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Emergence delirium and agitation in children

Jerrold Lerman, MD, FRCPC, FANZCA
Section Editor
Andrew Davidson, MD
Deputy Editor
Marianna Crowley, MD


Delirium and agitation can occur as a child awakens, or emerges, from anesthesia. Emergence delirium (ED) may be distressing to the patient, parents, and caregivers, and can result in inadvertent removal of intravenous catheters, drains, and dressings, and rarely, self-harm. This topic will discuss the definition, risk factors, prevention, and treatment of ED and agitation in children. ED in adults is discussed separately. (See "Delayed emergence and emergence delirium in adults".)


Emergence delirium (ED) is an altered state of consciousness, which begins with emergence from anesthesia and continues through the early recovery period. ED is a disturbance of awareness of, or attention to, the child's environment, and manifests as disorientation, hyperactive behavior, and hypersensitivity in the immediate period after anesthesia [1]. Agitation related to pain is not considered ED [2].


The true incidence of emergence delirium (ED) and agitation in children is unclear, and is reported from 10 to 80 percent [3-5]. The incidence of ED varies with the choice of anesthetic agent, age of the child, and especially with the criteria used to diagnose of ED. In particular, in young patients, agitation due to pain can be confused with ED. In our experience, incomplete pain relief remains the most common cause of inconsolable behavior in the recovery room and is far more common than ED.

When all factors are considered, we believe that ED may occur in as many as 30 to 50 percent of children who have general anesthesia [6,7]. In order for the diagnosis of ED to be made, however, pain must be completely controlled.


The mechanism responsible for emergence delirium (ED) and for its increase in frequency in preschool-age children remain poorly understood. A variety of explanations have been proposed. Some experts have attributed ED to the unique neurodevelopmental characteristics in this age group and the effects of the newer ether anesthetics on them. Alternately, some associate ED with the unique electroencephalographic (EEG) findings associated with sevoflurane anesthesia. However, ED occurs with a similar frequency after desflurane and isoflurane even though the EEG of these inhaled anesthetics are quite dissimilar from sevoflurane [8,9].

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Literature review current through: Dec 2017. | This topic last updated: Mar 30, 2017.
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