What is Emergence Delirium?

As an anesthesiologist I have answered every question about the risks of anesthesia before procedures. I understand, it can be scary.  Including questions like: “my child just had her tonsils out, why is she acting like a child possessed?” “My child just had ear tubes and he woke up and is hitting me and doesn’t know who I am.  What is going on?” My answer to these questions: Emergence delirium.  But before I tell you what that is, let me explain how anesthesia works.

When we have a surgical procedure, we often refer to “going to sleep” for the surgery, and the anesthesiologist is often referred to as “the sleep doctor.”  In reality, anesthesia is nothing at all like sleep. If we were to look at what is happening in the brain, the brainwaves we would see on an EEG would not resemble sleep. The child under an anesthetic may look like they are asleep, but that’s where the similarities end.

There are a multitude of drugs that we use to induce and maintain an anesthetic, and unlike medicines that you take at home, these drugs are very potent and also very short acting. So short in fact, that we have to continuously administer them to keep someone anesthetized. Some of the most potent medicines that we use are gasses, and we get them into the body by having the patient breathe them. For children, this is quite convenient because it avoids the all-terrifying shot. In a complex but elegant process, the inhaled medicines pass through the lungs, into the blood stream, and then into the brain, where they take their effects and induce unconsciousness.

At this point, surgery commences and we get down to why you brought your child to the hospital in the first place. Once the surgery is over, it’s time to “wake the patient up.” The anesthesiologist will have been preparing for this moment for quite awhile and has been administering an appropriate amount of pain medicines and begins titrating off the anesthesia gasses so that the patient emerges from anesthesia within a few minutes of the surgery’s end.

That amazing process of putting the child “to sleep” now reverses. The body doesn’t metabolize the anesthetic gasses in the same way as, say, an antibiotic that your pediatrician may prescribe for strep throat. So, rather than relying on your body to break down the drugs, our anesthetic gasses are exhaled more-or-less unchanged. The drugs dissolve out of the brain and back into the blood, and then into the lungs. This is one reason why your daughter’s breath smells so strange after surgery. Then, it’s off to the recovery room, where your daughter will gradually emerge from anesthesia, oftentimes actually slipping into a true sleep. After a short period of time, we’ll gently wake her up from her nap, and reunite her with her family; she may be a little sleepy, or a little groggy at first, but in a few hours, she’ll be as good as new.

That’s how it’s supposed to work, and most of the time, that’s exactly how it works. But people (and children in particular) do not always emerge from anesthesia in such a gentle fashion. Sometimes, children wake up acting like they are possessed.  hey are irritable, combative, inconsolable, or uncompromising. They do not recognize familiar objects or people. Oftentimes the child is thrashing around in bed, eyes closed, incoherent, kicking and crying. These are symptoms of emergence delirium, sometimes also known as emergence excitation or emergence agitation, which was first reported in the early 1960’s. It’s a shocking sight, and for those not previously initiated to the event, can be quite frightening.

The condition has been observed after anesthetics of all types: from ether, the first anesthetic, to our newest and greatest medicines. Unfortunately, no one is completely certain why this phenomenon occurs. It ranges in incidence from 10-80 percent. Such a broad range of incidence exists because it’s been difficult for us to come up with a set of criteria to describe it. Is a child crying in the recovery room because he is suffering from emergence delirium, in pain, missing Mom, or does he just really not like his IV?

There is a component of pain in emergence delirium, but we’ll also often see it after an MRI, which causes no pain. Some surgeries have a higher incidence as well; these include tonsil and adenoidectomies, eye surgery, and middle ear surgery. There is a component of unfamiliarity, but we often also see it when the parents are present in the recovery room. Children and parents who are especially anxious prior to surgery are also at higher risk of having the child develop emergence delirium in the recovery room. But we sometimes also see it even if we pre-medicate a child with a sedative or anti-anxiety medicine prior to coming into the operating room. Children aged 2-5 years seem to have a higher incidence of emergence delirium. There are other child-specific characteristics that may also be associated with emergence delirium, but again, those are harder to define and therefore study.

So, why does emergence delirium happen? Honestly, nobody really knows. Some speculate that it has to do with the immaturity of the brain, others with the rapidity with which the anesthesia drugs leave the brain. Others point to the surgery itself, or the temperament of the child. This all leaves us in a quandary. If we don’t know why it happens, how can we predict it, and how can we prevent it? Multiple different anesthetic techniques and medications have been tried. And they have all been found to be helpful, although maybe not to the extent we would want, and definitely not to the point where the incidence is zero percent.

The good news is that emergence delirium is not permanent, and does not cause any long-term side effects. In most cases, we tend to ride out the storm, which passes after 5-15 minutes. That’s not to say that harm cannot occur during an episode of emergence delirium. Such a child usually requires extra hands to help the recovery room nurse keep the patient from pulling out IV catheters, dressings, or drains. We also have to ensure that the child doesn’t injure himself on the bed or harm the surgical site.

If we are faced with an especially robust bout of emergence delirium, we will give additional sedatives. I think of this sort of like a soft reset for your phone or computer. We quickly put the child back “to sleep” and then let them “wake up” again. That almost always works. Reuniting children with their parents tends to help as well.

