Hypnotic depth and the incidence of emergence agitation and negative postoperative behavioral changes

Abstract

Background Emergence agitation (EA) and negative postoperative behavioral changes (NPOBC) are common in children, though the etiology remains unclear. We investigated whether longer times under deep hypnosis as measured by Bispectral Index™ (BIS) monitoring would positively correlate with a greater incidence of EA in the post anesthesia care unit (PACU) and a greater occurrence of NPOBC in children after discharge. Methods We enrolled 400 children, ages 1–12 years old, scheduled for dental procedures under general anesthesia. All children were induced with high concentration sevoflurane and BIS monitoring was continuous from induction through recovery in the PACU. A BIS reading <45 was considered deep hypnosis. The presence of EA was assessed in the PACU using the Pediatric Anesthesia Emergence Delirium Scale (PAED). NPOBC were assessed using the Post-Hospital Behavior Questionnaire (PHBQ), completed by parents 3–5 days post-operatively. Data were analyzed using logistic regression, with a p<0.05 considered statistically significant. Results The incidence of EA was 27% (99/369) and the incidence of NPOBC was 8.8% (28/318). No significant differences in the incidence of EA or NPOBC were seen with respect to length of time under deep hypnosis as measured by a BIS value of less than 45. Conclusion Our data revealed no significant correlation between the length of time under deep hypnosis (BIS<45) and the incidence of EA or NPOBC. Within this population, these behavioral disturbances do not appear to be related to the length of time under a deep hypnotic state as measured by the BIS.

Identifying Pediatric Emergence Delirium by Using the PAED Scale: A Quality Improvement Project

“…12 The PAED Scale consists of five characteristics that are each scored by using a 5-point Likert scale. 6,7,9,20 Therefore, we chose to implement the PAED Scale to provide a more clearly defined set of criteria for identification of pediatric emergence delirium at our facility. Two items, "the child makes eye contact with the caregiver" and "the child is aware of his [or] her surroundings," respectively, are reflections of the child's state of consciousness and ability to focus attention and to thoughtfully organize external stimuli.…”

“…[2][3][4][5][6][7][8][9] Children who experience emergence delirium postoperatively are at risk for unintentional self-injury, including removal of catheters and drains as well as wound dehiscence. 1(p19) Although emergence delirium occurs in patients of all ages, it appears to occur three to eight times more frequently in the pediatric population.…”

“…[2][3][4][5][6][7][8][9] Children who experience emergence delirium postoperatively are at risk for unintentional self-injury, including removal of catheters and drains as well as wound dehiscence. 9 Pediatric emergence delirium also can place the RN at risk for injury if he or she tries to restrain the child to keep the child from hurting himself or herself. 11 A recent study showed that 49% of children who developed emergence delirium required extra PACU personnel to care for them compared with only 15% of children not experiencing emergence delirium.…”

“…1(p19) Although emergence delirium occurs in patients of all ages, it appears to occur three to eight times more frequently in the pediatric population. [2][3][4][5][6][7][8][9] Children who experience emergence delirium postoperatively are at risk for unintentional self-injury, including removal of catheters and drains as well as wound dehiscence. 10 Additionally, management of pediatric emergence delirium requires extra attention from nursing personnel, placing undue strain on nurseto-patient ratios and resource allocation in the postanesthesia care unit (PACU).…”

Are postoperative behavioural changes after adenotonsillectomy in children influenced by the type of anaesthesia?

“…15,25 Different authors use different NPOBC cut-off points and the resulting NPOBC incidences vary. 25,34,41 Probably, additional validation and improvement of the original PHBQ is needed. Finally, the original version with 27 questions is not suitable for everyday clinical use.…”