Abstract
Introduction
Post-anesthetic pediatric emergence delirium results in acute confusion and hallucinations during recovery from anesthesia. Early recognition and intervention by peri-operative nurses is crucial, particularly in rural areas where nurses are required to manage a diverse array of medical scenarios. The aim of this review is to enhance awareness among peri-operative nurses of the importance of recognizing and managing post-anesthetic pediatric emergence delirium.
Methods
A narrative review finalized in May 2025 identified literature reporting peri-operative nurses’ experiences recognizing and managing post-anesthetic pediatric emergence delirium. This review utilized the databases PubMed, CINAHL, and Scopus, hand searching and reference list checking to identify relevant articles.
Results
Five core themes specific to post-anesthetic pediatric emergence delirium were distilled: identification, risk factors; diagnostic challenges; post-anesthetic screening tools; and nursing interventions. Commonly used anesthetic agents increase the risk of post-anesthetic pediatric delirium for children undergoing surgery. Implementation of validated screening tools to detect symptoms and initiate interventions is recommended. Nurses have a crucial role in the post-operative monitoring of children, identifying early signs of post-anesthetic pediatric emergence delirium and taking timely action to mitigate its impact to ensure optimal health outcomes. Developing, implementing, and evaluating robust educational strategies to develop nurses’ competency to recognize and respond effectively to post-anesthetic pediatric emergence delirium are recommended.
Conclusion
While post-anesthetic pediatric emergence delirium is not well understood, it is essential that peri-operative nurses are familiar with this phenomenon and are able to recognize and initiate appropriate interventions. This is particularly important in rural health care environments given the generalist nursing staff profile.
Introduction
Post-anesthetic pediatric emergence delirium presents as complex psychomotor agitation and perceptual disturbances that usually develop immediately following emergence from anesthesia (Kamienski et al., 2019; Ringblom et al., 2022). Symptoms indicating a child is experiencing post-anesthetic emergence delirium include confusion, restlessness, hyperkinesis, and hallucinations (St. Rose et al., 2022; Wang et al., 2023). The etiology of post-anesthetic emergence delirium in the pediatric population is poorly understood (Mason, 2017; Wong & Bailey, 2015). There is evidence that children who experience post-anesthetic emergence delirium that is undetected or untreated, have an extended length of hospital stay, prolonged recovery, can experience physical harm and a range of behaviors such as apathy and withdrawal, sleeping and eating disorders, and separation anxiety (Kamienski et al., 2019; Klabusayová et al., 2022).
Post-anesthetic pediatric emergence delirium can cause significant psychological distress to patients and families. Thus, nurses need to recognize and respond to post-anesthetic pediatric emergence delirium to reduce the impact of psychological distress (St. Rose et al., 2022; Wang et al., 2023). While this condition has been clearly described, nurses’ capacity to identify symptoms of this phenomenon, and intervene to limit the impact is compromised by misunderstanding and poor screening (Mason, 2017). To minimize the associated risks, nurses, particularly those working in rural located environments with limited access to a specialist anesthetist and other medical support, must be able to recognize and promptly respond to a child who develops post-anesthetic pediatric emergence delirium.
Purpose of this Review
This review seeks to enhance awareness among peri-operative nurses about the importance of recognizing and managing post-anesthetic pediatric emergence delirium.
Why is this Review Important?
To illustrate the importance of this review, this vignette as experienced by the first author graphically demonstrates the impact of a lack of awareness on both the child and caregiver when peri-operative nurses are unable to recognize post-anesthetic emergence delirium.
When my daughter was two-and-a-half years old, she was admitted to day surgery for examination under anesthesia in a rural acute care hospital. She had been experiencing recurrent nosebleeds lasting up to 30-min. The surgery was to identify any obvious nasal injury that could be cauterized and insert grommets in her ears to relieve the build-up of fluid impacting her hearing.
On the day of the procedure, she was calm and settled, even during the induction of anesthesia. The procedure itself was brief, lasting under an hour. She was then transferred to the recovery unit. When I was called to her side, she was asleep but woke up a few minutes later. She was given an ice block and transferred to the day surgery unit where she fell asleep again.
