Emergence Delirium in Children for Magnetic Resonance Imaging
Condition: Delirium; Pediatric Disorder; Anesthesia
MeSH terms: Delirium; Emergence Delirium
Study type: Observational

Summary: 
      Sedation or anaesthesia is necessary to be able to perform magnetic resonance imaging (MRI)
      on children who cannot keep still or are uncooperative, and thus the targets of maximum
      patient safety, successful imaging, and the highest imaging quality can be achieved. There
      are various drugs for sedation in MRI. A child with Anaesthesia Emergence Delirium (AED) has
      a state of consciousness which can be described as "irritable, uncompromising, inconsistent,
      crying inconsistently, wailing, and kicking". The incidence of AED worldwide has been
      reported to vary between 18% and 80%, depending on the diagnostic criteria used. This
      difference can usually be explained by the use of different scales and defining criteria. In
      2004, Sikich and Lerman developed the Paediatric Anaesthesia Emergence Delirium (PAED) scale,
      including cognitive evaluation components in addition to agitation behaviours, and the
      validity and reliability of this scale have been proven. In a study of anaesthesia early
      delirium in children by Bong et al.7 a score of ≥10 on the PAED scale was shown to have the
      greatest sensitivity and specificity for the diagnosis of anaesthesia early delirium.

      The aim of this study was to investigate the effect on the occurrence of emergence delirium,
      and recovery, of propofol and ketofol in paediatric patients undergoing diagnostic MRI
      following premedication with intranasal dexmedetomidine and midazolam.
    

Detailed description: 
      This was a prospective, observational, and single-center study conducted between
      July-November 2018. The study protocol was approved by the Local Ethics Committee. The study
      was conducted in accordance with the principles of the Declaration of Helsinki. Written
      informed consent was obtained from the parent.

      The patients were separated into four groups according to the anaesthetic agents
      given.Intranasal premedication was applied to all the patients, then an intravenous cannula
      was placed and the anaesthetic agents were administered intravenously. The Ramsay Sedation
      Scale (RSS) was used to evaluate the level of sedation, with a target of 5 points. The RSS is
      scored from 1-6 as follows: 1: the patient is worried and anxious, or restless, 2: the
      patient is calm and co-operative, and can be directed, 3: the patient only responds to
      instructions, 4: the patient responds rapidly to painful stimuli, 5: the patient demonstrates
      a slow response to painful stimuli, 6: the patient does not respond. When RSS 5 was reached
      following the first bolus dose of the drug, an additional dose was administered. When RSS 5
      was obtained and hemodynamic stability was ensured, the patient was placed on the MRI table.

      The patient was monitored in the recovery room for regaining consciousness for up to 30 mins
      after the procedure. AED was evaluated using the PAED scale by a nurse trained in the use of
      this scale. PAED scoring was repeated every 5 mins until the patient was discharged from the
      recovery room. If the PAED score was ≥10, a diagnosis of AED was made. Adverse events such as
      laryngospasm, desaturation (SpO2 <95%), respiratory depression, bradycardia, allergy,
      hiccoughs, nystagmus, nausea, and vomiting were recorded. When a Modified Aldrete Score of >9
      was obtained, the child was observed for a further 15 mins then transferred from the recovery
      room.
    

Intervention name(s): Outpatient Anesthesia
Intervention type(s): Procedure
Intervention description(s): The inclusion criteria were children aged between 2 and 10 years, undergoing outpatient anaesthesia for elective MRI under sedation, and classified as American Society of Anesthesiologists (ASA) grade I-II. The study exclusion criteria were defined as difficult airway, allergies to the study drugs, asthma, severe central nervous system disease (eg, brain tumour, uncontrolled seizures), mental motor retardation, the application of another procedure after MRI sedation, and those whose parents declined to participate in the study.
Intervention MeSH terms: Anesthetics
Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        children undergoing outpatient anaesthesia for elective MRI under sedation
      
Keywords: MRI scans; pediatric; delirium; anaesthesia