Delayed emergence and emergence delirium in adults
- Sher-Lu Pai, MD
Sher-Lu Pai, MD
- Assistant Professor of Anesthesiology
- Mayo Clinic College of Medicine
Failure to return to normal consciousness in a timely fashion following administration of general anesthesia may manifest as delayed emergence or emergence delirium. In most cases, these conditions are temporary and gradually resolve as anesthetic agents are metabolized and eliminated. Rarely, the cause is a serious medical or neurologic condition that requires urgent intervention.
This topic will review the causes and management of delayed emergence and emergence delirium after general anesthesia. Management of persistent postoperative delirium is addressed separately. (See "Diagnosis of delirium and confusional states".)
Other problems that occur in the post-anesthesia care unit (PACU) are discussed separately. (See "Overview of post-anesthetic care for adult patients".)
Emergence is the gradual return of consciousness after discontinuing administration of anesthetic and adjuvant agents at the end of the surgical procedure. Most patients transition smoothly from a surgical anesthetic state (Stage III) to an awake state with intact protective reflexes (Stage I) (table 1) . After emergence in the operating room, transport to the post-anesthesia care unit (PACU) is typically accomplished when the patient has been extubated and is breathing spontaneously with adequate oxygenation and ventilation, is hemodynamically stable, and can be aroused to follow simple verbal commands (eg, eye opening or hand squeezing).
Most patients become more fully conscious (ie, awake and aware of surroundings and identity) within approximately 15 minutes of extubation, and all patients should be responsive within 60 minutes after the last administration of any sedative, opioid, or anesthetic agent [2-4]. However, the time required for return of consciousness varies depending on the specific anesthetic agents employed; dosing, duration, and timing of last administration; the type and duration of the surgical procedure; and the patient's preoperative physical and mental status. (See 'Risk factors' below.)
- Hewer CL. THE STAGES AND SIGNS OF GENERAL ANAESTHESIA. Br Med J 1937; 2:274.
- Zelcer J, Wells DG. Anaesthetic-related recovery room complications. Anaesth Intensive Care 1987; 15:168.
- Frost EA. Differential diagnosis of delayed awakening from general anesthesia: a review. Middle East J Anaesthesiol 2014; 22:537.
- Pavlin DJ, Rapp SE, Polissar NL, et al. Factors affecting discharge time in adult outpatients. Anesth Analg 1998; 87:816.
- Hendrickx JF, Eger EI 2nd, Sonner JM, Shafer SL. Is synergy the rule? A review of anesthetic interactions producing hypnosis and immobility. Anesth Analg 2008; 107:494.
- Mcclain RL, Ramakrishna H, Aniskevich S III, et al. Anesthetic pharmacology and perioperative considerations for the end stage liver disease patient. Curr Clin Pharmacol 2015; 10:35.
- Aniskevich S, Pai SL, Shine TS. Anesthetic pharmacology for kidney transplantation. Curr Clin Pharmacol 2015; 10:47.
- Smallridge RC. Metabolic and anatomic thyroid emergencies: a review. Crit Care Med 1992; 20:276.
- Abbott TR. Anaesthesia in untreated myxoedema. Report of two cases. Br J Anaesth 1967; 39:510.
- Kim JM, Hackman L. Anesthesia for untreated hypothyroidism: report of three cases. Anesth Analg 1977; 56:299.
- Datta D, Scalise P. Hypothyroidism and failure to wean in patients receiving prolonged mechanical ventilation at a regional weaning center. Chest 2004; 126:1307.
- Lele AV, Clutter S, Price E, De Ruyter ML. Severe hypothyroidism presenting as myxedema coma in the postoperative period in a patient taking sunitinib: case report and review of literature. J Clin Anesth 2013; 25:47.
- Boyer EW. Management of opioid analgesic overdose. N Engl J Med 2012; 367:146.
- Clarke SF, Dargan PI, Jones AL. Naloxone in opioid poisoning: walking the tightrope. Emerg Med J 2005; 22:612.
- Dahan A, Aarts L, Smith TW. Incidence, Reversal, and Prevention of Opioid-induced Respiratory Depression. Anesthesiology 2010; 112:226.