When she woke next, it was apparent that she was not fully conscious. Although she sat up, her eyes remained closed, and her movements were unfocused. At the same time, she seemed to be crying, but without tears. Despite my attempts to settle her, she did not respond and seemed to be unaware that I was there. I was worried for her safety given the bed rails had no soft covering. I tried to hold her to stop her injuring herself. This was difficult as she was thrashing around. I asked another parent to ring the call bell.
When the registered nurse arrived she suggested my daughter might be upset or throwing a tantrum, saying I could open the curtains to distract her by looking outside. It was apparent the nurse did not recognize my daughter's behavior as concerning. As a registered nurse with experience in pediatric anesthesia, I was concerned my daughter was experiencing post-anesthetic pediatric emergence delirium. I conveyed my concerns and asked the registered nurse to contact the anesthetist promptly. She simply dismissed my concerns and walked away.
After a second request for assistance also failed. I decided to use the REACH (Patient and Family Activated Escalation) system, which allows families to escalate their concerns. I informed the nurse that I would contact REACH and asked her to initiate a Medical Emergency Team (MET) call. Again, I expressed my anxiety about possible injury to my daughter or myself. The nurse simply attempted to contact the nurse unit manager, initially without success. Eventually, both the clinical nurse educator and the nurse unit manager arrived. I reiterated my concerns about the unusual nature of my daughter's behavior and suggested that the anesthesia might not have been properly reversed, resulting in a post-anesthetic pediatric emergence delirium. Although still reluctant to act, a MET call was initiated.
When the emergency team arrived, they quickly confirmed my daughter was experiencing post-anesthetic pediatric emergence delirium and immediately transferred her back to the Post-Anesthetic Care Unit. Sedatives and analgesia were administered intravenously after which she woke up settled and calm. She was transferred back to the day surgery unit and discharged later that day.
On returning home, my daughter displayed persistent behavioral changes including disrupted sleep and was withdrawn. This continued for about 6 months before she returned to her usual, bubbly self. Even now, her sleep remains somewhat restless, a notable change from before this experience. Fortunately, there have been no other significant issues, and she is otherwise well.
This challenging personal experience motivated me, as both a registered nurse and academic, to collaborate with my academic colleagues in reviewing research on peri-operative nurses’ ability to identify and manage post-anesthetic pediatric emergence delirium. The experience underscored the need to enhance awareness of post-anesthetic pediatric emergence delirium among registered nurses caring for children undergoing surgical procedures.
Methods
Search Methods
After initial review of the literature, a narrative literature review was identified as the most suitable method for exploring this subject given the limited papers available, the heterogeneous nature and quality of available evidence. Narrative reviews provide a comprehensive description, analysis, and summary of the current major literature on a topic (Sukhera, 2022). In this review, research focused on peri-operative nurses’ experiences in identifying and managing post-anesthetic pediatric emergence delirium was sought. The PCC framework informed the development of the search strategy. Population: Pediatric peri-operative nurses; Concept: Detection, assessment and management of pediatric post-anesthetic emergence delirium; and Context: Peri-operative period in hospital
The literature search was conducted from 4–24 October 2024, by Author 1 and rerun on 29 May 2025 by Author 5, with support from a senior university librarian, using PubMed, CINAHL, and Scopus databases. A search strategy involving Boolean operators AND/OR was used to combine Medical Subject Headings terms with keywords (Berkenstadt et al., 2008). Table 1 details the search strategy as applied to PubMed.
PubMed Search Strategy.
Inclusion/Exclusion Criteria
The search was confined to articles in English, including peer-reviewed primary research with no date restrictions (Table 2).
Inclusion and Exclusion Criteria.
From an initial 404 articles, duplicates were removed, leaving 259 articles whose abstracts were reviewed. Articles that did not meet inclusion criteria were excluded. Full texts of the 13 articles were closely examined, and their reference lists were searched for additional relevant studies. Eight were excluded following assessment for eligibility. Hand searching of relevant institutional repositories, including conference abstracts where available, and manual review of reference lists of included studies followed. An additional manual search of Google Scholar, PubMed, and Scopus using targeted keywords to identify additional unpublished or non-indexed material identified two further eligible studies.
Assessment against the Joanna Briggs Institute Critical Appraisal Checklists for Case Reports and Analytical Cross-Sectional Studies was undertaken by four of the authors who conducted a double-blind review. Following the double-blind review, a fifth team member resolved any identified discrepancies. Seven articles were identified as meeting the inclusion criteria (Figure 1 for PRISMA flow diagram).
