Emergence delirium, pain or both? a challenge for clinicians

BackgroundChildren commonly display early postoperative negative behavior (e-PONB) after general anesthesia, which includes emergence delirium (ED), discomfort, temperament, and pain. However, it is often difficult for the caregiver to discriminate between various aspects of e-PONB. ObjectiveThis prospective observational study evaluates the possibility to distinguish between ED and pain in young children using validated pediatric observational scales in the early postoperative phase. MethodsFollowing institutional approval and written consent, children undergoing elective adenoidectomy and/or tonsillectomy were enrolled. Following standardized anesthesia, two trained observers simultaneously evaluated children's behavior with the Paediatric Anaesthesia Emergence Delirium Scale (PAED) and with the Face, Legs, Activity, Cry, Consolability scale (FLACC) at extubation, and at 5, 10, and 15min. ResultsOf 150 children that completed the study, 32 (21%) had ED, 7 (5%) had pain, and 98 (65%) had simultaneously both ED and pain. The association of No eye contact', No purposeful action' and No awareness of surroundings' (ED1) had a sensitivity of 0.96 and a specificity of 0.80 (PPV 0.97, NPV 0.78) to identify ED. Inconsolability' and Restlessness' (ED2) had a sensitivity of 0.69 and a specificity of 0.88 (PPV 0.83 and NPV 0.78) to identify pain. ConclusionIt is difficult to differentiate between ED and pain using FLACC and PAED scores. No eye contact', No purposeful action', and No awareness of surroundings' significantly correlated with ED. Inconsolability' and Restlessness' are not reliable enough to identify pain or ED in the first 15min after awakening.