- Cuss FM, Colaço CB, Baron JH. Cardiac arrest after reversal of effects of opiates with naloxone. Br Med J (Clin Res Ed) 1984; 288:363.
- Andree RA. Sudden death following naloxone administration. Anesth Analg 1980; 59:782.
- Michaelis LL, Hickey PR, Clark TA, Dixon WM. Ventricular irritability associated with the use of naloxone hydrochloride. Two case reports and laboratory assessment of the effect of the drug on cardiac excitability. Ann Thorac Surg 1974; 18:608.
- Ward S, Corall IM. Hypertension after naloxone. Anaesthesia 1983; 38:1000.
- Estilo AE, Cottrell JE. Naloxone, hypertension, and ruptured cerebral aneurysm. Anesthesiology 1981; 54:352.
- Azar I, Turndorf H. Severe hypertension and multiple atrial premature contractions following naloxone administration. Anesth Analg 1979; 58:524.
- Tanaka GY. Letter: Hypertensive reaction to naloxone. JAMA 1974; 228:25.
- Nath SS, Tripathi M, Pandey C, Rao B. Naloxone-induced pulmonary edema: a potential cause of postoperative morbidity in laparoscopic donor nephrectomy. Indian J Med Sci 2009; 63:72.
- Horng HC, Ho MT, Huang CH, et al. Negative pressure pulmonary edema following naloxone administration in a patient with fentanyl-induced respiratory depression. Acta Anaesthesiol Taiwan 2010; 48:155.
- Brimacombe J, Archdeacon J, Newell S, Martin J. Two cases of naloxone-induced pulmonary oedema--the possible use of phentolamine in management. Anaesth Intensive Care 1991; 19:578.
- Wride SR, Smith RE, Courtney PG. A fatal case of pulmonary oedema in a healthy young male following naloxone administration. Anaesth Intensive Care 1989; 17:374.
- Partridge BL, Ward CF. Pulmonary edema following low-dose naloxone administration. Anesthesiology 1986; 65:709.
- Prough DS, Roy R, Bumgarner J, Shannon G. Acute pulmonary edema in healthy teenagers following conservative doses of intravenous naloxone. Anesthesiology 1984; 60:485.
- Taff RH. Pulmonary edema following naloxone administration in a patient without heart disease. Anesthesiology 1983; 59:576.
- Osterwalder JJ. Naloxone--for intoxications with intravenous heroin and heroin mixtures--harmless or hazardous? A prospective clinical study. J Toxicol Clin Toxicol 1996; 34:409.
- Hughes MA, Glass PS, Jacobs JR. Context-sensitive half-time in multicompartment pharmacokinetic models for intravenous anesthetic drugs. Anesthesiology 1992; 76:334.
- Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg 2010; 111:120.
- Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg 2010; 111:129.
- Grosse-Sundrup M, Henneman JP, Sandberg WS, et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ 2012; 345:e6329.
- Fortier LP, McKeen D, Turner K, et al. The RECITE Study: A Canadian Prospective, Multicenter Study of the Incidence and Severity of Residual Neuromuscular Blockade. Anesth Analg 2015; 121:366.
- Stohl HE, Daher R, Aguirre F, Chen CC. Seizure and mental status change after surgery for pelvic organ prolapse. Int Urogynecol J 2011; 22:1463.
- Nilanont Y, Komoltri C, Saposnik G, et al. The Canadian Neurological Scale and the NIHSS: development and validation of a simple conversion model. Cerebrovasc Dis 2010; 30:120.
- Whiteley WN, Wardlaw JM, Dennis MS, Sandercock PA. Clinical scores for the identification of stroke and transient ischaemic attack in the emergency department: a cross-sectional study. J Neurol Neurosurg Psychiatry 2011; 82:1006.
- Selim M. Perioperative stroke. N Engl J Med 2007; 356:706.
- Bateman BT, Schumacher HC, Wang S, et al. Perioperative acute ischemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes. Anesthesiology 2009; 110:231.
- Ng JL, Chan MT, Gelb AW. Perioperative stroke in noncardiac, nonneurosurgical surgery. Anesthesiology 2011; 115:879.
- Vlisides P, Mashour GA. Perioperative stroke. Can J Anaesth 2016; 63:193.
