A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veterans Affairs Medical Center





general anesthesia, monitored anesthesia care, MAC, post-traumatic stress disorder, PTSD, trauma, military veteran, agitation, aggression, PACU, propofol, dexmedetomidine, ketamine, midazolam, volatile anesthetic


Emergence delirium (ED) is a temporary condition associated with a patient awakening from an anesthetic and/or adjunct agent (e.g., sedatives and analgesics). During the condition, patients risk harming themselves or staff by engaging in dangerous behavior, which may include thrashing, kicking, punching, and attempting to exit the bed/table.

A multidisciplinary team at Veterans Affairs Pittsburgh Healthcare System (VAPHS) developed and implemented a multicomponent intervention to reduce the severity and occurrence of ED. The intervention consists of a training component and 21 clinical components. The 21 clinical components are implemented on a patient-by-patient basis and include routine screening for risk factors, enhanced communication among staff, adjusting the environment, following a specific medication strategy, and application of manual restraint (hands-on). The authors provide 15 online Supplemental Materials (S1–S15) to promote replication of the intervention.

To our knowledge, this is the first manuscript that describes this type of multicomponent intervention in sufficient detail to allow others to replicate it. Following implementation of the intervention at VAPHS, perioperative staff reported that they observed a substantial reduction in the occurrence and severity of ED, ED-related patient and staff injuries, and ED-related loss of intravenous access and airway patency. Despite staff’s reported success of the intervention, rigorous research is needed to evaluate the efficacy of the intervention.

Author Biographies

Matthew A. Taylor, PhD, Patient Safety Authority

Matthew A. Taylor (MattTaylor@pa.gov) is a patient safety analyst for the Patient Safety Authority (PSA), where he conducts research, uses data to identify patient safety concerns and trends, and develops solutions to prevent recurrence. He is a core team member of PSA’s Center of Excellence for Improving Diagnosis. Prior to joining the PSA, Taylor was a scientific writer and research specialist at the University of Pittsburgh School of Pharmacy, and he has served fellowships at the Centers for Disease Control and Prevention (CDC) and the VA Pittsburgh Healthcare System. His expertise in data analysis and research covers a range of topics, including patient safety, public health, employee training, process efficiency, human factors, workplace culture/climate, behavior change interventions, and organizational management.

William Pileggi, MSN, CRNA, MAJ, USAR/AN (Ret.), VA Pittsburgh Healthcare System

William Pileggi (William.Pileggi@va.gov) is a certified registered nurse anesthetist for the VA Pittsburgh Healthcare System’s (VAPHS) Department of Anesthesiology. He is the lead anesthesia team instructor for VAPHS’s PTSD/Emergence Delirium Safety Training and Response Team, collaborating with physician anesthesiologists in anesthesia care and delivery. In this role, he teaches perioperative staff how to better identify and assess those veterans most at risk for emergence delirium and co-instructs anesthesia personnel on medication choice and strategy to prevent and/or treat emergence delirium. Pileggi has worked in healthcare since joining the Army in 1984. He is a retired 26-year Army Reserve major, Nurse Corps officer, which includes five years as an enlisted operating room technician (sergeant). Pileggi also had 20 years of practice at the University of Pittsburgh Medical Center.

Michael Boland, MSEd, VA Pittsburgh Healthcare System

Michael Boland is a training specialist for the Department of Veterans Affairs, VA Pittsburgh Healthcare System (VAPHS). Working within the Department of Education and Innovative Learning, he is responsible for providing staff education and training regarding behavioral emergency response, crisis prevention and intervention, team training, and verbal de-escalation, as well as psychological first aid and resiliency training. For the past 10 years he has served as a volunteer member of the VAPHS behavioral emergency response team and currently provides stress management support and education for employees following traumatic situations. Prior to working for VAPHS, he worked as a clinical educator for University of Pittsburgh Medical Center Western Psychiatric Hospital.