PRISMA flow diagram.
Data was extracted to an Excel spreadsheet. One author extracted, compiled and summarized the data. A summary table (Table 3) was compiled with author(s), country of study, publication date, aims/objectives, study design, study population, data sources, (analysis where applicable), and results/key findings. All team members independently reviewed and validated the extracted data for accuracy. Through collaborative discussion, preliminary codes were generated based on recurring concepts and codes then iteratively refined into themes. Differences in interpretation were resolved through discussion until agreement was reached. This process ensured that the thematic synthesis was rigorous, transparent, and grounded in the data.
Summary Table of Included Studies.
F: Female; M: Male; PACU: post-anesthesia care unit; PAED: Pediatric Anesthesia Delirium Scale.
Results
Characteristics of Studies
Of the seven included studies, five were undertaken in the USA (Hajdini et al., 2024; Hudek, 2009; Kamienski et al., 2019; Voepel-Lewis et al., 2005, 2007), one in China (Lin et al., 2021), and one in Sweden (Sjöberg et al., 2025). These comprised two observational studies, three case reports, one quantitative and one qualitative study. Included studies were published between 2005 and 2025.
Systematic appraisal of the studies identified five themes related to nurses’ capacity to recognize and respond effectively to a child who is at risk or has developed post-anesthetic pediatric emergence delirium. These are illustrated in Figure 2.
Themes.
Each of these themes will be examined separately.
Theme 1: Ability to Recognize the Occurrence of Post-Aanesthetic Emergence Delirium
Each study emphasized that nurses who provide pediatric peri-operative nursing care should have the ability to recognize when a child is experiencing post-anesthetic emergence delirium. Children who are distressed prior to surgery and those who are mechanically ventilated are at heightened risk of developing this form of delirium (Kamienski et al., 2019; Lin et al., 2021). In the post-anesthetic period, symptoms associated with this form of delirium are most likely to occur within 15–30 min (Hudek, 2009). However, some children can experience delayed onset of post-anesthetic emergence delirium (Voepel-Lewis et al., 2007). Voepel-Lewis et al. (2007) described a male child aged 5 years who was discharged after an uneventful recovery from a minor surgical procedure. The child developed symptoms indicative of post-anesthetic emergence delirium on the drive home approximately 110 min later. His mother returned to the hospital emergency department where the child was treated for post-anesthetic emergence delirium.
Symptoms indicative of post-anesthetic pediatric emergence delirium include both physical and emotional symptoms such as agitation, irritability, fretfulness, and restlessness (Voepel-Lewis et al., 2005). The child may also be emotionally distressed and exhibit out-of-character behaviors such as uncooperativeness, yelling, crying, kicking, and biting (Voepel-Lewis et al., 2005).
Theme 2: Identifying Children at Risk
A growing body of research indicates that screening for post-anesthetic pediatric emergence delirium, recognizing symptoms and initiating strategies to alleviate the symptoms is achievable using non-pharmacological, pharmacological, and non-invasive strategies (Hudek, 2009; Kamienski et al., 2019; Voepel-Lewis et al., 2005). Children at greatest risk of developing post-anesthetic emergence delirium are those aged 0–2 years although, all children including those with a developmental delay are potentially susceptible (Kamienski et al., 2019; Lin et al., 2021). Risk factors also include the severity of illness, parental and child distress, type of surgery, post-operative pain, and pre-existing medical conditions (Hudek, 2009; Lin et al., 2021). A range of anesthetic agents (such as dexmedetomidine, propofol), and medications (such as benzodiazepines, opioid receptor antagonists, neuromuscular blockers, anticholinergics, and corticosteroids) (Hudek, 2009; Lin et al., 2021) may increase the risk of delirium. Children who experience a large intra-operative bleed and emerge from anesthetic agents faster than expected are also at increased risk (Hudek, 2009). Nursing staff involved in Voepel-Lewis et al.'s (2005), Voepel-Lewis et al. (2007), and Sjöberg et al. (2025) research, also considered children who were in pain, anxious, hungry, thirsty, awakened too early, had a distended bladder or requested the intravenous catheter be removed, as being at risk. Nurses who are familiar with known risk factors are likely to identify children experiencing this form of delirium and initiate actions to limit the impact (Hudek, 2009; Kamienski et al., 2019; Lin et al., 2021).
