scored highly on the PAED, Cravero and Watcha
scales as seen in Tables 7 and 8. This suggests that it
is highly likely that if a patient is assessed as having
ED by an experienced observer, they will also score
highly in all three of the scales assessed in this study.
It should be noted that none of the scales are
specifically advocated for routine clinical use.
It appears from our study’s findings, of the
different sensitivity and specificity data of the three
scales, that the PAED score of ‡10 may be set too low

Table 6
Sensitivity and specificity data according to whether PAEDS, Cravero or Watcha are designated the Gold Standard 95% confidence
intervals are shown in parentheses

PAED ‡10 as the gold standard Cravero as the gold standard Watcha as the gold standard

Scales Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity

PAED 1 1 0.68 (0.53–0.80) 0.88 (0.79–0.94) 0.87 (0.70–0.95) 0.87 (0.79–0.93)

Cravero 0.76 (0.60–0.87) 0.84 (0.74–0.91) 1 1 0.93 (0.79–0.98) 0.85 (0.76–0.91)
Watcha 0.70 (0.54–0.83) 0.95 (0.88–0.98) 0.68 (0.53–0.80) 0.97 (0.91–0.99) 1 1

PAED, Pediatric Anesthesia Emergence Delirium.

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7 08 S.A. BAJWA ET AL.

Table 7
The eight children subjectively assessed by the experienced
observer anesthetist as having emergence delirium (ED) in the
PACU and their worst individual scores using Pediatric Anesthe-
sia Emergence Delirium (PAED), Watcha and Cravero scales

Individual Patients Worst score Worst score on Worst score on

with assessor ED on PAED scale Cravero scale Watcha scale

P1 17 4 3
P2 13 4 4
P3 18 5 4
P4 13 5 4
P5 14 4 3
P6 15 4 3
P7 16 4 3
P8 14 5 3

Figure 3
ROC curve for observer assessment and PAED scale.
Table 8
Median PAED scores (interquartile ranges) for patients assessed
as having emergence delirium (ED) present or absent according to
Table 9
the Watcha, Cravero scales and the experienced anesthetist
Detailed report of KOC curve sensitivity and specificity data
ED absent ED present
Cutpoint Sensitivity (%) Specificity (%)
Watcha 7 (4,8) 12 (11,14)
(‡0) 100 0
Cravero 7 (4,8) 11 (9,13)
(‡1) 100 8
Experienced Anesthetist 7 (6,10) 14.5 (13.5, 16.5)
(‡2) 100 9
PAED, Pediatric Anesthesia Emergence Delirium. (‡3) 100 11
(‡4) 100 15
(‡5) 100 20
(‡6) 100 23
(‡7) 100 34
(‡8) 100 52
(‡9) 100 67
(‡10) 100 73
(‡11) 100 79
(‡12) 100 88
(‡13) 100 95
(‡14) 75 97
(‡15) 50 97
(‡16) 37 98
(‡17) 25 99
(‡18) 13 99
Figure 2
(‡19) 0 99
Numbers of patients and percentage with emergence delirium, as
(>19) 0 100
assessed by CRAVERO (m) and WATCHA (n), at each score on
the PAED scale.

agitation. In addition, agitation may indicate any

to reliably detect ED. This threshold gave an ED rate
of just over 30% while approximately 20% of
patients fulfilled criteria for ED in all three scales.
The fact that the experienced pediatric anesthetist
assessed only 7% of patients as having ED suggests
the possibility that ED was not being detected by the
observer and ⁄ or the ED scales were providing false
positive assessments in some patients.
Some authors suggest that delirium may be
confused with agitation but may also be a cause of
number of sources such as pain, physiological
compromise or anxiety (3). One might argue that
the experienced observer assessments are subjective
and that the scales we have studied are objective
measures. However, it appears that the assessment
of ED involves a multiplicity of observations and
considerations that are inadequately incorporated in
the scales and their equivalents that were used in
this study. This difficulty has been implied by other
researchers where they have simultaneously used