Although I have no scientific data to back this up, I feel that there is a fundamental difference between an adult emerging from anesthesia and a child. When an adult emerges from an anesthetic they are confused and disoriented. They look around, see that nobody looks like they are going to kill them, and they all seem friendly enough. Then, some part of them remembers that “oh yeah, I came in for surgery.” As a child emerges from anesthesia, they too are confused and disoriented. But in this case, all they know is that, this nurse isn’t “Mom.” Emergence delirium is real, and it’s frightening to witness. While we may not completely understand how it happens, we are prepared, and we are adept at treating it – whether with sophisticated medications or a caring touch, or the irreplaceable comfort of Mom or Dad.

Marco Corridore, MD
Marco Corridore, MD, is an attending anesthesiologist at Nationwide Children's Hospital and the The Heart Center as well as a Clinical Assistant Professor of Anesthesiology at The Ohio State University College of Medicine. Dr. Corridore and his wife have two children, a 10-year-old son and an 8-year-old daughter. His interests include music, hiking and traveling.

7 thoughts on “What is Emergence Delirium?

  1. My daughter had her wisdom teeth out 2 weeks ago. Since then she is seeing things acting very strange with involuntary body movement, bouts of hysteria, delirium, weird head movement, facial gestures, rolling her eyes all around and black outs. She is on meds for bipolar, ADHD anxiety and odd. Anyone ever have any problems like this? I am at the end of my rope with ideas!

  2. Bob Hutchinson on said:

    My girlfriend who is 58 had her appendix out 2 years ago. After surgery she was irate and she was imagining her daughter and I were planning to kill her. The nurses said that happens sometimes from anesthesia and they said it would pass. It did after about 2 weeks. But then every few months she would fly into a rage for no reason. She left and went to her mothers at least 5 times. And finally in Sept it was for good.

  3. I have emergence delirium. I have experienced it four times. It was not until the 3rd time that it was identified as immersion delirium. I get combative, belligerent, suspicious, paranoid and a danger to staff and myself. Now at 65 years old, I explain the condition when I meet with anesthesia. My last surgery went well enough in PACU. Once on the nursing floor I was suspicious and questioned everything. When I did not get an answer I liked from the nurse,I pressed her, she pressed back, that was a mistake. I demanded the Supervisor, I got restrained and the nurse got trained. The RN should have known enough about “me,” so that immersion delirium would have been managed. Once I am completely clear of anesthesia and immersion delirium, I am remorseful and apologetic. Prior to that I am angry and fearful. I remember the last couple of hours or so as I am clearing. Initially with me, immersion delirium presents as a an escalating tantrum. Now, I advise anesthesia and staff to restrain me as soon as possible and keep me restrained once on the nursing until I am apologetic and remorseful. I am not certain which agents cause my delirium. I think it is better with Propofol and Versed, but I am not certain. I am not recovered until I look and act sane. Length of time under anesthesia may be a factor. The key with me is to restrain me as soon as I am in the bed I will recovered in and keep the valium flowing Once fully recovered I am remorseful and apologetic.

  4. My 18 year old had anesthesia for an MRI. She woke up so aggressive and mean. It took me (mom) and two nurses to hold her down. She was screaming and sometimes swearing. Kicking, arms and legs flailing, and she was trying to rip out her I.V. She was saying that she hated the hospital and everyone in it and that she was never coming there again.

    The nurses claim she woke up too quickly. They tried putting some different meds in her I.V. to calm her down. I was mortified and embarrassed. This was at a children’s hospital and there were young kids all around her with their families in the recovery room and my child was acting “possessed”.

    At one point the nurses were going to strap her down and take her to psych evaluation.

    I did notice that during this ‘episode’, my daughter’s eyes were very seldom open. Do you think she’ll remember this episode? What do I tell the doctor’s the next time she needs anesthesia?

    1. Donna Teach on said:

      Our team says It is hard to just say it was emergence delirium. Often times we have patients who, upon emerging from the anesthetic, reveal their true feelings about what they are going thru. It’s pretty normal, especially for teens, to feel angry about being diagnosed with something. So, seeing those types of emotions are real and do happen.

      We would encourage you to talk with your daughter about her experience and talk to her doctor about the possible need for counseling.

  5. stephanie on said:

    hello, my son was operated 3 years ago, and the devil that woke up when he had his emergency delirium has never gone back to rest. he was a quiet and gentil child until then, and since then, he cannot control his anger. when he seem red its scary. hehas even put his hands around another childs neck because he was so angry. is it possible for the side effects to cause irreversible damage? I don’t know what to do.

    1. Diane Lang on said:

      I’m sorry to hear about what is happening to your son.

      Having a medical procedure is a very stressful event. In our efforts to comfort, we often time try to minimize the experience in the hopes of making it less scary and easier to deal with. Each one of us handles stress and pain in different ways. Most people develop healthy coping mechanisms to deal with adversity, but sometimes people need a little outside help. I would strongly recommend seeing a child therapist. Having an operation is a big deal! Often times, children don’t understand why they need to have the operation, they only know how scary the experience was, and how much they hurt after. Developing ways to deal with that trauma is incredibly important! Often times too, having the stress of a surgery is enough to bring others stresses to the surface. Learning how to handle those emotions in a healthy way are essential as he starts to mature. A pediatric therapist can be of tremendous benefit. Best of luck.

Leave a Reply

Your email address will not be published. Required fields are marked *