Theme 3: Recognition and Diagnostic Challenges
Recognizing the symptoms indicative of a child experiencing post-anesthetic emergence delirium and initiating interventions is the expectation; however, there are challenges associated with these aspects of post-anesthetic care. If symptomatic children post-anesthesia are to be recognized and appropriate interventions implemented, nurses need to understand the etiology of this phenomenon and respond in a timely manner (Kamienski et al., 2019; Lin et al., 2021). To ensure best possible outcomes, identifying risk factors prior to surgery and instigating appropriate pediatric assessment processes to guide care, pre- and post-operatively, is advocated (Kamienski et al., 2019; Lin et al., 2021; Voepel-Lewis et al., 2007).
Communicating with pediatric patients can be difficult (Sjöberg et al., 2025), requiring nurses to utilize a range of age-appropriate techniques that include being calm, using simple language, and being reassuring when providing and or gathering information from pediatric patients. Hudek (2009) recommends that when nurses engage with pediatric patients post-anesthesia they use “reality orientation” to assist the children understand where they are. Having a parent/s or carer/s present in the Pediatric Post-Anesthesia Care Unit (PACU) is an accepted and useful strategy to reorient and comfort pediatric patients and is cited as aiding alleviation of distress in children (Hudek, 2009; Sjöberg et al., 2025). Ensuring the post-operative recovery environment is peaceful has been highlighted as a determinant for positive emergence from anesthesia (Hudek, 2009).
Pain is a known risk factor for children developing post-anesthetic delirium (Kamienski et al., 2019; Lin et al., 2021). Determining pain status and ensuring adequate pain relief is expected; however, skilled assessment techniques are required to determine the level of pain and the appropriate intervention (Hudek, 2009; Voepel-Lewis et al., 2005). Utilization of both pharmacological and non-pharmacological strategies to relieve pain, improve respiration, and reduce anxiety is recommended. Position changes, encouraging deep breathing techniques, and having family members assisting are examples of non-pharmacological interventions to reduce pain (Hudek, 2009). Provision of information (verbal and written) to parents of children pre-surgery regarding symptoms of post-anesthetic emergence delirium, contact details, and directions if symptoms are identified is recommended (Hudek, 2009).
Theme 4: Validated Screening Tools
The studies included in this review emphasized post-anesthetic pediatric emergence delirium as discrete from delirium in adults and older people post-anesthetic. In the absence of a comprehensive screening tool to differentiate potential causes of post-anesthetic emergence delirium, Voepel-Lewis et al. (2005) reported on the development of a post-anesthetic agitation algorithm. This algorithm enabled clinicians to identify and respond appropriately to physiological factors, pain, and anxiety prior to concluding that the child's agitation could be attributed to a drug-induced delirium (i.e., post-anesthetic pediatric emergence delirium). Described as a clinical decision-making framework, this tool enables nurses to implement appropriate interventions to effectively manage post-anesthetic pediatric emergence delirium. Of note, Voepel-Lewis et al. (2005) cautioned that this algorithm was developed in the context of a PACU staffed by experienced PACU nurses. Voepel-Lewis and colleagues’ case report utilized this same algorithm (Voepel-Lewis et al., 2007).
Hudek's (2009) case report highlighted the need to identify underlying factors that may be attributing to a possible emergence delirium. However, both the recommended Richmond Agitation-Sedation scale (Sessler et al., 2002) and the Riker Sedation-Agitation scale (Riker et al., 2001) were developed for and validated in adult populations only.
Kamienski et al.'s (2019) case report referenced two pediatric specific scales. The Pediatric Anesthesia Delirium Scale (PAED) developed and evaluated by Sikich and Lerman (2004) specifically to standardize measurement of transient emergence delirium in children and the Cornell Assessment of Pediatric Delirium (CAPD) (Traube et al., 2014). Adapted from the PAED, the CAPD was developed to measure fluctuations in delirium across the duration of a nursing shift. It is regarded as a rapid observational screening tool suitable for children of all age groups. Lin and colleagues contend this tool is the only “tool that has been validated across the entire paediatric age range” and assert that the tool can “successfully discriminate between delirium and other causes of altered mental status” (Lin et al., 2021, p. 2). The findings from Hajdini et al.'s (2024) study yielded a statistically significant reduction in the assessment and treatment times when nurses used the PAED scale in comparison to another tool. This is worth noting as reliable and efficient methods are essential in improving the assessment processes and patient safety.
