Behavioral changes after hospital discharge in preschool children experiencing emergence delirium after general anesthesia: A prospective observational study.

The study looks specifically at whether the experience of emergence agitation after anaesthesia in small children will lead to deteriorating behaviour a week post-operatively. This is a fraught area: we know post-operative behavioural regression is a real phenomenon, but ascertaining which factors in the peri-operative journey contribute can be complex. Pre-existing anxiety, pain, prolonged admissions and a departure from usual routines will all factor into a child experiencing behavioural regression after surgery.

The numbers in the study are small – 100 children, ages 2-7 were recruited, with only 73 being included in the final analysis. Inclusion involves a parent completing a child behaviour checklist (CBCL) pre-operatively, and then repeating this same checklist a week post surgery. Children also had a pre-op anxiety score collected (mYPAS score), as well as an emergence delirium score (PAED) and a pain score (FLACC). Of note, 58% were recorded as having emergence delirium, a relatively high proportion, which was attributed to a high representation of children undergoing ophthalmological and ENT surgery.

Regression analysis of the data found that the non-emergence delirium group had lower rates of behavioural disturbance post-op than those who had emergence delirium. As one might expect, pre-operative anxiety and emergence delirium were related.

Comments/Take Home Message

In this study, the children routinely had an IV line inserted pre-operatively, and many of them had an IV midazolam or ketamine pre-medication (they do not say how many had pre-medication) followed by sevoflurane anaesthesia. For those anaesthetists who practice high volumes of propofol-based anaesthesia, these findings may not be applicable to their practice.  Furthermore, the low numbers in this study make it impossible to determine whether pre-medication had any effect at mitigating any pre-operative anxiety.

The findings of this study become relevant if we can now determine meaningful ways in which to reduce emergence delirium in our local institutions. Perhaps identifying those children who are particularly anxious pre-operatively and intervening at this stage would be helpful. The study used a somewhat cumbersome assessment of anxiety which would not be practical in most busy hospitals. There may be a role for shorter and simpler scales to identify and treat at-risk children and their families.

Overall, the results of this study may not be surprising, but they are a reminder that hospital encounters can be stressful. Exactly what methods we may use to lessen the risk of post-operative behavioural disturbance remains an area in need of further examination.

Reviewed by Amanda Dalton