Occurrence and Management Strategies for Emergence Delirium in Children

Suchith L et al | DOI: 10.65188/nurexus.1042

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Journal of MedVerse Research & Practice

ISSN: 3107-4278

Occurrence and Management Strategies for Emergence Delirium in

Children

Dr. L Suchith

, Dr. F Joshaw

Postgraduate, Associate Professor

Department of Pediatric Anesthesiology, Indira Gandhi Institute of Medical Sciences, Puducherry,

Email: Suchith1992@gmail.com

Submission Date: 26.08.2025

Accepted Date: 22.09.2025

Published Date: 30.09.2025

DOI: 10.65188/nurexus.1042

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: Emergence delirium (ED), or emergence agitation, is a common and challenging postoperative

complication in children recovering from general anesthesia. It is characterized by restlessness, inconsolable crying,

thrashing, and confusion, posing risks to patient safety and prolonging the recovery process. This study aimed to

determine the incidence of ED, evaluate management strategies, and identify associated risk factors in pediatric

patients.

Methods: A retrospective cohort study was conducted at the Department of Pediatric Anesthesiology, Indira Gandhi

Institute of Medical Sciences, Puducherry. Medical records of 150 children aged 1–12 years who underwent elective

or emergency general anesthesia between January and June 2025 were reviewed. Data collected included

demographics, surgical and anesthetic details, postoperative behavioral observations, and interventions for the ED.

Delirium incidence, severity, and management efficacy were analyzed using descriptive statistics, Chi-square tests,

and ANOVA, with p < 0.05 considered significant.

Results: ED occurred in 31 of 150 children (20.7%). The highest incidence was observed in children aged 4–6 years

(38.6%), followed by 1–3 years (29.5%), while children aged 7–12 years showed the lowest incidence (10.9%). Male

and female patients were affected almost equally (21.6% vs. 19.4%). ED incidence was higher in emergency

surgeries (27.3%) than in elective procedures (17.9%), although the difference was not statistically significant.

Management strategies included dexmedetomidine (32.3%, 90% effective), propofol (19.4%, 83.3% effective),

parental presence (25.8%, 75% effective), and distraction techniques (22.5%, 71.4% effective), with minimal

complications reported.

Conclusion: Emergence delirium affects approximately one in five pediatric patients, with younger age being the

primary risk factor. Both pharmacological and non-pharmacological strategies effectively manage ED, with

dexmedetomidine showing the highest efficacy. Early identification of high-risk children and timely interventions

can improve postoperative safety, reduce agitation, and enhance recovery, highlighting the need for standardized

prevention and management protocols in pediatric anesthesia.

Keywords: Emergence delirium, pediatric anesthesia, dexmedetomidine, propofol, postoperative agitation, risk

factors

Introduction

Emergence delirium (ED), also termed emergence agitation, is a frequent and challenging complication

observed in children recovering from general anaesthesia. It is defined as a transient state of marked

irritability, confusion, inconsolable crying, and purposeless physical activity, often accompanied by

thrashing and aggressive behaviour during the immediate postoperative period [1]. Such manifestations can

be distressing to caregivers and healthcare providers, and may also jeopardize patient safety by increasing

Suchith L et al | DOI: 10.65188/nurexus.1042

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the risk of self-injury, accidental removal of catheters, or disruption of surgical wounds [2].

The reported incidence of ED varies widely, ranging from 10% to 80% in paediatric patients, depending on

age, anaesthetic technique, type of surgery, and the diagnostic criteria applied [3,4]. Children younger than

five years are particularly vulnerable, with a peak incidence in preschoolers [5]. Although the exact

pathophysiological mechanism remains unclear, multiple factors have been implicated. These include the

use of low-solubility volatile anaesthetics such as sevoflurane and desflurane [6], rapid awakening from

anaesthesia [7], preoperative anxiety [8], inadequate pain control [9], and certain types of surgical

procedures such as otorhinolaryngologic or ophthalmic surgeries [10].

From a clinical perspective, ED is a significant perioperative concern. Besides patient safety risks, it can

prolong recovery room stay, increase nursing workload, and result in emotional distress for parents and

staff [11]. Moreover, repeated episodes may potentially affect a child’s future response to anaesthesia and

medical environments [12]. Thus, identifying high-risk groups and implementing preventive as well as

therapeutic strategies are of paramount importance. Various pharmacological approaches, including the use

of propofol, dexmedetomidine, clonidine, and opioids, along with non-pharmacological interventions such

as parental presence and behavioural preparation, have been evaluated with variable success [13–15].

