Emergence Delirium in Children Receiving Sevoflurane in Postoperative

This article discusses the effects of inhalational sevoflurane anaesthesia (SEVO) in comparison to total intravenous anaesthesia (TIVA) with propofol and remifentanil upon the emergence delirium (ED) in children. The study concluded that the occurrence of ED among the children after employing TIVA is less in comparison to SEVO. The paper also discusses the physiological implications, management and introduction towards change of practice, legal and ethical considerations.

0Running head: EMERGENCE DELIRIUM IN CHILDREN
Emergence agitation and delirium in children receiving Sevoflurane in postoperative
Name of the Student
Name of University
Author’s note

1
EMERGENCE DELIRIUM IN CHILDREN
Rationale
One of the common phenomenon in surgical care settings is emergence delirium (ED)
(Shaw and DeMaso 2010). This phenomenon is high among the children (Anderson 2015). The
clinical manifestation of ED includes altered orientation, violent behaviour, lethargy and at times
confusion (Shaw and DeMaso 2020). According to Lerman(2009), ED is mostly associated with
the decision making process of anaesthetic and the medium used for anaesthesia and this in turn
increases the overall time of the therapy. Most commonly used process referred for general
anaesthesia includes Inhalational anaesthesia (IA) and Total Intravenous Anaesthesia (TIVA)
(Aoud and Nasr 2005).
The importance of the proper anaesthetic therapy in paediatric care is extremely
important for the health and well-being of the children. According to Kain et al. (2004), ED is
associated with several complications among the children. This kind of behaviour predisposes
children to lasting memory impairment along with maladaptive behaviour development (Kain et
al. 2004)). All inhalational anaesthetic therapy is associated with the development of ED and
among them high rate of occurrence is noted with sevoflurane (Vlajkovic and Sindjelic 2007).
This assignment aims to provide a detailed insight in the effects of inhalational
sevoflurane anaesthesia (SEVO) in comparison to total intravenous anaesthesia (TIVA) with
propofol and remifentanil upon the ED in children. This will lead to a e improvement of the
paediatric surgery outcome via nullifying the ill-effects of ED.
Search strategy
A literature review was conducted based on the relevant articles that were selected
electronically from PubMed database. The main keywords which were used for the search

2
EMERGENCE DELIRIUM IN CHILDREN
include paediatric anaesthesia OR pediatricanestheisa AND inhalational anestheisa AND total
intravenous anestheisa OR propofol AND sevoflurane AND emergence agitation OR emergence
delirium AND pain AND recovery AND child OR children AND pain. Only the studies which
are designed over the human placebo (children) in the last 10 years were selected for this study.
Inclusion criteria Exclusion criteria
Children above the age of 2 years and below the
age of 6 years
Studies carried on the children with neurological
injury, developmental delay and psychiatric
problems
General anaesthesia
Critique of research
Chandler et al. (2013) carried a randomised controlled double-blinded trial (RCT)
centring 112 children in order to tally the occurrenceof ED among the children after the
propofol-remifentanil TIVA and SEVO. However, 17 were later excluded from the study for
further analysis and this made the total number 94 at the end of the study. The importance of the
study lies in the fact that it is done via taking the research framework of RCT and according to
Parahoo (2014).
Suresh and Chandrashekara (2012) opined that determination of the optimal sample size
is crucial for the study because it helps in the determination of the significance of the statistical
analysis. In this study, conducted by Chandler et al. (2013) power calculation is used based on
the previous study conducted by Abu-Shahwan (2008). In this ground, Parahoo have stated that
determination of the sample size according to the power computation will help in the

3
EMERGENCE DELIRIUM IN CHILDREN
enhancement of the external accuracy of the experiment while giving it universality. It was
elucidated that in order to ascertain an average of 50% of reduction in incidence of ED (alpha:
0.05 and beta: 0.8), 95 total subjects were required to be studied per arm. This provided a chance
of 95% of significantly elucidating an intervention after effect if it exists within a minimum
probability of type II error, as stated by Salkind in the year 2014. In this study a P-value of
<0.025 was considered to be significant. However, at the end of the study, the total number of
participants accounted to 94 and he same data is elaborated in the table format.
In the grounds of inclusion and exclusion criteria, Chandler et al. (2013) has clearly
stated their preference. According to Rees (2011), the criteria for inclusion and exclusion must
be thoroughly stated. Greenhalgh (2014) further argued that determination of this guidelines help
in the enhancement of external accuracy and universality and thereby decreasing he prejudice
within the study. The study carried by Chandler et al. (2013) selected an inclusion criteria of <=
2 and >=6 years for the incorporation of the children into the focused group. Children who are
suffering from developmental delays, injury of nerves, diagnosed with psychosis, have abnormal
high blood concentration of lipid or carbohydrate or abnormal metabolism were excluded from
the study.
The paper published by Chandler et al. (2013) has conducted several steps in order to
limit the bias. This assistant was otherwise not the part of the central study. The randomised was
done via computerised random numbers in order to sub-divide the participants into two seperate
groups (TIVA = 57 and SEVO group = 57).
According to Rees (2011), the process of data collection must be the preliminaryfocus of
the study because based on this, the results are interpreted. For proper data collection, accurate

