Emergence Delirium: Past, Present and Future

Emergence Delirium: Past, Present and Future

Emergence Delirium: Past, Present and Future

2/11/2019 1 Emergence Delirium: Past, Present and Future Sapna R. Kudchadkar, MD, PhD Associate Professor, Anesthesiology and Critical Care Medicine, Pediatrics & Physical Medicine & Rehabilitation #PAF57 #PedsAnes #delirium @SapnaKmd Disclosures Emergence Delirium: Past, Present and Future Sapna Kudchadkar, MD, PhD • I have no relevant financial relationships with the manufacturer(s) or any commercial product(s) and/or provider of commercial products or services discussed in this CME activity • I do not intend to discuss unapproved/investigative use of commercial product(s)/device(s) in my presentation

Emergence Delirium: Past, Present and Future

2/11/2019 2 @SapnaKmd Objectives @SapnaKmd World Delirium Day 2019

Emergence Delirium: Past, Present and Future

2/11/2019 3 @SapnaKmd @SapnaKmd Delirium Definition Abrupt onset of inattention and other cognitive signs with fluctuation during day • Inattention – inability to direct, sustain & shift attention • Decreased awareness of environment – disoriented • Change in cognition &/or perception – Short-term memory, language/speech abnormalities – Hallucinations: auditory or tactile [not a requirement] • May have delusions, emotional lability including significant anxiety, sleep-wake disturbance. Adapted from DSM -5 American Psychiatric Association.


Emergence Delirium: Past, Present and Future

2/11/2019 4 @SapnaKmd What’s the difference? • Emergence Agitation: restlessness, thrashing, inconsolability during emergence from anesthesia with NO lucid interval • Emergence Delirium: above PLUS incoherence, inattention and/or non-purposeful movements, minutes-hours • Postoperative Delirium: Lasts hours or longer with or without lucid interval • Postoperative Cognitive Decline: subtle, long-term cognitive impairment noted on neuropsych testing Who screens for delirium in the PACU using a validated tool?

Emergence Delirium: Past, Present and Future

2/11/2019 5 @SapnaKmd • Only 2% of respondents reported delirium screening is performed for all mechanically ventilated patients once per shift • When asked which tools were being used for delirium, several listed withdrawal scales –Sophia Observation Scale –Withdrawal Assessment Tool-1 (WAT-1) Crit Care Med 2014 @SapnaKmd Delirium is everyone’s problem J Am Geriatr Soc 2011

Emergence Delirium: Past, Present and Future

2/11/2019 6 Insight from half a century ago… ‘The problem of delirium is far from an academic one. Not only does the presence of delirium often complicate and render more difficult the treatment of a serious illness, but also it carries the serious possibility of permanent irreversible brain damage’ -Engel & Romano, 1959

Emergence Delirium: Past, Present and Future

2/11/2019 7 March 2017 JAMA 1945

Emergence Delirium: Past, Present and Future

2/11/2019 8 AMA Am J Dis Child 1953 stress.

Emergence Delirium: Past, Present and Future

2/11/2019 9 1990: Sevoflurane introduced in Japan; 1995: Approved in United States - 375 ASA I or II children - Phase III RCT While the incidence of adverse events caused by sevoflurane were similar to halothane, there was an almost 3-fold greater incidence of agitation attributable to sevoflurane.

Emergence Delirium: Past, Present and Future

2/11/2019 10 Paed Anaes 2002 “30% of children experienced a period of inconsolable crying or restlessness and disorientation during emergence” • 521 children over 1 year • 18% incidence of emergence agitation – EA defined as agitation with nonpurposeful movement, restlessness or thrashing; incoherence, inconsolability and unresponsiveness – Subset of 250 children had a pre-surgery behavioral questionnaire

2/11/2019 11 Watcha Scale and Cravero Scale

2/11/2019 12 Which scale to use? Ped Anes 2010 Pediatrics 2006

2/11/2019 13 Risk Factors • Volatile anesthetics (sevoflurane> isoflurane & desflurane • Type of surgery: optho/ENT • Patient age: 18% in 3-7 age group • Parental anxiety • Patient pre-existing behavior • Patient and parent interaction with health-care providers Mason 2017 BJA DDx in the PICU: “I WATCH DEATH” • Infection: Sepsis, Pneumonia, etc.