Monique Y. Boudreaux-Kelly, PhD, VA Pittsburgh Healthcare System

Monique Y. Boudreaux-Kelly is an epidemiologist and biostatistician with the VA Pittsburgh Healthcare System’s (VAPHS) Department of Research. She is the head statistician with VAPHS’s Research Office StatCore. In this position, she advises on study design and statistical methods; conducts statistical analysis; and contributes to presentation materials and manuscripts for research, clinical, and administrative projects for local and national VA facilities. Boudreaux-Kelly has held this position since 2011 and prior to this position she worked for a contract research organization as a medical writer and completed a postdoctoral position at the University of Pittsburgh Medical Center Western Psychiatric Hospital.

David V. Julian, MEd, VA Pittsburgh Healthcare System

David V. Julian is the designated learning officer for the VA Pittsburgh Healthcare System’s (VAPHS) Department of Education and Innovative Learning. With experience in behavioral health and simulation education, he is a team instructor for VAPHS’s PTSD/Emergence Delirium Safety Training and Response Team. In this role he teaches prevention and de-escalation techniques specifically related to veterans at risk for emergence delirium. Prior to coming to the VAPHS in 2010, Julian was the program coordinator at the University of Pittsburgh Healthcare System’s Crisis Training Institute. Throughout his career, he has designed and facilitated a variety of courses related to crisis prevention and trauma response.

Amanda K. Beckstead, DNP, CRNA, University of Pittsburgh Medical Center Altoona

Amanda Beckstead received her doctor of nursing practice in nurse anesthesia at the University of Pittsburgh (Pitt) in 2020. Her doctoral capstone dissertation, “Implementation of a Medication Administration Didactic Session and Protocol to Effect Provider Willingness to Utilize Best Anesthetic Practices for Patients With Post-Traumatic Stress Disorder Undergoing Surgery,” was completed at the VA Pittsburgh Healthcare System. She received the Pennsylvania Association of Nurse Anesthetists’ 2020 Outstanding Student of the Year Award. She completed three years of CCRN practice at the University of Pittsburgh Medical Center (UPMC) Presbyterian Medical intensive care unit before returning to Pitt for her graduate research and nurse anesthesia doctor of nursing practice studies. Beckstead currently practices full-time at the UPMC Altoona medical center.


Taylor MA, Pileggi W. Perioperative Delirium/Agitation Associated With the Use of Anesthetics and/or Adjunct Agents: A Study of Patient Behaviors, Injuries, and Interventions to Mitigate Risk. Patient Saf. 2021;3(4):16-27.

Urits I, Peck J, Giacomazzi S, Patel R, Wolf J, Mathew D, et al. Emergence Delirium in Perioperative Pediatric Care: A Review of Current Evidence and New Directions. Adv Ther. 2020;37(5):1897-909.

Lepouse C, Lautner C, Liu L, Gomis P, Leon A. Emergence Delirium in Adults in the Post-Anaesthesia Care Unit. Br J Anaesth. 2006;96(6):747-53. doi: 10.1093/bja/ael094.

Cole JW, Murray DJ, McAllister JD, Hirshberg GE. Emergence Behaviour in Children: Defining the Incidence of Excitement and Agitation Following Anaesthesia. Paediatr Anaesth. 2002;12(5):442-7.

Lee S-J, Sung T-Y. Emergence Agitation: Current Knowledge and Unresolved Questions. Korean J Anesthesiol. 2020;73(6):471-85.

Tolly B, Waly A, Peterson G, Erbes CR, Prielipp RC, Apostolidou I. Adult Emergence Agitation: A Veteran-Focused Narrative Review. Anesth Analg. 2021;132(2):353-64.

McGuire JM. The Incidence of and Risk Factors for Emergence Delirium in US Military Combat Veterans. J Perianesth Nurs. 2012;27(4):236-45.

Beckstead A, Boland MJ, Julian DV, Pileggi W. Emergence Delirium: Maintaining Veteran and Employee Safety. Durham, NC: Eighth Annual Durham VA - DUSON Advanced Practice Provider Veteran's Health Symposium; 2020. Available from: https://youtu.be/MlNdme5tikY.

