Emergence Delirium Jane Bolton CN PARU RAH

Postoperative Neurobehavioral Disturbances 3 distinct forms : emergence delirium postoperative delirium postoperative cognitive decline

Emergence delirium Definition Altered state of consciousness & agitation during emergence from anaesthesia Usually lasts 15 – 30 mins, no interval Poorly understood Lack of studies Affects about 5-20 % of patient population Emergence delirium Definition

RECOGNITION of CONDITION extremely important allows for appropriate treatment hastens response time hastens treatment time improves outcome Recognition

Risk Factors Non modifiable : age cognitive impairment dementia depression comorbid disease type of surgery genetic factors Risk Factors

Risk Factors Modifiable : infection & inflammation metabolic disturbances medication pain & discomfort sleep disruption Risk Factors

Physiological hypoxemia, hypercarbia, hyponatremia, hypoglycemia head injury, dementia, sepsis, alcohol withdrawal, airway obstruction full bladder, pain, hypothermia, sensory overload or deprivation Causes

Causes Pharmacological : Ketamine Droperidol Benzodiazepines Opioids Atropine Scopolamine Inhalation agents eg sevoflurane, desflurane Causes

Signs and symptoms excitement alternating with sedation excitement and disorientation inappropriate behaviour and language violence and threatening behaviour unresponsive to commands disinhibited behaviour Signs and symptoms

Treatment Patient and staff safety top priority Treat possible cause with : oxygen F & E replacement analgesia warming IDC sedation Treatment

Violent Patient Protocol Protocol is located in PARU calm patient assistance : anaesthetist, code black safety top priority TC to coordinate response team chemical sedation: IV Haloperidol 1mg-10mgs physical restraint if threatening Violent Patient Protocol

Treatment Code Black if uncontrollable & dangerous Medications : Haloperidol 1 mg per ml up to 10 mgs Olanzapine IV or wafer for longer effect Literature suggests midazolam if above drugs are ineffective but in practice this can exacerbate situation Treatment

Treatment calming reassurance quiet orientation to time and place do not yell at patient do not try and reason or argue reduce number of people at scene explain procedures to patient gentle physical restraint as a last resort References : 1. Delirium during emergence from anaesthesia : a case study Crit Care Nurse February 2003 . Vol. 23 no. 1 66-69 2. Anticipating and managing postoperative delirium and cognitive decline in adults BMJ 2011 ; 343:d4331 Treatment