• Withdrawal: Sedative-hypnotic, alcohol, barbiturate • Acute metabolic: Acidosis, alkalosis, electrolyte abnl, hepatic or renal failure • Trauma: Closed-head injury, heat stroke, postoperative, severe burn • CNS pathology: Abscess, hemorrhage, hydrocephalus, subdural hematoma, seizures, stroke, tumors, metastases, encephalitis, meningitis • Hypoxia: Pulmonary or cardiac failure, hypotension, anemia • Deficiencies: Vitamin B12, folate, niacin, thiamine • Endocrinopathies: Hyper/hypoadrenocorticism, hyper/hypoglycemia, Myxedema, hyperparathyroidism • Acute vascular: Hypertensive encephalopathy, stroke, arrhythmia, shock • Toxins or drugs: Prescription drugs, illicit drugs, pesticides, solvents • Heavy Metals: Lead, manganese, mercury

2/11/2019 14 Differential Diagnosis for Emergence Delirium • Pain • Hypoxia • Hypotension • Hypocarbia or hypercarbia • Hypothermia • Hypoglycemia • Increased intracranial pressure How can we prevent emergence delirium?

2/11/2019 15 Prevention/Treatment Approaches • Behavior management • Choice of volatile anesthetic • Choice of medications • Benzodiazepine • Opioid • Alpha-2 agonists • Gabapentin • Melatonin • Propofol • Ketamine • Magnesium • Acupuncture • Regional Techniques • Pain control Behavior Management • ADVANCE: Anxiety-reduction, Distraction, Video modeling & Education, Adding Parents, No excessive reassurance, Coaching, Exposure/shaping

2/11/2019 16 Behavior Management • ADVANCE: Anxiety-reduction, Distraction, Video modeling & Education, Adding Parents, No excessive reassurance, Coaching, Exposure/shaping Behavior Management • ADVANCE: Anxiety-reduction, Distraction, Video modeling & Education, Adding Parents, No excessive reassurance, Coaching, Exposure/shaping • Less emergence delirium • Earlier discharge • Fewer analgesics

2/11/2019 17 Mother knows best? Mother knows best?

2/11/2019 18 Mother knows best? Choice of Volatile

2/11/2019 19 Choice of Anesthetic Technique: What about TIVA? Regional? J Anesth 2014 Time to emergence: does it matter?

2/11/2019 20 Propofol • 230 children • Randomized to propofol 3 mg/kg over 3 minutes or no propofol at the end of sevoflurane anesthesia • PAED scale monitored to 30 minutes post-anesthesia • Improved EA incidence and quality of emergence, no difference in time to discharge home Time for some Forest plots!

2/11/2019 21 “Based on high quality evidence, prophylactic propofol appears to be effective for reducing the incidence and severity of EA in children emerging from general anesthesia.” Opioids “..prophylactic μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil could significantly decrease the incidence of EA under sevoflurane anesthesia in children compared to placebo.

Considering the limitations of the included studies, more clinical studies are required.”