Given the clinical implications, the present study aims to (i) determine the incidence of ED in paediatric

patients undergoing general anaesthesia, (ii) evaluate the efficacy of different management strategies, and

(iii) identify risk factors associated with its occurrence. The insights gained are expected to inform better

perioperative practices and contribute to safer paediatric anaesthetic care.

Materials & Methods

Study Setting: The study was carried out in the Department of Paediatric Anaesthesiology at Indira

Gandhi Institute of Medical Sciences, Puducherry. IGIMS is a tertiary care teaching hospital that offers a

wide range of surgical and anaesthetic services. Due to the high volume of paediatric surgeries performed,

it provided an ideal setting for investigating the prevalence and management of emergence delirium.

Study Duration: The study included data collected over six months, from January 2025 to June 2025.

Sample Size: A total of 150 paediatric patients who underwent general anaesthesia were included. This

sample size was chosen to ensure sufficient statistical power to assess the incidence of emergence delirium,

associated factors, and treatment outcomes.

Inclusion Criteria

• Children aged 1 to 12 years.

• Patients undergoing elective or emergency surgical procedures under general anaesthesia.

• Postoperative monitoring for emergence of delirium symptoms as part of routine care.

• Availability of complete anaesthesia records and postoperative notes.

Exclusion Criteria

• Patients younger than 1 year or older than 12 years.

• Children receiving anaesthesia by methods other than general anaesthesia (e.g., regional or local).

• Incomplete medical records or missing essential data.

• Children with pre-existing neurodevelopmental or psychiatric disorders, which could confound the

assessment of emergence delirium.

Data Collection

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• Data were retrieved from medical and anaesthetic records of paediatric patients who received

general anaesthesia during the study period. Information extracted included:

• Demographics (age, sex).

• Surgical details (type of procedure, duration).

• Anaesthetic details (drugs administered, dosage, and duration).

• Postoperative notes documenting behavioural symptoms such as anxiety, agitation, restlessness, or

confusion.

• Management interventions, including pharmacological measures (e.g., propofol, dexmedetomidine)

and non-pharmacological methods (e.g., parental presence, behavioural reassurance).

• Emergence delirium episodes were identified and categorized by anaesthesiologists and nursing

staff based on postoperative recovery room documentation.

Variables: The primary variable was the incidence of emergence delirium, recorded as the number and

proportion of children who developed symptoms. Delirium severity was classified as mild, moderate, or

severe using clinical observations and standardized scales. Management strategies were classified as

pharmacological or non-pharmacological. Other variables included patient age, sex, type of surgery,

preoperative anxiety, and comorbid health conditions, which were evaluated as potential risk factors.

The study received ethical approval from the Institutional Ethics Committee of Indira Gandhi Institute of

Medical Sciences, Puducherry (Ref No: IGIMS/EC/2024/78125). A detailed Participant Information Sheet

was provided to all participants, and written informed consent was obtained prior to their participation in

the study.

Statistical Analysis: All analyses were conducted using SPSS version 28.0. Descriptive statistics such as

mean, standard deviation, frequencies, and percentages were used to summarize demographic and clinical

variables. The Chi-square test was applied to explore associations between categorical variables (e.g.,

treatment method vs. delirium incidence). Independent t-test or ANOVA was used to compare continuous

variables (e.g., age, recovery duration) across groups. A p-value < 0.05 was considered statistically

significant.

Results

Figure 1: Incidence of Emergence Delirium and Demographic Characteristics (n = 150)

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Out of 150 pediatric patients, 31 (20.7%) developed emergence delirium, while 119 (79.3%) showed no

symptoms. This indicates that approximately one in five children experienced delirium during recovery

from general anesthesia.

Table 1: Age distribution among the participants (n = 150)

Age Group

Number (%)

Emergence Delirium

No Emergence Delirium

Total (%)

1–3 Years

44 (29.3)

13 (29.5)

31 (26.1)

44 (29.3)

4–6 Years

56 (37.3)

17 (38.6)

39 (32.8)

56 (37.3)

7–12 Years

50 (33.4)

5 (10.9)

45 (37.9)

50 (33.4)

Out of 150 pediatric patients, the incidence of emergence delirium was highest in the 4–6 years age group

(38.6%), followed by 1–3 years (29.5%). The lowest incidence occurred in the 7–12 years group (10.9%).

These findings indicate that younger children, especially those between 1 and 6 years, are more prone to

experiencing emergence delirium after general anesthesia.