U.S. Department of Veterans Affairs. Providing Health Care for Veterans. VA website. https://www.va.gov/health/. Updated December 6, 2022. Accessed March 3, 2022.

U.S. Department of Veterans Affairs. Eligibility for VA Health Care. VA website. https://www.va.gov/health-care/eligibility/. Updated December 6, 2022. Accessed March 3, 2022.

Meffert BN, Morabito DM, Sawicki DA, Hausman C, Southwick SM, Pietrzak RH, et al. US Veterans Who Do and Do Not Utilize Veterans Affairs Health Care Services: Demographic, Military, Medical, and Psychosocial Characteristics. Prim Care Companion CNS Disord. 2019;21(1):1-18.

McGuire JM, Burkard JF. Risk Factors for Emergence Delirium in US Military Members. J Perianesth Nurs. 2010;25(6):392-401.

Viswanath O, Kerner B, Jean Y-K, Soto R, Rosen G. Emergence Delirium: A Narrative Review. J Anesthesiol Clin Sci. 2015;4(2):e1-e8.

Thomson JL. PTSD Perceptions in US Military Members and Their Families: A Qualitative Study. SAGE Open. 2021;11(1). doi: 10.1177/21582440211006393.

Bisson JI, Cosgrove S, Lewis C, Roberts NP. Post-Traumatic Stress Disorder. BMJ. 2015;351:1-7. doi: 10.1136/bmj.h6161.

Kintzle S, Barr N, Corletto G, Castro CA. PTSD in US veterans: The Role of Social Connectedness, Combat Experience and Discharge. Healthcare. 2018;6(3). doi: 10.3390/healthcare6030102.

U.S. Department of Veterans Affairs. About the VA Pittsburgh Healthcare System: Fast Facts. VA website. https://www.va.gov/pittsburgh-health-care/about-us/. Updated November 17, 2022. Accessed March 3, 2022.

Guedel AE. Anesthesia: A Teaching Outline. Stages of Anesthesia. Anesth Analg. 1936;15(1):1-4.

Nagelhout JJ, Elisha S, editors. Nurse Anesthesia. 6th ed. St. Louis, MO: Elsevier; 2018.

Hospira Inc. Dosing Guidelines for Precedex: Nonintubated Procedural Sedation and ICU Sedation. Lake Forest, IL: Hospira Inc; 2009. p. 1-15.

Myers C. FDA Approves New Indication for Hospira's Precedex (Dexmedetomidine HCL) Injection. Fierce Biotech website. https://www.fiercebiotech.com/biotech/fda-approves-new-indication-for-hospira-s-precedex-dexmedetomidine-hcl-injection. Published October 31, 2008. Accessed May 12, 2022.

Hospira Inc. Precedex- Dexmedetomidine Hydrochloride Injection, Solution, Concentrate [package insert LAB-1346-3.0]. Pfizer labeling website. https://labeling.pfizer.com/ShowLabeling.aspx?id=4404. Revised August 2022. Accessed December 9, 2022.

Gerlach AT, Blais DM, Jones GM, Burcham PK, Stawicki SP, Cook CH, et al. Predictors of Dexmedetomidine-Associated Hypotension in Critically Ill Patients. Int J Crit Illn Inj Sci. 2016;6(3):109-14. Epub 2016/10/11. doi: 10.4103/2229-5151.190656. PubMed PMID: 27722111; PubMed Central PMCID: PMCPMC5051052.

Mason KP, Turner DP, Houle TT, Fontaine PJ, Lerman J. Hemodynamic Response to Fluid Management in Children Undergoing Dexmedetomidine Sedation for MRI. AJR Am J Roentgenol. 2014;202(6):W574-9. Epub 2014/05/23. doi: 10.2214/AJR.13.11580. PubMed PMID: 24848852.

Baughman V, Golembiewski J, Gonzalez J, Alvarez W, editors. Anesthesiology & Critical Care Drug Handbook. 10th ed. Hudson, OH: Lexi-Comp Inc; 2011.