4
EMERGENCE DELIRIUM IN CHILDREN
study tools are required to be selected and need to be simultaneously justified by the examiners
(Moule 2015). Chandler et al (2013) employed numerous scales of observation and scoring was
done perioperatively. Employing perioperative child behaviour interaction scale (PACBIS), a
researcherrecorded the pre-induction behaviour of the children and their parents during 60s of
initial induction. The Pediatric Anaesthesia Emergence Delirium Scale was employed to measure
the principal outcome of the ED variable. Moreover, the FLACC scale (Face,Legs, Activity, Cry,
Consolability scale) was employed to assess the intensity of the pain during the post-operative
span. FLACC scale can be regarded as one of the most significant for the measurement of the
pain as stated by Merkel, Voepel-Lewis and Malviya (2002). According to them, FLACC scale
is the most notable behavioural tool that can be used for the examination of pain both in infants
and among the young children.
According to Rees (2011), one of the core element of RCT is blinding that can modulate
the accuracy of the results. Chandler et al. (2013) employed double-blinded RCT and this
suggests a strong yet reliable design. Two investigators, both of them were blinded in regards to
the technique of anaesthesia employed. Both of them assessed the PAED, PACBIS and FLACC
scores.
Both the patient demographic and the surgery types were kept identical for both the
groups at the baseline and this again helped to improve the overall validity of the outcomes
(Parahoo 2014).
Statistical analysis was done via using MedCalc software. Houser (2011) illustrated that
this process ensures that the data is concisely evaluated. It helped to supply a rigorous
elaboration of the recorded results. T-tests along with Mann-Whitney U-tests were employed to

5
EMERGENCE DELIRIUM IN CHILDREN
examine continuous parametric and non-parametric data. The examination of preliminary
hypothesis was done via employing Fisher’s Exact test.
Young and Langford (2013) stated that in the findings, it is the role of the investigator to
highlight on the answering portion of the research questions. Chandler et al. (2013) vividly
described their results in text format and then thoroughly represented them via using tables’
illustrations, statistics and other linear graphs in order to state the outcomes. However, the
research failed to highlight any chances of delusions, restlessness and excitation associated with
the children. Since there are few of the most important symptoms of ED, assessment of such
symptoms are important in comparative study (Kain et al. 2004).
Parahoo (2014) stressed on the fact the authors of the research should be capable of
discussing the limitations of their own study instead of stating them in points. In this study, the
researchers thoroughly discussed the limitations of their study and then delivered the required
recommendations.
The study concluded that the occurrence of ED among the children after employing
TIVA is less in comparison to SEVO. This stated conclusion is backed by numerous findings.
Main study findings
It was demonstrated by Chandler et al. (2013) that the incidence of ED is higher among
the SEVO group than that of the TIVa group (38% Vs 14.9%; P=0.018). In the domain of post-
operative intensity of pain, the FLACC score was higher among the SEVO group in comparison
to that of the TIVA group (media 3 vs 1; P=0.033). Moreover, the participants who displayed ED
showed higher FLACC scores in comparison to that of those who remained unaffected by the ED
(media 7 vs 1; P,0.0001). This study thus further concluded that in infant or paediatric

6
EMERGENCE DELIRIUM IN CHILDREN
population, the imitation and maintenance of anaesthesia via employing TIVA diminished the
rate of incidence of ED in comparison to SEVO.
Physiological Implication
Malamed (2009) stated that the reactions which are associated with ED can be considered
to be as the manifestation of the central anticholinergic syndrome which manifests in the form of
anxiety, hyperactivity, hallucinations and delirium. When the situation further aggravate, there
are chances of medullary paralysis, coma, apnoea and even death (Malamed 2009). Bissonnette
and Anderson in the year 2011 mentioned that although ED is self-limiting, numerous strategies
for the management of the same can be adopted.
Management and Introduction towards change of practise
Anaesthesia Practitioner Curriculum Framework states the responsibility of anaesthetists
towards ensuring the safety of the patients (Government of UK 2017). Huddy in the year 2010
asserted that ED is the main root of distress not only for the children, but also for their parents
the care givers and the health care professionals. Sieber (2006) asserted that lack of pain
management set-up can trigger delirium. An anaesthetist must play a vital role in restricting the
occurrence of ED with their choice of proper anaesthesia technique (Mason, Noel-Storr and
Ritchie 2010). Moreover, it is the duty of the nurse to restrict the chances of the development of
ED before the onset of the surgery. The strategies that can be employed by the nurse in order to
reduce the chance of ED include early mobility and free hand exercise(Vasilevskis et al. 2012).
Nurses are also required to taken numerous non-pharmacological interventions like parental
acupuncture, hypnotherapy, clown doctors and low level of sensory stimulation (Yip et al. 2011).