- Fathi AR, Eshtehardi P, Meier B. Patent foramen ovale and neurosurgery in sitting position: a systematic review. Br J Anaesth 2009; 102:588.
- Chiappa V, Gonzalez RG, Manian FA, Deshpande V. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 23-2016. A 46-Year-Old Man with Somnolence after Orthopedic Surgery. N Engl J Med 2016; 375:370.
- Card E, Pandharipande P, Tomes C, et al. Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit. Br J Anaesth 2015; 115:411.
- Stamper MJ, Hawks SJ, Taicher BM, et al. Identifying pediatric emergence delirium by using the PAED Scale: a quality improvement project. AORN J 2014; 99:480.
- Guenther U, Riedel L, Radtke FM. Patients prone for postoperative delirium: preoperative assessment, perioperative prophylaxis, postoperative treatment. Curr Opin Anaesthesiol 2016; 29:384.
- Munk L, Andersen G, Møller AM. Post-anaesthetic emergence delirium in adults: incidence, predictors and consequences. Acta Anaesthesiol Scand 2016; 60:1059.
- Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med 2000; 160:786.
- Bowdle TA, Radant AD, Cowley DS, et al. Psychedelic effects of ketamine in healthy volunteers: relationship to steady-state plasma concentrations. Anesthesiology 1998; 88:82.
- Kleinloog D, Uit den Boogaard A, Dahan A, et al. Optimizing the glutamatergic challenge model for psychosis, using S+ -ketamine to induce psychomimetic symptoms in healthy volunteers. J Psychopharmacol 2015; 29:401.
- Grace RF. The effect of variable-dose diazepam on dreaming and emergence phenomena in 400 cases of ketamine-fentanyl anaesthesia. Anaesthesia 2003; 58:904.
- Avidan MS, Maybrier HR, Abdallah AB, et al. Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390:267.
- Sharma PT, Sieber FE, Zakriya KJ, et al. Recovery room delirium predicts postoperative delirium after hip-fracture repair. Anesth Analg 2005; 101:1215.
- Neufeld KJ, Leoutsakos JM, Sieber FE, et al. Outcomes of early delirium diagnosis after general anesthesia in the elderly. Anesth Analg 2013; 117:471.
- Lepousé C, Lautner CA, Liu L, et al. Emergence delirium in adults in the post-anaesthesia care unit. Br J Anaesth 2006; 96:747.
- Fritz BA, Kalarickal PL, Maybrier HR, et al. Intraoperative Electroencephalogram Suppression Predicts Postoperative Delirium. Anesth Analg 2016; 122:234.
- American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative delirium in older adults: best practice statement from the American Geriatrics Society. J Am Coll Surg 2015; 220:136.
- Bitsch M, Foss N, Kristensen B, Kehlet H. Pathogenesis of and management strategies for postoperative delirium after hip fracture: a review. Acta Orthop Scand 2004; 75:378.
- Scholz AF, Oldroyd C, McCarthy K, et al. Systematic review and meta-analysis of risk factors for postoperative delirium among older patients undergoing gastrointestinal surgery. Br J Surg 2016; 103:e21.
- Whitlock EL, Vannucci A, Avidan MS. Postoperative delirium. Minerva Anestesiol 2011; 77:448.
- Dasgupta M, Dumbrell AC. Preoperative risk assessment for delirium after noncardiac surgery: a systematic review. J Am Geriatr Soc 2006; 54:1578.
- Zaal IJ, Devlin JW, Peelen LM, Slooter AJ. A systematic review of risk factors for delirium in the ICU. Crit Care Med 2015; 43:40.
- NORMAL EMERGENCE
- DELAYED EMERGENCE
- Consider specific drug effects
- - Risk factors
- - Opioids
- - Benzodiazepines
- - Sedative-hypnotic agents
- - Volatile inhalation anesthetics
- - Anticholinergic agents
- - Neuromuscular blocking agents
- Evaluate and treat hypoxemia and/or hypercapnia
- Evaluate and treat temperature and metabolic derangements
- Assessment for neurologic disorders
- EMERGENCE DELIRIUM
- Clinical features
- Evaluation and treatment
- SUMMARY AND RECOMMENDATIONS