Deshmukh PV, Kulkarni SS, Parchandekar MK, Sikchi SP. Comparison of Preanesthetic Sedation in Pediatric Patients With Oral and Intranasal Midazolam. J Anaesthesiol Clin Pharmacol. 2016;32(3):353-8.

Bergendahl H, Lönnqvist P-A, Eksborg S. Clonidine: An Alternative to Benzodiazepines for Premedication in Children. Curr Opin Anesthesiol. 2005;18(6):608-13.

Butterworth J, Mackey D, Wasnick J. Morgan & Mikhail's Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill Education, LLC; 2013.

Stoelting RK, Miller RD. Basics of Anesthesia. 4th ed. Philadelphia, PA: Churchill Livingstone; 2000.

Radtke F, Franck M, Hagemann L, Seeling M, Wernecke K, Spies C. Risk Factors for Inadequate Emergence After Anesthesia: Emergence Delirium and Hypoactive Emergence. Minerva Anestesiol. 2010;76(6):394-403.

Wang W, Huang P, Gao W, Cao F, Yi M, Chen L, et al. Efficacy and Acceptability of Different Auxiliary Drugs in Pediatric Sevoflurane Anesthesia: A Network Meta-Analysis of Mixed Treatment Comparisons. Sci Rep. 2016;6(1):1-11. doi: 10.1038/srep36553.

Kim KM, Lee KH, Kim YH, Ko MJ, Jung J-W, Kang E. Comparison of Effects of Intravenous Midazolam and Ketamine on Emergence Agitation in Children: Randomized Controlled Trial. J Int Med Res. 2016;44(2):258-66. doi: 10.1177/0300060515621639.

Lovestrand D, Lovestrand S, Beaumont DM, Yost JG. Management of Emergence Delirium in Adult PTSD Patients: Recommendations for Practice. J Perianesth Nurs. 2017;32(4):356-66.

McLott J, Jurecic J, Hemphill L, Dunn KS. Development of an Amygdalocentric Neurocircuitry-Reactive Aggression Theoretical Model of Emergence Delirium in Posttraumatic Stress Disorder: An Integrative Literature Review. AANA J. 2013;81(5):379-84.

Greiner S, Kremer MJ. Clarifying the Confusion of Adult Emergence Delirium. AANA J. 2019;87(3):243-51.

Kurhekar P, Vinod K, Rajarathinam B, Krishna JSD, Raghuraman M. Randomized Comparison Between Dexmedetomidine and Midazolam for Prevention of Emergence Agitation After Nasal Surgeries. Saudi J Anaesth. 2018;12(1):61-6.

Levanen J, Makela M-L, Scheinin H. Dexmedetomidine Premedication Attenuates Ketamine-Induced Cardiostimulatory Effects and Postanesthetic Delirium. Anesthesiology. 1995;82(5):1117-25.

Kim JC, Kim J, Kwak H, Ahn SW. Premedication With Dexmedetomidine to Reduce Emergence Agitation: A Randomized Controlled Trial. BMC Anesthesiol. 2019;19(144):1-6.

Pasin L, Febres D, Testa V, Frati E, Borghi G, Landoni G, et al. Dexmedetomidine vs Midazolam as Preanesthetic Medication in Children: A Meta-Analysis of Randomized Controlled Trials. Paediatr Anaesth. 2015;25(5):468-76.

Rao Y, Zeng R, Jiang X, Li J, Wang X. The Effect of Dexmedetomidine on Emergence Agitation or Delirium in Children After Anesthesia—A Systematic Review and Meta-Analysis of Clinical Studies. Front Pediatr. 2020;8:1-19.

Sethi P, Mohammed S, Bhatia PK, Gupta N. Dexmedetomidine Versus Midazolam for Conscious Sedation in Endoscopic Retrograde Cholangiopancreatography: An Open-Label Randomised Controlled Trial. Indian J Anaesth. 2014;58(1):18-24.

Lovestrand D, Phipps PS, Lovestrand S. Posttraumatic Stress Disorder and Anesthesia Emergence. AANA J. 2013;81(3):199-203.