Table 2: Gender distribution among the participants (n = 150)

Gender

Number (%)

Emergence Delirium

No Emergence Delirium

Total (%)

Male

88 (58.7)

19 (21.6)

69 (57.9)

88 (58.7)

Female

62 (41.3)

12 (19.4)

50 (42.1)

62 (41.3)

Among the 150 pediatric patients, 21.6% of males (19/88) and 19.4% of females (12/62) developed

emergence delirium. This indicates that both genders were affected almost equally, with a slightly higher

incidence in males, though the difference was not statistically significant.

Table 3: Incidence of Emergence Delirium by Type of Surgery (n = 150)

Surgery Type

Number (%)

Emergence Delirium

No Emergence Delirium

Total (%)

Elective

106 (70.7)

19 (17.9)

87 (82.1)

106 (70.7)

Emergency

44 (29.3)

12 (27.3)

32 (72.7)

44 (29.3)

Total

150 (100)

31 (20.7)

119 (79.3)

150 (100)

Of the 150 pediatric patients, emergence delirium occurred in 17.9% of elective surgeries (19/106) and

27.3% of emergency surgeries (12/44). Although the incidence was higher in emergency procedures, this

difference was not statistically significant, suggesting that factors other than surgery type may also

influence the development of emergence delirium.

Table 4: Management Strategies for Emergence Delirium (n = 31)

Management

Strategy

Number of

Patients (%)

Effectiveness

(%)

Resolved

Delirium

(n, %)

No Effect / Partial

Resolution (n, %)

Complications

Dexmedetomidine

10 (32.3)

90.0

9 (90.0)

1 (10.0)

None reported

Propofol

6 (19.4)

83.3

5 (83.3)

1 (16.7)

Mild sedation

Parental Presence

8 (25.8)

75.0

6 (75.0)

2 (25.0)

None reported

Distraction

Methods

7 (22.5)

71.4

5 (71.4)

2 (28.6)

None reported

Total

31 (100)

—

Among the 31 patients who developed emergence delirium, dexmedetomidine was the most frequently used

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intervention (32.3%) and showed the highest effectiveness, resolving delirium in 90% of cases. Propofol

was used in 19.4% of cases and successfully resolved symptoms in 83.3%, with mild sedation reported as a

complication in one patient. Non-pharmacological strategies, including parental presence (25.8%) and

distraction techniques (22.5%), were also effective, resolving delirium in 75% and 71.4% of cases,

respectively, with no significant complications. These findings indicate that both pharmacological and non-

pharmacological interventions are effective, with dexmedetomidine showing the greatest efficacy.

Discussion

Emergence delirium (ED), also referred to as emergence agitation, is a transient postoperative behavioral

disturbance characterized by restlessness, inconsolable crying, thrashing, and confusion in children

recovering from general anesthesia. In the present study of 150 pediatric patients aged 1–12 years, the

overall incidence of ED was 20.7%. This finding is consistent with previously reported incidences ranging

from 10% to 80%, depending on patient age, type of surgery, anesthetic technique, and assessment tools, as

described by Sikich et al and Lerman et al and Vlajkovic et al and Sindjelic et al [1,2]. The relatively

moderate incidence observed in our cohort may be attributed to advances in anesthetic practice, improved

perioperative pain control, and vigilant postoperative monitoring.

The highest incidence of ED in our study was observed in children aged 4–6 years (38.6%), followed by

those aged 1–3 years (29.5%), while the lowest incidence occurred in the 7–12-year age group (10.9%).

This age-related distribution closely parallels findings reported by Cravero et al. and Bajwa et al., who

identified preschool-aged children as the most vulnerable group for ED [5,4]. Furthermore, Aono et al. and

Kain et al. proposed that the increased susceptibility in younger children may be related to immature central

nervous system development, limited cognitive understanding of the perioperative experience, and

heightened separation anxiety [6,8]. In contrast, older children demonstrate improved emotional regulation

and cognitive adaptability, which likely explains the reduced incidence of ED in the 7–12-year age group.

In the present study, ED occurred slightly more frequently in males (21.6%) than females (19.4%),

although this difference was not statistically significant. This observation aligns with studies by Vlajkovic

and Sindjelic and Mason, both of whom reported no significant gender-based differences in ED incidence

[2,12]. Although earlier research by Aono et al. suggested a marginally higher incidence in boys [6],

contemporary evidence indicates that gender alone is not a major determinant of ED, with perioperative

factors playing a more influential role.

