Post-surgery emergence delirium in kids has no long-term impact

The use of general anaesthesia (GA) in children undergoing elective surgeries does not lead to long-term deterioration in behavioural outcomes, according to a study presented at Anesthesiology 2022.

“In young children who undergo GA for elective surgery, no measurable decline in behaviour was found up to 3 months after the surgery, regardless of the history of emergence delirium,” the authors noted.

The study, conducted at Mayo Clinic Rochester, Minnesota, US, involved 68 children aged 2.5–6 years (median age 4.6 years, 54 percent female, 99 percent White) who were scheduled to receive GA before undergoing elective surgery. Their behaviour was assessed using the third edition of the Behavior Assessment System for Children (BASC-3) once prior to surgery (1 week to 1 day before receiving anaesthesia) and at 3 months post-surgery.

Most children had an American Society of Anesthesiologists (ASA) status of 1 or 2 (50 and 43 percent, respectively). The most common procedures performed were ear, nose, and throat (ENT) related (74 percent). The median duration of anaesthesia was 75 minutes. Intraoperative medications administered were anaesthetic gases (97 percent), fentanyl (88 percent), propofol (75 percent), or dexmedetomidine (35 percent).

Thirty-five percent (n=24) experienced emergence delirium, defined as a score of ≥3 on the Watcha scale. [Anesthesiology 2022, abstract JS02]

Overall, at 3 months post-surgery, there were significant reductions in mean T scores – translating to improvements – compared with pre-surgery in terms of anxiety (from 50.9 to 48.4; p=0.015), somatization (from 52.5 to 49.5; p=0.007), and internalizing (from 50.7 to 48.0; p=0.001).

Scores for other outcomes such as hyperactivity, aggression, depression, attention problems, adaptability, social skills, and behavioural symptoms did not significantly differ between the two assessments.

There was no interaction according to presence or absence of emergence delirium pertaining to any of the outcomes (eg, p_interactions of 0.464, 0.783, and 0.339 for change in T score between the two assessments for anxiety, somatization, and internalizing scores, respectively).

“Sitting in the waiting room while your child has surgery is always a distressing time for parents and it’s even more upsetting watching your child come out of anaesthesia displaying unusual behaviour such as inconsolability, unresponsiveness, restlessness, or incoherence,” said study author Dr Amira Joseph from the Mayo Clinic at Rochester.

“It was previously unknown if emergence delirium affects children’s behaviour in the longer term,” said Joseph. “Our study provides reassurance to healthcare providers and parents of children who need surgery that there won’t be behavioural issues long-term from having GA administered,” she concluded.

Noise affects short-term behavioural outcomes

Another study, this time conducted at the Nationwide Children’s Hospital, Columbus, Ohio, US, found that noise levels in the operating room (OR) may impact children’s behaviour post-surgery. [Anesthesiology 2022, abstract A3028]

Sixty-four children aged 4–5 years receiving GA for tonsillectomy/adenoidectomy or longer (≥30 minutes) dental procedures were randomized to a reduced noise group (low ambient lighting, muted communication devices, and reduced OR personnel; n=33) or a control group (n=31). All children received oral midazolam (0.3–0.5 mg/kg to a maximum of 15 mg) before receiving GA.

Adverse behaviour at anaesthesia induction, as per Induction Compliance Checklist (ICC), and pre-surgery anxiety, as per Modified Yale Preoperative Anxiety Scale (m-YPAS), did not significantly differ between patients in the reduced noise and control groups (p=0.0872 and p=0.2717, respectively).

However, behavioural changes post-surgery, assessed with the Post Hospitalization Behavior Questionnaire at days 1 and 5, showed that children assigned to the reduced noise groups had significantly fewer temper tantrums (p=0.0044), were less fussy about eating (p=0.0418), and were more interested in their surroundings (p=0.0079) in the first 5 days after surgery.

“For the first time, we’ve been able to show how reduced noise in the OR can improve postoperative behaviour in children in the first several days after having GA,” remarked study author Dr Nguyen Tram from the Nationwide Children’s Hospital.

“Excessive noise not only directly affects patients but can potentially impact patient safety by impairing provider communication and recognition of audible and visual alarms during the critical induction period. Future research is needed to further determine the best way to optimize the OR and perioperative environment to improve patient outcomes after surgery and anaesthesia,” Tram concluded.