Mahmoud M, Mason K. Dexmedetomidine: Review, Update, and Future Considerations of Paediatric Perioperative and Periprocedural Applications and Limitations. Br J Anaesth. 2015;115(2):171-82.

Kaur M, Singh P. Current Role of Dexmedetomidine in Clinical Anesthesia and Intensive Care. Anesth. : essays res. 2011;5(2):128-33.

Wiatrowski R. Current State of Pain Treatment: Does Dexmedetomidine Have a Role to Play? AANA J. 2021;89(1):77-86.

Bartoszek M, McGuire JM, Wilson JT, Sorensen JS, Vice TF, Hudson AJ. The Effectiveness of Dexmedetomidine as a Prophylactic Treatment for Emergence Delirium Among Combat Veterans With High Anxiety: A Randomized Placebo-Controlled Trial. Mil Med. 2021;usab212:1-9.

Haselman MA. Dexmedetomidine: A Useful Adjunct to Consider in Some High-Risk Situations. AANA J. 2008;76(5):335-9.

Maldonado JR, Wysong A, Van Der Starre PJ, Block T, Miller C, Reitz BA. Dexmedetomidine and the Reduction of Postoperative Delirium After Cardiac Surgery. Psychosomatics. 2009;50(3):206-17.

Zhang J, Yu Y, Miao S, Liu L, Gan S, Kang X, et al. Effects of Peri-operative Intravenous Administration of Dexmedetomidine on Emergence Agitation After General Anesthesia in Adults: A Meta-analysis of Randomized Controlled Trials. Drug Des Dev Ther. 2019;13:2853-64. doi: 10.2147/DDDT.S207016.

Dahmani S, Stany I, Brasher C, Lejeune C, Bruneau B, Wood C, et al. Pharmacological Prevention of Sevoflurane-and Desflurane-Related Emergence Agitation in Children: A Meta-Analysis of Published Studies. Br J Anaesth. 2010;104(2):216-23.

Hauber JA, Davis PJ, Bendel LP, Martyn SV, McCarthy DL, Evans M-C, et al. Dexmedetomidine as a Rapid Bolus for Treatment and Prophylactic Prevention of Emergence Agitation in Anesthetized Children. Anesth Analg. 2015;121(5):1308-15.

Shukry M, Clyde MC, Kalarickal PL, Ramadhyani U. Does Dexmedetomidine Prevent Emergence Delirium in Children After Sevoflurane-Based General Anesthesia? Paediatr Anaesth. 2005;15(12):1098-104.

Nguyen S, Pak M, Paoli D, Neff DF. Emergence Delirium With Post-Traumatic Stress Disorder Among Military Veterans. Curēus. 2016;8(12):e921.

Sun M, Peng T, Sun Y, Huang Z, Jiang J, Wang C, et al. Intraoperative Use of Low-Dose Dexmedetomidine for the Prevention of Emergence Agitation Following General Anaesthesia in Elderly Patients: A Randomized Controlled Trial. Aging Clin Exp Res. 2022;34(3):611-8.

Ni J, Wei J, Yao Y, Jiang X, Luo L, Luo D. Effect of Dexmedetomidine on Preventing Postoperative Agitation in Children: A Meta-Analysis. PLoS One. 2015;10(5):e0128450.

Hu J, Zhu M, Gao Z, Zhao S, Feng X, Chen J, et al. Dexmedetomidine for Prevention of Postoperative Delirium in Older Adults Undergoing Oesophagectomy with Total Intravenous Anaesthesia: A Double-Blind, Randomised Clinical Trial. Eur J Anaesthesiol. 2021;38:S9-S17.

Lee HS, Yoon HY, Jin HJ, Hwang SH. Can Dexmedetomidine Influence Recovery Profiles From General Anesthesia in Nasal Surgery? Otolaryngol Head Neck Surg. 2018;158(1):43-53.

Read MD, Maani CV, Blackwell S. Dexmedetomidine as a Rescue Therapy for Emergence Delirium in Adults: A Case Series. A A Case Rep. 2017;9(1):20-3.