Lin and colleagues used an authorized Chinese version of this tool to screen for post-anesthetic pediatric emergence delirium in their study (Lin et al., 2021). Nurses who were skilled in assessment of children post-operatively using the CAPD collected data from 1, 134 children (Lin et al., 2021). A total of 126 out of 1, 134 children in the Lin et al., (2021) study were diagnosed with post-anesthetic pediatric emergence delirium (prevalence rate of 11.1%). This prevalence rate of post-anesthetic pediatric emergence delirium demonstrates the importance of health professionals screening for post-operative delirium using a validated tool (Lin et al., 2021).
Hajdini et al. (2024) further added that integrating the post-anesthetic pediatric emergence delirium also requires targeted education and updated clinical guidelines to improve the nurses’ confidence in undertaking the post-operative assessment processes. Sjöberg et al. (2025) emphasized the need for including monitoring vital signs such as pulse and respiration as well as clinical judgements over and above using the post-anesthetic pediatric emergence delirium tools. These recent publications highlight the importance of comprehensive pediatric post-operative assessments.
Theme 5: Nursing Treatments and Interventions
The ability to recognize that a child is experiencing post-anesthetic emergence delirium is essential. Recognition alone is insufficient, nurses need to implement efficacious nursing interventions to effectively support the child, reduce the length of the delirium, and decrease the likelihood of longer-term sequalae. The algorithm developed by Voepel-Lewis and colleagues (2005), listed a range of actions to be initiated. These include discontinuation of the “causative agent,” reversal, if possible, avoidance of other agents known to precipitate delirium, instigation of supportive care, and the administration of medication as required.
Each of the three case reports documented individual cases of emergence delirium. Voepel-Lewis et al. (2007) described the administration of multiple medications (midazolam, lorazepam, and phenobarbital) to a child experiencing delirium without effect. The patient eventually had a positive outcome after flumazenil was administered by nurses in consultation with the anesthesiologist (Voepel-Lewis et al., 2007). Hudek (2009) described a possible unrecognized emergence delirium that resulted in transfer to another facility post re-anesthetizing a 13-year-old girl. Kamienski et al. (2019) described a child scoring 5 on the PAED (i.e., the child was inconsolable), whose post-anesthetic recovery period was longer than expected. Post-discharge, the child displayed behavioral changes requiring therapeutic interventions for 9 months.
Reuniting the child with their parent was identified by Voepel-Lewis et al., (2005), as most effective with the time taken to implement this intervention having a positive correlation with the duration of the patient's post-anesthetic pediatric emergence delirium. Reuniting children with parents calmed 71% of those who experienced post-anesthetic pediatric emergence delirium in comparison to administration of analgesia/anxiolytics which only calmed 18% of these children (Voepel-Lewis et al., 2005). Sjöberg et al. (2025) assert that reuniting parents with their child postoperatively provides a sense of security for their child as they have better knowledge of their child's behaviors than the nurses. The nurses, however, have overall responsibility for closely monitoring children post-anesthetic. The administration of analgesia to manage patient's post-anesthetic pediatric emergence delirium was identified as the second most effective intervention after re-union with the parent (Voepel-Lewis et al., 2005). In the same study, only some nurses collaborated with the child's parent and other health professionals (Voepel-Lewis et al., 2005). Notably, those who had more than 8 years’ experience in the Post-Anesthetic Care Unit were more likely to engage in collaborative care with parents and other health professional than those with less experience (Voepel-Lewis et al., 2005).
Discussion
How do the Results of the Selected Studies Relate to the Purpose of this Review?
Post-operative pediatric emergence delirium was initially reported in the early 1960's (Vlajkovic & Sindjelic, 2007), however, despite the evidence that post-operative pediatric emergence delirium is recognizable and can be managed there is a dearth of nursing research, particularly Australian nursing studies on this topic. The vignette presented highlights the need for nurses to be familiar with symptomology of post-anesthetic pediatric emergence delirium. Nurses employed in rural located hospitals have limited access to anesthesiologists and other medical staff and therefore must be familiar with potential complications that may arise following surgery particularly in vulnerable groups including pediatric patients (Hibberson, 2019; Muirhead & Birks, 2019).
