Emergence delirium is a condition characterized by confusion, agitation, and a lack of environmental awareness during the recovery phase following anesthesia administration. It poses significant management challenges in post-operative care, particularly in pediatric and elderly patients. Continued investigation of the relationship between certain medications used during anesthesia and the increased incidence of emergence delirium can help improve surgical outcomes and reduce complications.
The use of inhalational anesthetics, especially sevoflurane, is associated with emergence delirium. Research by Kim et al. (2011) suggests that while sevoflurane is favored for its efficacy in the induction and maintenance of anesthesia (due to its rapid onset and recovery characteristics), it presents a higher risk of emergence delirium compared to alternative medications like propofol and isoflurane. It is hypothesized that rapid changes in cerebral function during the transition from a sevoflurane-induced anesthetized state may trigger the onset of delirium (1).
Another class of medications linked to emergence delirium is benzodiazepines, such as midazolam, which is commonly administered for preoperative sedation. A study by Radtke et al. (2010), among others, highlights the potential of these drugs to elevate the risk of postoperative delirium, including emergence delirium. The central nervous system is heavily affected by the sedative and amnestic effects of benzodiazepines, possibly extending the period of recovery from anesthesia and, consequently, increasing the likelihood of emergence delirium. This association underscores the need for cautious use of premedication, particularly among the elderly, who may be more susceptible to these effects (2).
Opioids are also very useful for pain management during and after surgical procedures, but their usage is not without risk. Moore et al. (2017) pointed out that there is a critical balance required in managing analgesia and opioid side effects, as insufficient pain control and excessive opioid use can amplify the risk of emergence delirium (3).
Anticholinergic medications, whether used within the anesthetic regimen or for managing pre-existing conditions, have been identified as potential contributors to emergence delirium. By disrupting acetylcholine transmission, these drugs may compromise cognitive function and lead to delirium. Tune and Egeli (1999) stress the importance of evaluating the anticholinergic load of medications, especially in the elderly, who are particularly vulnerable (4).
Careful consideration of the interplay between various anesthetic medications used during surgery and the risk of emergence delirium is necessary in clinical practice to avoid complications and a potentially distressing post-anesthesia experience for patients. Tailoring anesthetic plans to the specific needs and risk factors of each patient, optimizing analgesia, and minimizing the use of medications associated with delirium can significantly reduce the incidence of emergence delirium. Continued research and increased clinical awareness are critical to addressing this complex issue, with the goal of improving postoperative recovery and overall patient outcomes.
References
- Kim JH. Mechanism of emergence agitation induced by sevoflurane anesthesia. Korean J Anesthesiol. 2011;60(2):73-74. doi:10.4097/kjae.2011.60.2.73
- Radtke FM, Franck M, Lendner J, et al. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. Br J Anaesth. 2010;105(4): 461-467.
- Moore AD, Anghelescu DL. Emergence Delirium in Pediatric Anesthesia. Paediatr Drugs. 2017;19(6): 541-550.
- Tune LE, Egeli S. Acetylcholine and Delirium. Dement Geriatr Cogn Disord. 1999;10(4): 342-344.