Han X, Sun X, Liu X, Wang Q. Single Bolus Dexmedetomidine Versus Propofol for Treatment of Pediatric Emergence Delirium Following General Anesthesia. Paediatr Anaesth. 2022;32(3):446-51.

Ibacache ME, Muñoz HR, Brandes V, Morales AL. Single-Dose Dexmedetomidine Reduces Agitation After Sevoflurane Anesthesia in Children. Anesth Analg. 2004;98(1):60-3.

Laskowski K, Stirling A, Mckay WP, Lim HJ. A Systematic Review of Intravenous Ketamine for Postoperative Analgesia. Can J Anesth. 2011;58:911-23. doi: 10.1007/s12630-011-9560-0.

Kim SH, Kim SI, Ok SY, Park SY, Kim MG, Lee SJ, et al. Opioid Sparing Effect of Low Dose Ketamine in Patients with Intravenous Patient-Controlled Analgesia Using Fentanyl After Lumbar Spinal Fusion Surgery. Korean J Anesth. 2013;64(6):524-8.

Sleigh J, Harvey M, Voss L, Denny B. Ketamine–More Mechanisms of Action Than Just NMDA Blockade. Trends Anaesth Crit Care. 2014;4(2-3):76-81.

Hintzsche K. Subanesthetic-Dose Ketamine to Decrease Emergence Delirium in the Surgical Patient With Posttraumatic Stress Disorder. AANA J. 2018;86(3):220-4.

White PF, Way WL, Trevor AJ. Ketamine-Its Pharmacology and Therapeutic Uses. Anesthesiology. 1982;56(2):119-36. doi: 10.1097/00000542-198202000-00007.

Ng KT, Sarode D, Lai YS, Teoh WY, Wang CY. The Effect of Ketamine on Emergence Agitation in Children: A Systematic Review and Meta-Analysis. Paediatr Anaesth. 2019;29(12):1163-72.

Coşkun AS. Comparing the Effects of Propofol and Ketamine on the Emergence Agitation of Male Children Undergoing Circumcision. Ann Pediatr Surg. 2022;18(2):1-6.

Hesse S, Kreuzer M, Hight D, Gaskell A, Devari P, Singh D, et al. Association of Electroencephalogram Trajectories During Emergence From Anaesthesia With Delirium in the Postanaesthesia Care Unit: An Early Sign of Postoperative Complications. Br J Anaesth. 2019;122(5):622-34.

Sener S, Eken C, Schultz CH, Serinken M, Ozsarac M. Ketamine With and Without Midazolam for Emergency Department Sedation in Adults: A Randomized Controlled Trial. Ann Emerg Med. 2011;57(2):109-14. e2.

Ykeizumi L, Correia da Silva R, Villar e Silva G, Martins Santiago BV. Combined Dexmedetomidine and Ketamine in Pediatric Anesthesia: A Brief Review. Anesth Pain Res. 2021;5(1):1-8.

Gupta K, Gupta A, Gupta PK, Rastogi B, Agarwal S, Lakhanpal M. Dexmedetomidine Premedication in Relevance to Ketamine Anesthesia: A Prospective Study. Anesth. : essays res. 2011;5(1):87-91.

Tobias JD. Dexmedetomidine and Ketamine: An Effective Alternative for Procedural Sedation? Pediatr Crit Care Med. 2012;13(4):423-7.

Cheng X, Huang Y, Zhao Q, Gu E. Comparison of the Effects of Dexmedetomidine-Ketamine and Sevoflurane-Sufentanil Anesthesia in Children with Obstructive Sleep Apnea after Uvulopalatopharyngoplasty: An Observational Study. J Anaesthesiol Clin Pharmacol. 2014;30(1):31-5.

Lee YS, Kim WY, Choi JH, Son JH, Kim JH, Park YC. The Effect of Ketamine on the Incidence of Emergence Agitation in Children Undergoing Tonsillectomy and Adenoidectomy Under Sevoflurane General Anesthesia. Korean J Anesthesiol. 2010;58(5):440-5.