Recent studies have highlighted both the global prevalence and risk factors for emergence delirium in pediatric patients undergoing general anesthesia, particularly identifying the increased prevalence in children undergoing head and neck surgeries (Aniley et al., 2024; Chen et al., 2024). The need for nurses to fully comprehend both the prevalence and risk factors is emphasized, with recommendations that increasing staff capabilities, may impact recognition and timely intervention. (Chen et al., 2024). The risk factors identified in these studies are consistent with previous literature (Kanaya, 2016; Shin et al., 2021; Voepel-Lewis et al., 2003; Weldon, 2007) (see Table 4: Post-anesthetic pediatric emergence delirium risk factors).
Post-Anesthetic Pediatric Emergence Delirium Risk Factors.
Information compiled from: Chen et al., (2024); Hudek, (2009); Kamienski et al., (2019); Kanaya, (2016); Lin et al., (2021); Shin et al., (2021); Voepel-Lewis et al. (2003), Voepel-Lewis et al., (2005), and Weldon, (2007).
To facilitate early recognition of post-anesthetic pediatric emergence delirium, nurses should have adequate knowledge of post-anesthetic pediatric emergence delirium, the etiology, and risk factors (Hudek, 2009). Essential to detection is knowing that pediatric post-anesthetic emergence delirium can occur within 15 to 45 min post-anesthetic and may last from 31 to 60 min and even longer in some cases (Huett et al., 2017; Nair & Wolf, 2018). Awareness of when and how long pediatric post-anesthetic emergence delirium occurs enables nurses to be alert for symptoms indicative of this phenomenon. The importance of ensuring parents are aware of the potential for behavioral disturbances continuing post-discharge for children who have experienced pediatric emergence delirium has recently been highlighted (Houben et al., 2024).
Monitoring for signs of post-operative pediatric emergence delirium and acting promptly limits the potential for complications (Hibberson, 2019). Failure to implement a structured screening tool may result in the diagnosis being missed for three in four patients (Menser & Smith, 2020). Accurate diagnosis necessitates the use of appropriate screening tools given the complexity of pediatric post-anesthetic emergence delirium which mimics other forms of agitation. Each unit should implement protocols for pediatric post-anesthetic care that include the routine use of validated screening and monitoring processes, and actions to be taken. The protocol must include a prompt request for anesthetist review in conjunction with initiating appropriate nursing interventions when a child is identified as experiencing post-anesthetic pediatric emergency delirium.
The multiple risk factors associated with this phenomenon further support the use of appropriate screening tools to enable timely recognition and management. However, despite the necessity for accurate and timely detection of pediatric post-anesthetic emergence delirium, only a few clinicians are reported to use a screening tool (Huett et al., 2017). Notable was the failure to re-evaluate the child's condition post initial implementation of interventions resulting in multiple ineffective treatments (Huett et al., 2017). Not only should screening tools be used for routine screening, but ongoing assessment is also required to prevent complications associated with the pediatric post-anesthetic emergence delirium (Mason, 2017).
The pediatric post-anesthetic emergence delirium screening tools identified in this review (CAPD, the PAED), and The Richmond sedation—agitation scales) are recommended in current literature as assessment effective tools (Petre et al., 2021; Stamper et al., 2014). This review highlights that the failure by nurses to use pediatric post-anesthetic emergence delirium screening tools results in underdiagnosis and ineffective nursing interventions/treatments.
Evidence-based post-anesthetic pediatric emergence delirium management depends on a multi-factorial response beginning with an accurate patient assessment prior to surgery to identify a child at risk. Discussing the risk with parents and carers prior to surgery is recommended and encouraging parents and carers to talk and read to their child. Effective use of validated standardized screening tools is required in conjunction with prompt initiation of both nursing and medical interventions. Interventions include administration of analgesia and anxiolytics and re-uniting the child with their parent (Currie, 2015). A reliance on medication alone may be ineffective. Re-uniting the child with their parent was highlighted as the most appropriate nursing intervention; however, the effectiveness of this intervention was influenced by the time it took for implementation (Snell, 2017; Voepel-Lewis et al., 2005). Active collaboration with parents and caregivers both pre-operatively and post-operatively is an essential component of effective management.
