PACU Management and Emergence Delirium

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.