Demir CY, Yuzkat N. Prevention of Emergence Agitation with Ketamine in Rhinoplasty. Aesthetic Plast Surg. 2018;42(3):847–53. doi: 10.1007/s00266-018-1103-4.

Aroke EN, Crawford SL, Dungan JR. Pharmacogenetics of Ketamine-Induced Emergence Phenomena: A Pilot Study. Nurs Res. 2017;66(2):105-14.

Strayer RJ, Nelson LS. Adverse Events Associated with Ketamine for Procedural Sedation in Adults. Am J Emerg Med. 2008;26(9):985-1028.

Abu‐Shahwan I, Chowdary K. Ketamine is Effective in Decreasing the Incidence of Emergence Agitation in Children Undergoing Dental Repair Under Sevoflurane General Anesthesia. Paediatr Anaesth. 2007;17(9):846-50.

Domino EF, Warner DS. Taming the Ketamine Tiger. Anesthesiology. 2010;113(3):678-84.

Ibrahem Amin OA, Kamel AAF. Effects of Adding Ketamine to Dexmedetomidine on Smooth Recovery From Isoflurane Anesthesia in Adults Undergoing Endoscopic Sinus Surgery. Egypt J Anaesth. 2020;36(1):50-5.

Hadi SM, Saleh AJ, Tang YZ, Daoud A, Mei X, Ouyang W. The Effect of KETODEX on the Incidence and Severity of Emergence Agitation in Children Undergoing Adenotonsillectomy Using Sevoflurane Based-Anesthesia. Int J Pediatr Otorhinolaryngol. 2015;79(5):671-6.

Eger EI, Eisenkraft JB, Weiskopf RB. The Pharmacology of Inhaled Anesthetics. United States of America: Edward I. Eger; 2002.

Garcia PS, Kolesky SE, Jenkins A. General Anesthetic Actions on GABA-A Receptors. Curr Neuropharmacol. 2010;8(1):2-9.

Weir C, Mitchell S, Lambert J. Role of GABAA Receptor Subtypes in the Behavioural Effects of Intravenous General Anaesthetics. Br J Anaesth. 2017;119:i167-i75. doi: 10.1093/bja/aex369.

Kanaya A, Kuratani N, Satoh D, Kurosawa S. Lower Incidence of Emergence Agitation in Children After Propofol Anesthesia Compared with Sevoflurane: A Meta-Analysis of Randomized Controlled Trials. J Anesth. 2014;28(1):4-11.

Uezono S, Goto T, Terui K, Ichinose F, Ishguro Y, Nakata Y, et al. Emergence Agitation After Sevoflurane Versus Propofol in Pediatric Patients. Anesth Analg. 2000;91(3):563-6. doi: 10.1213/00000539-200009000-00012.

Kim Y-S, Chae YK, Choi YS, Min J-H, Ahn SW, Yoon JW, et al. A Comparative Study of Emergence Agitation Between Sevoflurane and Propofol Anesthesia in Adults After Closed Reduction of Nasal Bone Fracture. Korean J Anesthesiol. 2012;63(1):48-53.

Nakayama S, Furukawa H, Yanai H. Propofol Reduces the Incidence of Emergence Agitation in Preschool-Aged Children as Well as in School-Aged Children: A Comparison With Sevoflurane. J Anesth. 2007;21(1):19-23.

Kim H-J, Kim D-K, Kim H-Y, Kim J-K, Choi S-W. Risk Factors of Emergence Agitation in Adults Undergoing General Anesthesia for Nasal Surgery. Clin Exp Otorhinolaryngol. 2015;8(1):46-51.

Yu D, Chai W, Sun X, Yao L. Emergence Agitation in Adults: Risk Factors in 2,000 Patients. Can J Anesth. 2010;57(9):843-8.

Chandler JR, Myers D, Mehta D, Whyte E, Groberman MK, Montgomery CJ, et al. Emergence Delirium in Children: A Randomized Trial to Compare Total Intravenous Anesthesia with Propofol and Remifentanil to Inhalational Sevoflurane Anesthesia. Paediatr Anaesth. 2013;23(4):309-15.