7
EMERGENCE DELIRIUM IN CHILDREN
Chandler et al. (2013) stated that TIVA reduces the rate of occurrence of ED along with
reduction of the postoperative pain in the children. Therefore the application of TIVA under the
surgical settings should be encouraged. One of the major challenges is the lack of the proper
expertise along with the staff knowledge. According to Hall, Meagher and MacLullich (2012),
there exists a significant lack of staff knowledge towards the proper and timely identification of
the symptoms of ED among the hospital staffs in outside the ICU settings. According to Hall,
Meagher and MacLullich (2012), incorporation of both formal and systematic assessment and
screening into day-to-day clinical practice can help in the substantial improvement of the
diagnosis of delirium along with its treatment.
Legal and Ethical Consideration
Rees in the year 2011 opined that the investigators along with the medical practitioners
must consider the rights of the individuals and guarantee full protection of the confidentiality and
proper well-being of the participants in the research. The same data has been supported by the
Health and Care Professions Council (HCPC 2016). Moreover, Koelch and Fegert 2010, asserted
that the expectation of beneficence from the healthcare professionals is a normal process and the
patients expect that their care givers will function as per their best possible interest under each
and every circumstance. The introduction of TIVA for the proper management of the post-
operative pain and ED seem to align inherently with beneficence. Thus introduction of TIVA in
such scenario seems to be ethically justified. From the nursing perspectives it can be said that
beneficence, justice and autonomy are the three core principles that come into consideration
during the child care. However, the concept of beneficence comes into forefront in case of child
(Koelch and Fegert2010).

8
EMERGENCE DELIRIUM IN CHILDREN
Conclusion
Thus from the above discussion it can be summarised that ED is one of the major
problem among the paediatric surgical patients. Replacement of sevoflurane along with TIVA is
expected to decrease the rate of incidence of ED. However, the selection of the process of
anaesthesia must be totally based on associated health factors.

9
EMERGENCE DELIRIUM IN CHILDREN
References
Government of UK., 2017. Anaesthesia Practitioner Curriculum Framework. Retrieved from:
https://www.gov.uk/government/publications/anaesthesia-practitioner-curriculum-framework
Hall, R.J., Meagher, D.J. and MacLullich, A.M., 2012. Delirium detection and monitoring
outside the ICU. Best Practice & Research Clinical Anaesthesiology, 26(3), pp.367-383.
Kain, Z.N., Caldwell-Andrews, A.A., Maranets, I., McClain, B., Gaal, D., Mayes, L.C., Feng, R.
and Zhang, H., 2004.Preoperative anxiety and emergence delirium and postoperative
maladaptive behaviors. Anesthesia& Analgesia, 99(6), pp.1648-1654.
Koelch, M. and Fegert, J.M., 2010. Ethics in child and adolescent psychiatric care: An
international perspective. International review of psychiatry, 22(3), pp.258-266.
Mason, S.E., Noel-Storr, A. and Ritchie, C.W., 2010. The impact of general and regional
anesthesia on the incidence of post-operative cognitive dysfunction and post-operative delirium:
a systematic review with meta-analysis. Journal of Alzheimer's Disease, 22(s3), pp.S67-S79.
Merkel, S., Voepel-Lewis, T. and Malviya, S., 2002. Pain Assessment in Infants and Young
Children: The FLACC Scale: A behavioral tool to measure pain in young children. AJN The
American Journal of Nursing, 102(10), pp.55-58.
Vasilevskis, E.E., Han, J.H., Hughes, C.G. and Ely, E.W., 2012. Epidemiology and risk factors
for delirium across hospital settings. Best practice & research Clinical anaesthesiology, 26(3),
pp.277-287.

10
EMERGENCE DELIRIUM IN CHILDREN
Vlajkovic, G.P. and Sindjelic, R.P., 2007. Emergence delirium in children: many questions, few
answers. Anesthesia& Analgesia, 104(1), pp.84-91.
Yip, P., Middleton, P., Cyna, A.M. and Carlyle, A.V., 2011. Cochrane Review: Non‐
pharmacological interventions for assisting the induction of anaesthesia in children. Evidence
‐
Based Child Health: A Cochrane Review Journal, 6(1), pp.71-134.

11
EMERGENCE DELIRIUM IN CHILDREN