The incidence of ED was higher in emergency procedures (27.3%) compared to elective surgeries (17.9%),

though this difference did not reach statistical significance. This trend is consistent with observations by

Dahmani et al. and Voepel-Lewis et al., who highlighted that emergency surgeries are often associated with

increased anxiety, inadequate preoperative preparation, and heightened psychological stress, all of which

may predispose children to ED [3,9]. The urgency of emergency interventions, coupled with unfamiliar

surroundings and limited psychological reassurance, may further exacerbate postoperative agitation.

Nevertheless, our findings suggest that age and anesthetic technique are stronger predictors of ED than

surgical urgency alone.

The role of anesthetic agents in the development of ED is well established. Volatile anesthetics such as

sevoflurane and desflurane have been strongly associated with a higher incidence of ED due to their rapid

emergence profile and low blood–gas solubility. Studies by Cravero et al. and Bajwa et al. demonstrated

that these agents can result in abrupt awakening and transient confusion, particularly in children with

immature coping mechanisms [5,4]. Similarly, Davis et al. reported a higher rate of agitation following

sevoflurane anesthesia compared to halothane [7]. Although the present study did not stratify ED incidence

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based on specific anesthetic agents, the observed pattern is consistent with these pharmacological findings.

Among the 31 children who developed ED, dexmedetomidine was the most frequently administered

pharmacologic intervention (32.3%) and demonstrated high efficacy, resolving ED in 90% of cases. This

outcome is consistent with findings reported by Sun et al., Kim et al., and Mason, who emphasized the

sedative, anxiolytic, and analgesic properties of dexmedetomidine without significant respiratory

depression [13,14,12]. Propofol, administered in 19.4% of cases, successfully resolved ED in 83.3% of

patients, corroborating earlier studies by Abu-Shahwan and Aouad and Nasr, which supported the use of

low-dose propofol at the end of surgery to attenuate emergence agitation [10,11].

Non-pharmacological interventions also played an important role in ED management. Parental presence

(25.8%) and distraction techniques (22.5%) were effective in resolving ED in 75% and 71.4% of cases,

respectively. These findings reinforce the conclusions of Kain et al., who emphasized that parental presence

and behavioral distraction significantly reduce both preoperative anxiety and postoperative agitation in

children [8]. Such strategies are safe, cost-effective, and easily implementable, making them valuable

adjuncts in pediatric anesthesia practice.

Overall, the findings of this study support existing literature indicating that younger age, perioperative

anxiety, and anesthetic technique are key predictors of ED. Although gender and surgical urgency were not

statistically significant predictors in our cohort, the slightly higher incidence observed in emergency

procedures aligns with observations by Dahmani et al. and Voepel-Lewis et al. [3,9]. These results

highlight the importance of psychological preparedness and individualized anesthetic strategies in

minimizing ED risk.

Clinical Implications

The results of this study underscore the need for a multimodal approach to the prevention and management

of emergence delirium. Dexmedetomidine should be considered the first-line pharmacologic agent, with

propofol serving as an effective alternative when appropriate. Non-pharmacological interventions,

particularly parental presence and distraction techniques, should be routinely incorporated into

perioperative care, especially for preschool-aged children. Preoperative psychological preparation and

anxiety-reduction strategies are also essential. These recommendations are supported by the work of

Dahmani et al. and Mason, who emphasized that such measures significantly improve recovery quality and

safety in pediatric anesthesia [15,12].

Limitations

This study has certain limitations. Its retrospective design relies on the accuracy and completeness of

medical records, which may introduce documentation bias. Additionally, the single-center setting may limit

the generalizability of the findings. The lack of stratification based on anesthetic agents, surgical duration,

and preoperative anxiety scores further restricts detailed risk analysis. Future prospective, multicenter

studies are warranted to validate these findings and to develop standardized protocols for ED prevention

and management.

Conclusion

Emergence delirium is a common postoperative complication in pediatric patients, affecting approximately

20% of children recovering from general anesthesia, with younger age (1–6 years) being the most

significant risk factor. Gender did not influence incidence, and emergency procedures were associated with

a slightly higher, though not statistically significant, occurrence. Effective management requires a

multimodal approach, with dexmedetomidine demonstrating the highest pharmacological efficacy,

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followed by propofol. Non-pharmacological strategies, such as parental presence and distraction

techniques, have also proven beneficial. Early identification of high-risk children and timely interventions

can improve safety, reduce postoperative agitation, and enhance recovery, underscoring the need for

standardized prevention and management protocols.

Conflict of Interest: Nil

Acknowledgment: Gratitude to my department faculty for supporting and encouraging to do my research

projects.

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