Prompt

A 3-year-old undergoes adenotonsillectomy under sevoflurane anaesthesia. In PACU the child is thrashing, non-consolable, and SpO2 is 98% in air. Discuss differential diagnosis, PAED scoring, prevention you would have used, management now, and your paediatric PONV plan including why codeine is avoided after tonsillectomy.

Model answer

Differential (3). ED vs pain vs hypoxia/hypercarbia vs full bladder vs residual drug vs rare seizure. Check airway, SpO2, glucose, surgical site pain, per local paediatric-emergence protocol.^[1]

PAED (3). Five items (1–4 each with reverse scoring; higher total means more delirium): eye contact, purposeful actions, awareness, restlessness, inconsolability; ≥10 is the commonly used clinical cut-off.^[1]

Prevention (4). Parental calm, analgesia/regional, propofol ~1 mg/kg at end, fentanyl (taught bundle; per local protocol), dexmedetomidine ~0.5 microg/kg IV bolus (Manning-exact, ages 1–15), consider TIVA.^[3]

Now (3). Protect safety; treat pain if FLACC high; small propofol if pure ED; reassess, per local paediatric-emergence protocol.^[1]

PONV (2). Risk high for ENT; ondansetron + dexamethasone prophylaxis; different-class rescue; no codeine post-tonsillectomy, per local paediatric-PONV protocol.^[2]

References3Show

[1]Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology, 2004.PMID 15114210
[2]Apfel CC et al. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology, 1999.PMID 10485781
[3]Manning AN et al. Dexmedetomidine dosing to prevent pediatric ED. AANA J, 2020.PMID 32990204

Model answer

Differential (3). ED vs pain vs hypoxia/hypercarbia vs full bladder vs residual drug vs rare seizure. Check airway, SpO2, glucose, surgical site pain, per local paediatric-emergence protocol.^[1]

Now (3). Protect safety; treat pain if FLACC high; small propofol if pure ED; reassess, per local paediatric-emergence protocol.^[1]

PONV (2). Risk high for ENT; ondansetron + dexamethasone prophylaxis; different-class rescue; no codeine post-tonsillectomy, per local paediatric-PONV protocol.^[2]

References3Show

[1]Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology, 2004.PMID 15114210
[2]Apfel CC et al. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology, 1999.PMID 10485781
[3]Manning AN et al. Dexmedetomidine dosing to prevent pediatric ED. AANA J, 2020.PMID 32990204

Paediatric emergence delirium and PONV

Model answer

Paediatric emergence delirium and PONV

Model answer