Early negative behavior in the pediatric postoperative anesthesia care unit- interference between frequently used observational assessment tools

Central to both clinical care and research is the use of observational assessment tools that help recognition and quantification of different behaviors in young children. In clinical practice it is common to experience difficulties when trying to discriminate between emergence delirium (ED) and pain after general anesthesia. The aim of this study was to explore the possible interference between two validated scores to assess ED and pain, respectively. In this prospective observational study, we included 231 children aged 1-6 years undergoing MRI scanning under general anesthesia. After awakening from general anesthesia,PAED score (ED) and FLACC score (pain) was repeatedly assessed by two observers. FLACC > 4 or a PAED score > 10 or both were defined as having early post-operative negative behavior (e-PONB). e-PONB was present in a total of 86 children(37%) during the first 30 minutes after spontaneous awakening. Children experiencing ED were three times more likely as also exhibiting pain behavior (RR 3.8 95%CI 2.8-5.2, p<0.00001). FLACC may erroneously indicate pain behavior in the early phase after awakening from general anesthesia when the true cause for the aberrant behavior is ED. The occurrence of e-PONB is much more common following sevoflurane exposure compared to propofol anesthesia.