2/11/2019 22 What about benzodiazepines? Midazolam, given as either premedication 30 min before induction of anaesthesia or after induction, does not have a prophylactic effect against EA [OR 0.88 (0.44, 1.76); P=0.11 J Peri Anes Nurs 2018 Distraction better than benzo? PAED scores significantly lower in distraction group at 15 minutes post- anesthesia compared to midazolam group (p

2/11/2019 23 Alpha-2 agonists: Dexmedetomidine Anaesthesia 2016 • ASA 1 or 2 children ages 2-8 undergoing infraumbilical surgery (n=100) • Dexmedetomidine 0.3 ug/kg 15 minutes before end of surgery, Propofol 1 mg/kg 5 minutes before or saline • Significant decrease in ED incidence, but increased sedation PLOS One 2016 1364 patients Dexmedetomidine reduced: - Incidence of emergence delirium - Incidence of nausea and vomiting - Number of patients requiring analgesic Dexmedetomidine increased: - Time to extubation and recovery room discharge

2/11/2019 24 IV Dexmedetomidine Mucocutaneous dexmedetomidine

2/11/2019 25 Intrathecal administration Favors Dex

2/11/2019 26 Melatonin • Produced by the pineal gland • Under control of circadian pacemaker of suprachiasmatic nuclei • Peaks at 2 a.m., decreases to daylight levels by 8 a.m. • Nocturnal melatonin suppression noted in ICU and post-operative patients @SapnaKmd

2/11/2019 27 What about gabapentin? 46 ASA I or II children randomized to saline or gabapentin 15 mg/kg before induction Does magnesium work for everything? • 70 ASA I school-age patients • 30 mg/kg magnesium followed by an infusion • Magnesium group relative risk of ED 0.51 (95% CI 0.31–0.84), with no difference in recovery time or side-effects

2/11/2019 28 • 120 ASA I or II patients 18-96 months old • Minor elective surgery • Randomized double-blinded (n=120) • Incidence of emergence delirium 32% in acupuncture group vs 57% in control (p

2/11/2019 29 When did “pediatric delirium” become recognized outside the PACU? When did “pediatric delirium” become recognized outside the PACU? • 0 articles in Pubmed mentioning “pediatric delirium” in 2006 • 67 articles in 2018 – PICU – CICU – NICU – Oncologic and other inpatient populations

2/11/2019 30 Crit Care Clin 2009 Crit Care Med 2008 Table 3 Adjusted odds ratios Variable Odds ratio (95% CI) Age > 2 years 0.7 (0.5, 1.0) Physical restraints 4.0 (2.0, 7.7) Mechanical ventilation 1.7 (1.1, 2.7) Narcotics 2.3 (1.5, 3.5) Benzodiazepines 2.2 (1.5, 3.3) Antiepileptics 2.9 (1.8, 4.8) General anesthesia 0.4 (0.3, 0.8) Vasopressors 2.4 (1.5, 3.8) 25% Delirium Prevalence N=835, Traube et al, Crit Care Med 2017

2/11/2019 31 Smith HA et al. Crit Care Med September 2017 - Nested retrospective cohort study - 1547 PICU admissions - 10% transfused - Transfusion was independently associated with development of delirium

2/11/2019 32 • 3 infants • Corrected gestational age 4, 11, and 17 weeks • Agitation unresponsive to increased medications • Improved after initiation of quetiapine Pediatrics 2016 • Younger age • Mech Vent • Benzo

2/11/2019 33 • 319 consecutive admissions • 186 patients/2731 hospital days • Delirium incidence 18% • Longer LOS • Younger, brain tumor, benzos are higher risk J Peds 2017 • Prospective observational study of 464 consecutive PICU admissions Crit Care Med 2016

2/11/2019 34 Why should we consistently screen for delirium in the perioperative setting? • Not just to diagnose delirium and treat it! • “A positive delirium screen after several negative screens is a warning sign for impending badness” - Wes Ely, MD Take-home points • Emergence delirium is a part of our daily practice as anesthesiologists- we can’t diagnose if we can’t screen! • Can have effects that persist beyond our care • Differentiating pain vs. delirium- inattention! • Non-pharmacologic approaches along with tailored anesthetic plans for each unique patient is the best approach • Decreasing role of benzos- avoid if possible in critically ill pts • Consider dexmedetomidine!

• Acupuncture, gabapentin melatonin on the horizon

2/11/2019 35 Thank you! @SapnaKmd @PICU_Up

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