EMERGENCE DELIRIUM. By Jane Harvey

Transcription

1 EMERGENCE DELIRIUM By Jane Harvey

2 What is it?? Emergence is the transition from anaesthesia to the full conscious state. Delirium is the group of difficult behaviours associated by fear & agitation & is exhibited during emergence An altered state of neurological functioning It can occur in all patient populations but is commonly seen in paediatrics, the eldery, the cognitive impaired or drug dependent

3 The statistics Emergence delirium occurs in approx 5% of the general population but 12-30% of the paediatric population but can also occur in the elderly, drug dependant & patients with a psychiatric history. Emergence delirium is a well researched but still poorly understood scenario which usually occur in the first 10 minutes after arrival in Recovery and may lat up to15-20 minutes.

4 Causes: Withdrawal Psychosis- withdrawal from alcohol & illicit drugs Toxic Psychosis- exposure to toxins in the OR Circulatory & Respiratory Causes- Hypoxemia & Hypercarbia due to CNS Depression/airway Obstruction/perfusion deficits. Hypoxemia is the cause until all others eliminated Functional Psychosis- brief reaction of paranoia not caused by organic abnormalities

5 Most likely causes in Children: Inhalational agents esp Sevoflurane Ketamine Nitrous Oxide Droperidol Atropine Midazolam Morphine Rapid emergence without appropriate analgesia Young or advanced age Poor adaptability Nil previous surgery Increased blood loss intraoperatively Increased preoperative anxiety Specific types of surgeries- ENT, ophthalmological, breast or abdominal

6 Differential diagnosis: Pain Withdrawal Respiratory/circulatory causes Medications Altered thermoregulation Anxiety Bladder distention Metabolic/electrolyte disturbances

7 Those difficult behaviours: Excitement Disorientation/ inability to be consoled Screaming/crying Kicking/thrashing/ non purposeful movements Non responsive Holding themselves rigid Restlessness Removing/dislodging IV, drains, dressing etc

8 Emergence Delirium V Pain Difficult to assess based on traditional VAS, or paediatric faces systems in small children.

9 Wong Faces Pain Rating System A little too simplistic for this situation.

10 FLACC Paediatric Pain scoring Works well for children aged 2months to 7 years. Used for children who cannot self report but are not cognitively impaired.

11 Treatment Rule Out Hypoxemia Treat any other causes Consider Sedation Maintain Patient Safety

12 Treatment: Begin with the basics- airway, breathing & circulation. Use adhesive pulse oximetre rather than a regular on more likely to stay on when thrashing around in bed. Constant supervision, often more than one nurse required. Some gentle restraint may be required to prevent injury Sit head of bed up, attempt to use Hudson Mask. Don t use elastic strap, just hold the mask a few millimetres from the face.

13 More Treatment Reassure child, orientate to person, place or time. If parent present, support them, explain what s going on Protect the IV site, it will be required for on going hydration Consider the use of opiates Feedback to anaesthetists- consider the use of Clonidine during anaesthesia, which has some mild calming & sedative effects in the first 24hrs postop.

14 References: Burns S (2003) Delirium During Emergence from Anaesthesia: a case study Critical Care Nurse 23(1) Drain C & Odom-Forren J (2009) 5 th ed Perianaesthesia Nursing-A Critical Care Approach Saunder Elsevier St Louis Hudek K (2009) Emergence Delirium: A Nursing Perspective AORN Journal 89(3) Manworren R, Paulos C & Pop R (2004) Treating Children for Acute Agitiation in the PACU: Differentiating Pain & Emergence Delirium Journal of Perianaesthesia Nursing 19(3) Mountain B, Smithson L, Cramolini, Wyatt T & Newman M (2011) Dexmedetomine as a Paediatric Anaesthesia Premedication to Reduce Anxiety & to Deter Emergence Delirium AANA Journal 79(3) Nagelhout J & Zaglaniczny K (2005) 3 rd ed Nurse Anaesthesia Elsevier Sanders St Louis Shields L (2010) Perioperative Care of the Child: A Nursing Manual Wiley Blackwell UK