While each of these interventions implementable by nurses emerge from the reviewed studies, identifying the most appropriate non-medication strategy has been described as challenging (Kim et al., 2024). An absence of nursing research assessing the impact of combining several of these strategies has recently been highlighted (Earwaker et al., 2024). Likewise, there is a need to undertake research evaluating a combination of medication and non-medication measures when managing pediatric emergence delirium (Earwaker et al., 2024).
Study Strengths and Limitations
This narrative review aimed to increase awareness among peri-operative nurses of the critical importance of identifying and addressing post-anesthetic pediatric emergence delirium. One of the strengths of this review is the impetus for undertaking the review, i.e., the real-world experience of the first author that drew attention to this gap in nurses’ awareness. A further lies in the systematic search undertaken for studies published on this topic. Peer-reviewed research pertaining to this subject was collated while the comprehensive analysis of each article facilitated the development of themes and key findings pertinent to nursing practice. While narrative reviews are described as limited by inherent constraints such as potential biases in objectivity, and limitations in the scope of the literature search, a systematic search supported by an experienced health librarian was undertaken to overcome this potential limitation (Basheer, 2022). A key limitation was the scarcity of nursing focused eligible studies for inclusion with available studies mostly case reports. Only studies and case reports published in English were considered. The phenomenon of pediatric post-anesthetic emergence delirium as recognized and responded to by pediatric nurses has not been widely reported with robust nursing research.
Implications for Practice
This review has provided insights into the peri-operative nurses’ experiences of recognizing and responding to post-anesthetic pediatric emergence delirium. It is evident that improving nurse's recognition of and implementation of interventions to limit the impact of this syndrome is crucial. The results from this review can be used to inform educational interventions to improve the identification of the post-anesthetic pediatric emergence delirium and implementation of appropriate responsive nursing interventions to enable better patient health outcomes.
In view of the identified challenges in peri-operative nurses’ detection and management of the post-anesthetic pediatric emergence delirium, this aspect of pediatric nursing care must be a key competency. Consideration should be given to incorporating this topic in all pre-service nursing curriculum to improve graduating nurses’ knowledge of post-anesthetic pediatric emergence delirium. Routine screening for emergence delirium post-anesthetic is needed to enable accurate recognition and appropriate intervention to limit the impact of this phenomenon. Incorporating competency in screening for post-anesthetic pediatric emergence delirium by nurses in rural emergency departments and pediatric units is integral to ensuring that the issues presented in the vignette are not experienced by other parents and children.
Given the limited studies, related to the peri-operative nurses’ experiences of recognizing and responding to post-anesthetic pediatric emergence delirium, this review provides evidence of the need for further research in this topic area. Research should be specifically focused on developing, implementing, and evaluating educational interventions that will improve nurses’ ability to both recognize and respond to a child displaying symptoms indicative of pediatric post-anesthetic emergence delirium.
Conclusions
Nurses play a vital role in caring for children after surgery, particularly given the risk of post-anesthetic emergence delirium. From the studies reviewed, it is evident that having straightforward protocols assists nurses to recognize early warning signs, use gentle, non-invasive approaches, and call on medical staff such as anesthetists when needed. Acting early not only improves outcomes for the child but can also shorten their hospital stay and ease pressure on families and the health system. Additional research is also needed to determine the efficacy of current screening tools and interventions; and establish whether other approaches, including those involving parents, should be routinely incorporated in the post-operative period.
Footnotes
Acknowledgments
The authors would like to thank Lorraine Rose (Academic Librarian) for guiding the development of the search strategy
Ethics Statement
Ethics approval was not required for this literature review.
Authors’ Contributions
Author 1 proposed the initial concept idea, conceived, and designed the literature review protocol with Authors 2, 3 4, and 5. All authors developed the search strategies under the guidance of a senior Academic Librarian. Authors 1–4 undertook the study selection, data extraction, and study quality assessment. Author 1 contributed the vignette with the assistance of Author 2 and Author 5 drafted the vignette, Author 1 checked the vignette for accuracy, Authors 2–5 wrote the first draft of the manuscript. All authors discussed and revised the manuscript. All authors read and accepted the final version and agree to be accountable for all aspects of the work.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declare no potential conflicts of interest with respect to undertaking the literature review, authorship, and submission of this article.
Patient or Public Contributions
This is a narrative review of published primary evidence. The included vignette is a personal experience written by the first author.