Study of paediatric postoperative delirium and acute pain in low surgical risk procedures
Postoperative delirium is not only an outcome of unknown precise incidence in pediatrics but also a controversial field for pediatric anesthesiology.
To estimate the incidence of postoperative pediatric delirium in low surgical risk procedures and to analyze risk factors (such as acute postoperative pain).
Materials and methodology:
Prospective analytical observational study of incident cohort that included patients between 2 and 10 years of age, American Society of Anesthesiology I to II, undergoing low-risk surgery. Sample size: probable incidence 33%, accuracy 5%, confidence 95%, n = 340 patients. Sequential sample selection was done after admission to the operating room. Concurrent and longitudinal follow-up was carried out.
Incidence of delirium was 13.2%. A strong relationship was found between the presence of severe acute postoperative pain and delirium. Dexamethasone was a risk factor. A high association was found between remifentanil and severe acute postoperative pain.
A low incidence of delirium was found as compared with other reports in the world literature. The diagnostic strength of the scales used is controversial because of the similarities between measurement parameters. Scientific evidence that challenges the use of dexamethasone as a triggering factor is offered. A direct association between pain and delirium is found, and it is even argued that the use of remifentanil could favor the presence of severe acute postoperative pain (hyperalgesia).
2. Peralta-Zamora E. Estrategias para disminuir la agitación y el delirio postoperatorio en anestesia ambulatoria. Rev Mex Anest 2012;35 (s1):112-115.
3. Uezono S, Goto T, Terui K, et al. Emergence agitation after sevoflurane versus propofol in pediatric patients. Anesth Analg 2000;91:563-566.
4. Davis PJ, Greenberg JA, Gendelman M, et al. Recovery characteristics of sevoflurane and halothane in preschool-aged children undergoing bilateral myringotomy and pressure equalization tube insertion. Anesth Analg 1999;88:34-38.
5. Vlajkovic GP, Sindjelic RP. Emergence delirium in children: many questions, few answers. Anesth Analg 2007;104:84-91.
6. Lankinen U, Avela R, Tarkkila P. The prevention of emergence agitation with tropisetron or clonidine after sevoflurane anesthesia in small children undergoing adenoidectomy. Anesth Analg 2006;102:1383-1386.
7. Dahmani S, Stany I, Brasher C, et al. Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies. Br J Anaesth 2010;104:216-223.
8. Fan KT, Lee Th Fau-Yu KL, Yu Kl Fau-Tang CS, et al. Influences of tramadol on emergence characteristics from sevoflurane anesthesia in pediatric ambulatory surgery. Kaohsiung J Med Sci 2000;16:255-260.
9. Pieters BJ, Penn E, Nicklaus P, et al. Emergence delirium and postoperative pain in children undergoing adenotonsillectomy: a comparison of propofol vs sevoflurane anesthesia. Pediatr Anesth 2010;20:944-950.
10. Vaurio LE, Sands LP, Wang Y, et al. Postoperative delirium: the importance of pain and pain management. Anesth Analg 2006;102:1267-1273.
11. Lynch EP, Lazor MA, Gellis JE, et al. The impact of postoperative pain on the development ofpostoperative delirium. Anesth Analg 1998;86:781-785.
12. Bock M, Kunz P, Schreckenberger R, et al. Comparison of caudal and intravenous clonidine in the prevention of agitation after sevoflurane in children. Br J Anaesth 2002;88:790-796.
13. Smessaert A, Schehr CA, Artusio JF. Observations in the immediate postanaesthesia period II. Mode of recovery. Br J Anaesth 1960;32:181-185.
14. Gooden R, Tennant I, James B, et al. The incidence of emergence delirium and risk factors following sevoflurane use in pediatric patients for day case surgery, Kingston, Jamaica. Rev Bras Anestesiol 2014;64:413-418.
15. JÖHr M. Postanaesthesia excitation. Pediatr Anesth 2002;12:293- 295.
16. Aono J, Ueda W, Mamiya K, et al. Greater incidence of delirium during recovery from sevoflurane anesthesia in preschool boys. Anesthesiology 1997;87:1298-1300.
17. Banchs RJ, Lerman J. Preoperative anxiety management, emergence delirium, and postoperative behavior. Anesthesiol Clin 2014;32:1-23.
18. Viitanen H, Annila P, Rorarius M, et al. Recovery after halothane anaesthesia induced with thiopental, propofol-alfentanyl or halothane for day-case adenoidectomy in small children. Br J Anaesth 1998;81:960-962.
19. Kotiniemi LH, RyhÄNen PT, Moilanen IK. Behavioural changes following routine ENT operations in two-to-ten-year-old children. Pediatr Anesth 1996;6:45-49.
20. Kotiniemi LH, Ryhänen PT, Moilanen IK. Behavioural changes in children following day-case surgery: a 4-week follow-up of 551 children. Anaesthesia 1997;52:970-976.
21. Holm-Knudsen RJ, Carlin JB, McKenzie IM. Distress at induction of anaesthesia in children. A survey of incidence, associated factors and recovery characteristics. Paediatr Anaesth 1998;8: 383-392.
22. Kain ZN, Wang SM, Mayes LC, et al. Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesth Analg 1999;88:1042-1047.
23. Khalili G, Sajedi P, Shafa A, et al. A randomized evaluation of intravenous dexamethasone versus oral acetaminophen codeine in pediatric adenotonsillectomy: emergence agitation and analgesia. Middle East J Anaesthesiol 2012;21:499-505.
24. Zhao M, Joo DT. Enhancement of spinal N-methyl-D-aspartate receptor function by remifentanyl action at (-opioid receptors as a mechanism for acute opioid-induced hyperalgesia or tolerance. Anesthesiology 2008;109:308-317.
25. Angst MS, Clark D. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology 2006;104:570-587.
26. Guignard B, Bossard AE, Coste C, et al. Acute opioid toleranceintraoperative remifentanyl increases postoperative pain and morphine requirement. Anesthesiology 2000;93:409-417.
27. DuPen A, Shen D, Ersek M. Mechanisms of opioid-induced tolerance and hyperalgesia. Pain Manag Nurs 2007; 8:113-121.
28. Kim SH, Stoicea N, Soghomonyan S, et al. Intraoperative use of remifentanyl and opioid induced hyperalgesia/acute opioid tolerance: systematic review. Front Pharmacols 2014;5:108.