Jo J-Y, Jung K-W, Kim H-J, Park S-U, Park H, Ku S, et al. Effect of Total Intravenous Anesthesia vs Volatile Induction With Maintenance Anesthesia on Emergence Agitation After Nasal Surgery: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg. 2019;145(2):117-23.

Grundmann U, Uth M, Eichner A, Wilhelm W, Larsen R. Total Intravenous Anaesthesia with Propofol and Remifentanil in Paediatric Patients: A Comparison with a Desflurane‐Nitrous Oxide Inhalation Anaesthesia. Acta Anaesthesiol Scand. 1998;42(7):845-50.

Munk L, Andersen G, Møller A. Post‐Anaesthetic Emergence Delirium in Adults: Incidence, Predictors and Consequences. Acta Anaesthesiol Scand. 2016;60(8):1059-66.

Cohen IT, Finkel JC, Hannallah RS, Hummer KA, Patel KM. Rapid Emergence does not Explain Agitation Following Sevoflurane Anaesthesia in Infants and Children: A Comparison with Propofol. Paediatr Anaesth. 2003;13(1):63-7.

Talih G, Yüksek A, Şahin E. Evaluation of Emergence Agitation After General Anaesthesia in Rhinoplasty Patients: Inhalation Anaesthesia Versus Total Intravenous Anaesthesia. Am J Otolaryngol. 2020;41(3):102387.

Pedersen N, Jensen A, Kilmose L, Olsen K. Propofol‐Remifentanil or Sevoflurane for Children Undergoing Magnetic Resonance Imaging? A Randomised Study. Acta Anaesthesiol Scand. 2013;57(8):988-95.

Bryan YF, Hoke LK, Taghon TA, Nick TG, Wang Y, Kennedy SM, et al. A Randomized Trial Comparing Sevoflurane and Propofol in Children Undergoing MRI Scans. Paediatr Anaesth. 2009;19(7):672-81.

Huett C, Baehner T, Erdfelder F, Hoehne C, Bode C, Hoeft A, et al. Prevention and Therapy of Pediatric Emergence Delirium: A National Survey. Paediatr Drugs. 2017;19(2):147-53.

Rosen HD, Mervitz D, Cravero JP. Pediatric Emergence Delirium: Canadian Pediatric Anesthesiologists' Experience. Paediatric Anesth. 2016;26(2):207-12.

Abu-Shahwan I. Effect of Propofol on Emergence Behavior in Children After Sevoflurane General Anesthesia. Pediatric Anesth. 2008;18(1):55-9.

Aouad MT, Yazbeck-Karam VG, Nasr VG, El-Khatib MF, Kanazi GE, Bleik JH. A Single Dose of Propofol at the end of Surgery for the Prevention of Emergence Agitation in Children Undergoing Strabismus Surgery During Sevoflurane Anesthesia. Anesthesiology. 2007;107(5):733-8.

Haile S, Girma T, Akalu L. Effectiveness of Propofol on Incidence and Severity of Emergence Agitation on Pediatric Patients Undergo ENT and Ophthalmic Surgery: Prospective Cohort Study Design. Ann Med Surg. 2021;69(102765):1-5.

van Hoff SL, O'Neill ES, Cohen LC, Collins BA. Does a Prophylactic Dose of Propofol Reduce Emergence Agitation in Children Receiving Anesthesia? A Systematic Review and Meta-Analysis. Paediatr Anaesth. 2015;25(7):668-76.

Abbas MS, Abd El-Hakeem EE, Kamel HE. Three Minutes Propofol After Sevoflurane Anesthesia to Prevent Emergence Agitation Following Inguinal Hernia Repair in Children: A Randomized Controlled Trial. Korean J Anesthesiol. 2019;72(3):253-9.

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Taylor, M. A., Pileggi, W., Boland, M., Boudreaux-Kelly, M. Y., Julian, D. V., & Beckstead, A. K. (2022). A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veterans Affairs Medical Center. Patient Safety, 4(4), 26–35. https://doi.org/10.33940/med/2022.12.3



Patient Safety Initiatives
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