Specific Postoperative Problems
Emergence Delirium
Pediatric patients will on occasion emerge from anesthesia disoriented
and inconsolable. This phenomenon is termed emergence delirium or emergence agitation
and may even require restraint of the patient. Emergence delirium has been associated
with the use of less soluble anesthetics as opposed to more soluble anesthetics such
as halothane.[205]
Adequate analgesia with opiates
or NSAIDs may reduce the incidence of delirium. Inviting the parents to visit in
the PACU may help calm a child. When evaluating a patient with suspected emergence
agitation, life-threatening complications such as hypoxia, acidosis, or increased
intracranial pressure should be ruled out.
Postintubation Croup
Postintubation subglottic edema is a complication that can occur
in 1% to 6% of patients younger than 4 years. Even a minimal amount of airway edema
can cause significant obstruction, especially at the level of the cricoid cartilage,
the narrowest section of the pediatric airway. Patients who have a history of Down's
syndrome or other congenital airway stenosis, a surgical procedure in and around
the airway, recent upper respiratory infection, coughing on the endotracheal tube,
prone position, or traumatic intubation are at increased risk.
Appropriate therapy includes cool mist by face tent and nebulized
racemic epinephrine (0.5 mL of 2.25% epinephrine in 2.5 mL of normal saline). Corticosteroids
such as dexamethasone have also been used to treat airway edema, but no data support
their routine use for postintubation subglottic edema. Rarely does a patient require
reintubation.
Postanesthetic Apnea
Former preterm infants (born before 37 weeks' gestation) are at
increased risk for apnea and bradycardia after even uncomplicated anesthesia.[206]
These events may be secondary to underlying neurologic, cardiac, or pulmonary disease.
[207]
Patients with anemia are at higher risk for
apnea.[208]
Ex-preterm infants who are less than 45 to 60 weeks' postconceptual
age (depending on the policy at the facility) are admitted for monitoring after surgery
for at least 12 to 18 hours. The overall risk of apnea in patients less than 48
weeks' postconceptual age is 5%, and this risk does not decrease to less than 1%
until patients reach 54 weeks' postconceptual age. Intravenous caffeine, 10 mg/kg,
has been used to treat apneic episodes in preterm infants and has been recommended
for prophylaxis against postoperative apnea.
