Emergence delirium
Aug 14, 2025
Stormy Wake-Ups: Recognising and Managing Emergence Delirium in PACU
Emergence delirium (ED), or emergence agitation, is a temporary disturbance in awareness and cognition occurring as a patient emerges from general anaesthesia. It may present as agitation, confusion, incoherent speech, restlessness, or combative behaviour, posing significant risks to patient and staff safety.
Causes
The cause of ED is largely unknown, however it is thought to arise from a mismatch between the rapid return of motor activity and the slower recovery of brain function. Certain factors that can contribute to its occurrence include:
🔹 Use of fast-acting volatile agents (sevoflurane, desflurane)
🔹 Pain, hypoxia, hypercapnia, or hypotension
🔹 Disorientation to time and place in the PACU
🔹 Pre-existing anxiety or psychiatric conditions
Predictors and Risk Factors
Evidence suggests ED is more likely in:
🔹 Children (especially preschool age) and older adults
🔹 Males - in some surgical populations
🔹 Patients undergoing ENT, ophthalmic, or certain abdominal procedures
🔹 Those with high preoperative anxiety, cognitive impairment, or sensory deficits
🔹 Patients receiving inhalational anaesthesia, high doses of opioids, or benzodiazepines
🔹 Emergency surgery or lengthy anaesthesia
Management in PACU
Early recognition is critical to ensure patient safety. Use structured assessments where possible, but observation remains key—look for sudden agitation, pulling at lines, or incoherence.
Immediate priorities:
- Ensure safety – prevent self-harm or injury to staff, protect airway, and avoid dislodgement of devices. Send for help, or press the emergency button if warranted
- Identify and treat reversible causes – check oxygenation, ventilation, haemodynamics, pain control, and temperature
- Calm environment – reduce noise and other stimuli, offer reassurance, and orient the patient.
- Medications – in severe or dangerous agitation, small doses of sedatives, such as propofol or dexmedetomidine, may be administered by an anaesthetist
ED is usually short-lived but can be distressing and dangerous. Recovery room nurses play a vital role in early detection, supportive care, and prompt escalation to the anaesthetic team, minimising harm and ensuring a smoother recovery.
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Reference:
Lee, S. J., & Sung, T. Y. (2020). Emergence agitation: current knowledge and unresolved questions. Korean journal of anesthesiology, 73(6), 471–485. https://doi.org/10.4097/kja.2009
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