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 COMPARISON OF EMERGENCE DELIRIUM SCALES
more than one scale in recent studies investigating
ED (8,14). We suspect that the apparent low inci-
dence of ED detected by the experienced anesthetist
observer is due in part to the fact that delirium is an
additional source of agitation that was able to be
separated from other causes such as pain, anxiety or
parental separation. This would explain the discrep-
ancy between the observer and the scales used in
this study, with regard to their differing specificity
and sensitivity data and incidence of ED.
The authors of the PAED scale have not defined a
score at which the patient could be considered as
having ED. Our data show the threshold value on
the PAED scale at which patients were assessed as
being positive for ED on the Cravero and Watcha
scales is for some patients lower than 10 (See
Figure 2). Our study findings show that at a PAED
score >5, we began getting positive measures of ED
according to both the Cravero and Watcha scales.
This suggests that either these patients were false
positive assessments of ED by the Watcha or
Cravero scales or the PAED scale was providing a
false negative assessment of ED. The original article
of the PAED scale provided sensitivity and specific-
ity data for a level of only ‡10. If we consider a
PAED scale of ‡10 as the gold standard for the
purpose of determining whether ED is present or
not, we show both Watcha and Cravero correlate
reasonably well although Cravero has a higher
sensitivity but lower specificity than the Watcha.
Nearly 10% of patients who scored highly on the
Cravero scale did not rate highly on the two other
scales. This could be because of item 4 (crying for
>3 min) on the Cravero scale being a relatively
nonspecific symptom of ED and could equally occur
in other causes of distress such as pain, hunger or
parental separation. Cravero gives different defini-
tions of EA in each of his three articles; in the first, he
describes a high-threshold definition for EA requir-
ing level 5 agitation (thrashing behavior that
requires restraint) for greater than 3 min and a
low-threshold definition for EA (which is the one we
used – ‘crying for at least 3 min’) (27), then only the
high threshold was used in a subsequent article (28).
In the 2003 article, the time criteria of the low-
threshold definition was changed to: ‘5 min despite
all calming efforts….’ (29).
The authors of the PAED scale have described in
the development and its evaluation, a sensitivity of
 2010 Blackwell Publishing Ltd, Pediatric Anesthesia, 20, 704–711
709
0.64 and a specificity of 0.86 with a PAED score of
‡10. Aouad et al. (8) simultaneously measured and
correlated the PAED scale with dichotomous out-
comes of ED as per a four-point scale very similar to
the Watcha scale (6). The authors describe a thresh-
old value of greater than 10 (i.e., one point higher on
the PAED scale) as the best discriminator between
the presence and absence of EA (8). Other workers
have used a quite different threshold score of the
PAED scale ‡16 to describe ED (10,11,13). However,
the rationale for this threshold is unclear. The PAED
scale is reported to have the advantage of being
validated and better reflects the presence of ED
rather than pain. Our experience suggests that it is
cumbersome to use in a busy clinical setting. In
addition, there is controversy at what threshold level
it reliably assesses the presence of ED. The Cravero
scale has the advantage of simplicity and also has a
‘sleep’ item (27). One could argue this is not
necessary in an assessment of agitation or delirium
that would only be diagnosed on emergence from
anesthesia. The main disadvantage of the Cravero
scale is that the authors have subsequently changed
the definition of the items used (28,29). The Watcha
scale has a higher correlation than Cravero with
respect to the PAED scale. A PAED score >12 and
the Watcha scale have maximal sensitivity and high
specificity in detecting ED. In terms of sensitivity
and specificity of each of these scales, they are
completely dependent on the endpoint chosen for
ED. We believe it is important to be reasonably sure
that when ED is detected this is a true finding.
False positives for ED may lead to under-treating
the cause. Difficulties with setting a cutoff for the
presence or absence of ED may be because the
condition is a behavioral spectrum that is best
represented using a graded score rather than a
dichotomous outcome.
There were several limitations of our study. First,
all the observations were made by a single observer.
It would have been preferable to confirm each
patient’s score when assessed for ED by having had
two experienced clinicians making the recordings to
confirm interobserver reliability. However, observer
bias was minimized as the experienced pediatric
anesthetist had no preference or additional experi-
ence with any particular scale. Videoing the emer-
gence of children in the PACU and then
independently scoring ED after the event using
7 10 S.A. BAJWA ET AL.
multiple independent assessors would allow for
repeated measures and an assessment of inter-
assessor variability. However, it has yet to be
determined whether video assessments are
comparable to ‘live’ assessments. Limited staffing
levels, time and funding constraints meant that the
only practical methodology at the time was to use a
single observer. The second possible limitation was
that the observer documented the scale items in the
same order making ‘criterion’ bias a possibility.
However, like other researchers (16), our observer
completely disregarded any evaluation of ED when
scoring the three scales. Criterion bias was mitigated
by the fact that the PACU raw scores for each of the
five items of the PAED scale were recorded and the
final PAED score was not calculated until after the
completion of the study. Thirdly, another source of
potential bias was that our observer also calculated
the scores. However, the effects of this were mini-
mized as our observer had no preference for any
particular score, and the scores were only generated
after the data collection phase was completed.
Another possible limitation was that we included
all age ranges below 18 years. Previous studies have
tended to measure ED in the age range from
6 months to 10 years as this age range is thought to
be the most frequently affected by ED. In our study,
all patients aged <18 were included. This may have
affected external validity, although this is unlikely as
only one patient was <6 months with only a further
20 children aged 11 years and upwards (17%).
Implications for practice
Subjective assessment of ED is highly likely to score
positive on all three scales. Although all three scales
have their limitations, they appear to be reasonably
reliable in detecting ED in clinical practice. The
Watcha scale and the PAED scale when >12 give the
highest sensitivity in detecting ED. However, no
scale appears to match the discriminating ability of
an experienced observer. In practice, the scales may
be of value in assessing ED when an experienced
observer or clinician is unavailable.
Implications for research
It would be useful to determine whether inexperi-
enced observers would assess ED in the same way as
an experienced observer. Multiple observers (with
videotapes) or observers who do not complete more
than one scale per child or the observers do not
know the threshold for diagnosing delirium with
each scale or all of the above could all serve to
reduce bias in future research on this topic. Future
studies could investigate whether preanesthetic agi-
tation, lack of cooperation or behavior disturbance at
induction predicted ED postoperatively. More
research is still required to determine the optimal
threshold of the existing scales, the items to include
in a scale and the duration of measurement that will
allow the detection of ED in clinical practice with a
high sensitivity and high specificity.
In summary, we have found that despite their
limitations all three scales correlate to some degree
but all have some advantages and disadvantages
over each other. The Watcha scale in its current form
has the higher overall sensitivity and specificity. In
the absence of developing an improved research tool
to assess ED, a PAED score >12 appears to provide
greater sensitivity with only a small fall in specificity
than a score ‡10. The PAED scale is currently the
most widely used scale in the assessment of ED and
appears primarily to be a useful research tool. The
Watcha scale appears to be a practical tool to use and
assess ED in the PACU.
Acknowledgements
The authors thank Kate Dowling and Peter Baghurst
for statistical advice.
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Accepted 26 March 2010