Pediatric Anesthesia: A Guide for the Non-Pediatric Anesthesia Provider Part I

PACU Management and Emergence Delirium

Author(s): Malgorzata Lutwin-Kawalec, Sheaba Varghese and Dinesh K. Choudhry

Pp: 156-181 (26)

DOI: 10.2174/9789815036245122010008

* (Excluding Mailing and Handling)


Recovery of children from anesthesia may be complicated by multiple
unique issues encountered in the postanesthesia care unit (PACU). Emergence
delirium is a dissociated state of consciousness, irritability, uncooperativeness, and
inconsolability that may cause injury to the child or staff. Malignant hyperthermia is
a rare genetic state of hypermetabolism that presents with hyperthermia, hypercarbia,
acidosis, rhabdomyolysis, and arrhythmias. Timely treatment with dantrolene is
lifesaving. Common postoperative respiratory events include stridor, laryngospasm,
and bronchospasm. Postextubation stridor is noisy breathing during inspiration
caused by airway mucosal injury or pressure from an endotracheal cuff, treated with
humidified oxygen, racemic epinephrine, and dexamethasone. Laryngospasm, a
partial or complete closure of the glottis, is an emergency that may lead to hypoxic
cardiac arrest and requires timely recognition and treatment with positive pressure
ventilation (PPV), medications, and possibly intubation. Bronchospasm is a clinical
manifestation of exacerbated underlying airway hyperreactivity, treated with inhaled
bronchodilators, intravenous epinephrine, and steroids. Cardiovascular events include
arrhythmias and blood pressure abnormalities. Bradycardia is a common dysrhythmia
in children usually caused by hypoxemia or vagal stimulation, treated with oxygen,
PPV, and intravenous epinephrine,or anticholinergics. Narrow complex
tachycardias—sinus tachycardia and supraventricular tachycardia—may be caused
by pain, hypoxia, emergence agitation, or medications such as epinephrine or
anticholinergics. Their management depends on etiology and consists of vagal
maneuvers, adenosine, or synchronized cardioversion. Known risk factors for
postoperative nausea and vomiting (PONV) in children include surgeries of longer
than 30 minutes, age over 3 years, strabismus surgery, and previous history of PONV.
Our standardized PACU handoff tool is discussed.

Keywords: Apnea of prematurity, Bradycardia, Bronchospasm, Cardiac arrest, Child Life, Discharge, Emergence delirium, Family-centered care, Guidelines, Handoff, Hypotension, Laryngospasm, Malignant hyperthermia, Narrow complex, Non-triggering anesthetic, Postanesthesia care unit, Postextubation stridor, Postobstructive pulmonary edema, Postoperative nausea and vomiting, Premature atrial contractions, Premature ventricular contractions, Tachycardia.

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