Emergence Delirium: A Nursing Perspective - AORN

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MARCH 2009, VOL 89, NO 3HudekIn older adult patients, conditionssuch as depression, drug dependency,or organic brain disease increase thelikelihood of emergence delirium.a dissociated state of consciousness in whichthe child is inconsolable, irritable, uncompromisingor uncooperative, typically thrashing,crying, moaning and incoherent. 3While much of the research has focused on pediatricpatients, people of all ages may exhibitsymptoms of emergence delirium. Emergencedelirium occurs in approximately 5.3% of allpostoperative patients; however, when the statisticsfocus on pediatric patients, the incidenceincreases to between 12% and 13%. 3 The incidenceof emergence delirium rises to between10% and 15% when only the geriatric populationis examined. 1,2Emergence delirium is noted in the immediatepostoperative period, usually occurring duringthe first 15 to 30 minutes after surgery. 3,4 Ingeriatric patients, delirium may be prolongedand may not be diagnosed until eight to 24hours postoperatively. 4 It takes longer for emergencedelirium symptoms to occur, possibly becauseolder adults metabolize anesthesia medicationsat a slower rate. Although most patientsexperiencing emergence delirium displayperiods of excitement alternating with periodsof lethargy, older adult patients may presentwith restlessness and behavioral regression (eg,the patient may be verbally abusive or displayinfantile behavior) without notable changes inphysical behavior. 1,4Many studies have examined the causes ofemergence delirium. Most inhalation agents andIV agents including midazolam, remifentanil,and propofol have been associated with thiscondition. 1,3,4 Other medications associated withan increased incidence of emergence deliriuminclude atropine, ketamine, droperidol, and possiblybarbiturates. 1,3 Factors correlated to the occurrenceof emergence delirium include• a rapid emergence from anesthesia withoutadequate pain control,• younger or advanced age,• no previous surgery,• poor adaptability,• large blood loss during surgery, 4• postoperative pain, 1,2,4• use of sevoflurane or isoflurane or a combinationof both, and• use of analgesics. 3,4In older adult patients, psychiatric conditionssuch as depression, drug dependency, or organicbrain disease increase the likelihood of emergencedelirium. 1,2 Patients undergoing ophthalmological,otorhinolaryngological, breast, or abdominalsurgeries also appear to run a higherrisk of emergence delirium. 1-3The factor that appears throughout the literatureas the most prevalent link to emergencedelirium is preoperative anxiety. 1-6 In the types ofsurgeries noted above, specific anxiety over disfigurement,suffocation, pain, and the generaloutcome of surgery add to the general anxietyabout having surgery that most patients experience.1,2 Children who experience acute separationanxiety or anxiety as a reaction to parental anxietyare at a greater risk for emergence delirium. 6NURSING CARE OF PATIENTSEXPERIENCING EMERGENCE DELIRIUMWhen a patient begins to display symptomsof what may be emergence delirium, it is importantthat the nurse search for an underlyingcause of this behavior. Urinary retention, hypoxia,severe hypercarbia, hypotension, hypoglyce -mia, increased intracranial pressure, electrolyteimbalance, sepsis, embolism, alcohol withdrawal,sensory deprivation, sensory overload, andpain are conditions that may lead the patientto exhibit a variety of emergence delirium-likebehaviors. 1,3,4 Behavior seen under these circumstancesmay not be emergence delirium. Painmay be a difficult factor to identify, especially inchildren, so the use of a pain scale may be helpful.4 The patient’s cognitive status and level ofconsciousness must be evaluated when assessingfor emergence delirium. 4510 • AORN JOURNAL
Hudek MARCH 2009, VOL 89, NO 3ASSESSMENT OF AGITATION. The use of an agitationscale may help to define the level of a patient’sagitation. Use of the Riker sedation-agitationscale and the Richmond sedation-agitationscale are recommended because they have excellentinterrater reliability and are easy to use,especially in emergency situations. 2,7-9 Bothscales allow clinicians to rate the quality of apatient’s level of consciousness and behavior.For emergence delirium, the Riker scale providesa spectrum of measurement that coverspatients who are “unarousable” to patientswho are “dangerously agitated.”TREATMENT. Treatment of emergence deliriumbegins with the basics—maintaining the patient’sairway, breathing, and circulation. Airwaymaintenance is always the priority in anysituation. If the patient is experiencing difficultymaintaining an open airway, the use of anoral airway or performing a jaw thrust or chinlift maneuver may aid in opening the airway.These actions, however, may make a patientexperiencing emergence delirium more combativeso the use of a chemical restraint (ie, sedatingmedications) may be necessary until theairway is well established. The anesthesia careprovider may prescribe treatment to relax theairway to reduce laryngospasms.An adhesive pulse oximeter reduces the bulkof a clip-on type and stays on the patient better ifhe or she is thrashing about. Although the fingeris often the digit of choice for application, the patientmay be less aware of it if it is attached to atoe, and this may reduce the patient’s agitation.The nurse can assist the patient’s breathingby placing the patient in a semi-Fowler position,providing supplemental oxygen, andmaking sure no weight is on his or her chest(eg, a casted arm). If the patient’s oxygen maskbecomes an irritant, the nurse can place it justoff the patient’s face where he or she may stillreceive some benefit from the oxygen. Somepatients find the nasal cannula in their naresannoying but demonstrate a higher tolerancefor the cannula resting on their lips.It is important to monitor blood pressure inany postoperative patient. The pressure of theblood pressure cuff, however, may feel invasiveto some patients and may trigger anepisode of agitated behavior. It may help toTreatment of emergence deliriumbegins with the basics—maintainingthe patient’s airway, breathing,and circulation.lessen the effects of the cuff’s presence by settingthe timed inflation intervals as far apart aspossible and preparing the patient by informinghim or her of the squeeze pressure just beforeinflation.If the patient’s blood pressure is lower thannormal postoperatively, the nurse can reviewthe effects of the medications given, and checkthe patient’s positioning and blood or fluidloss. Increasing the volume of the IV fluids infusing,if not detrimental to the patient’s condition,may assist in raising the patient’s bloodpressure. Most cases of emergence deliriumwill resolve spontaneously with no interventionother than supportive care. 2-4 While thereare many variables that contribute to emergencedelirium, presence of an endotracheal(ET) tube, pain, and anxiety appear to be themost prevalent. 2 Removal of the ET tube, treatmentof pain, and reassurance may assist thepatient in emerging from his or her confusion.There is much debate in the literature aboutthe use of pharmaceuticals in the treatment ofemergence delirium. 1,2,4 Opioids; propofol;flumazenil; benzodiazepines (eg, midazolam);and antipsychotics may be chosen to either reverseor relieve unwanted behaviors (ie, bychemical restraint) or treat underlying causesof emergence delirium. 3,4Much of the debate in the literature aboutthe use of pharmaceuticals to treat emergencedelirium concentrates on the use of midazolamas an anxiety reliever preoperatively. Onestudy found that preoperative use of midazolamversus a placebo reduced the incidence ofemergence delirium; however, the authorswere not sure whether this effect was causedAORN JOURNAL • 511
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Emergence Delirium: A Nursing Perspective - AORN

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