Pediatric Post-anesthesia Care Unit Challenges Update


Purpose of Review

The purpose of this review is to discuss the current management of various challenges the health care provider faces in the pediatric post-anesthesia care unit (PACU).

Recent Findings

Efforts to ameliorate and manage PACU issues in the pediatric patient continue to evolve as new medications and methods of anesthesia delivery are introduced and incorporated into the perioperative period. In this review, emergence delirium (ED), postoperative nausea and vomiting (PONV), residual neuromuscular blockade, and tracheal extubation in the operating room versus the PACU are addressed. As ED may be self-limited, pharmacologic treatment may only be indicated if there is a concern for patient harm. Midazolam, fentanyl, and propofol have all been shown to be effective in the treatment of emergence delirium. Dexmedetomidine has been shown to decrease the incidence of ED when administered preoperatively or intraoperatively. This has led practitioners to use dexmedetomidine to treat ED in the PACU, though this has not been studied. Postoperative nausea is difficult to assess in the pediatric patient leading to under treatment. In order to capture these children, the BARF score, initially validated for use in oncologic pediatric patients, is validated for use in postoperative pediatric patients 6 years and older. The approach to treating breakthrough PONV in the PACU is guided by the medications administered intraoperatively for prophylactic treatment. Rescue medications from a different class should be selected if fewer than 6 h have passed since the administration of prophylactic antiemetics. Inadequate reversal of neuromuscular blockade intraoperatively results in adverse respiratory events in the PACU. In the past, when maximum doses of reversal agents are administered, the only recourse in the PACU is to provide assisted ventilation. With the introduction of sugammadex, assisted ventilation can be avoided since sugammadex is capable of reversing dense neuromuscular blockade by vecuronium or rocuronium. In the current environment of achieving greater OR efficiency and cost savings, some institutions are moving tracheal extubation from the operating room by trained anesthesiologists to the PACU by trained nurses with physicians immediately available. This practice in two different children’s hospitals is shown to be safe with no greater incidence of adverse respiratory events and with the added benefit of decreasing operating room time.


PACU challenges in the pediatric patient continue to occur despite changes in anesthetic practice and introduction of newer medications. It is important to keep abreast of these newer modalities to best manage these PACU conditions.

This is a preview of subscription content, log in to check access.

Fig. 1


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Levy D. Psychic trauma of operations in children: and a note on combat neurosis. Am J Dis Child. 1945;69:7–25.

    Article  Google Scholar 

  2. 2.

    Naito Y, Tamai S, Shingu K, et al. Comparison between sevoflurane and halothane for paediatric ambulatory anaesthesia. Br J Anaesth. 1991;67:387–9.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Welborn LG, Hannallah RS, Norden JM, Ruttimann UE, Callan CM. Comparison of emergence and recovery characteristics of sevoflurane, desflurane, and halothane in pediatric ambulatory patients. Anesth Analg. 1996;83:917–20.

    CAS  Article  Google Scholar 

  4. 4.

    Lerman J, Davis PJ, Welborn JG, Orr RJ, Rabb M, Carpenter R, et al. Induction, recovery, and safety characteristics of sevoflurane in children undergoing ambulatory surgery. A comparison with halothane. Anesthesiology. 1996;84:1332–40.

    CAS  Article  Google Scholar 

  5. 5.

    Van Hoff S, O'Neill ES, Cohen LC, et al. Does a prophylactic dose of propofol reduce emergence agitation in children receiving anesthesia? A systematic review and meta-analysis. Paediatr Anaesth. 2015;25:668–76.

    Article  PubMed  Google Scholar 

  6. 6.

    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;28:4–11.

    Article  PubMed  Google Scholar 

  7. 7.

    Sun L, Guo R, Sun L. Dexmedetomidine for preventing sevoflurane-related emergence agitation in children: a meta-analysis of randomized controlled trials. Acta Anaesthesiol Scand. 2014;58:642–50.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Abu-Shahwan I. Effect of propofol on emergence behavior in children after sevoflurane general anesthesia. Paediatr Anaesth. 2008;18:55–9.

    Article  PubMed  Google Scholar 

  9. 9.

    Cravero J, Surgenor S, Whalen K. Emergence agitation in paediatric patients after sevoflurane anesthesia and no surgery: a comparison with halothane. Pediatr Anaesth. 2000;10:419–24.

    CAS  Article  Google Scholar 

  10. 10.

    Kuratani N, Oi Y. Greater incidence of emergence agitation in children after sevoflurane anesthesia as compared with halothane; a meta-analysis of randomized controlled trials. Anesthesiology. 2008;109:225–32.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Costi D, Ellwood J, Wallace A, Ahmed S, Waring L, Cyna A. Transition to propofol after sevoflurane anesthesia to prevent emergence agitation: a randomized controlled trial. Paediatr Anaesth. 2015;25:517–23.

    Article  PubMed  Google Scholar 

  12. 12.

    Voepel-Lewis T, Malviya S, Tait AR. A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit. Anesth Analg. 2003;96:1625–30.

    Article  PubMed  Google Scholar 

  13. 13.

    Rubia K, Smith AB, Taylor E, Brammer M. Linear age-correlated functional development of right inferior fronto-striato-cerebellar networks during response inhibition and anterior cingulate during error-related processes. Human Brain Mapp. 2007;28:1163–77.

    Article  Google Scholar 

  14. 14.

    Sikich N, Lerman J. Development and psychometric evaluation of the paediatric anesthesia emergence delirium scale. Anesthesiology. 2004;100:1138–45.

    Article  Google Scholar 

  15. 15.

    Bajwa SA, Costi D, Cyna AM. A comparison of emergence delirium scales following general anesthesia in children. Pediatr Anesth. 2010;20:704–11.

    Article  Google Scholar 

  16. 16.

    Aono J, Ueda W, Mamiya K, Takimoto E, Manabe M. Greater incidence of delirium during recovery from sevoflurane anesthesia in preschool boys. Anesthesiology. 1997;87:1298–300.

    CAS  Article  Google Scholar 

  17. 17.

    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;23:309–15.

    Article  PubMed  Google Scholar 

  18. 18.

    Kain ZN, Caldwell-Andrews AA, Maranets I, McClain B, Gaal D, Mayes LC, et al. Preoperative anxiety, emergence delirium and postoperative maladaptive behaviors: are they related? A new conceptual framework. Anesth Analg. 2004;99:1648–54.

    Article  PubMed  Google Scholar 

  19. 19.

    Kim H, Jung SM, Hwarim MD, et al. Video distraction and parental presence for the management of preoperative anxiety and postoperative behavior disturbance in children: a randomized controlled trial. Anesth Analg. 2015;12:778–84.

    Article  Google Scholar 

  20. 20.

    Kain ZN, Caldwell-Andrews AA, Mayes LC, Weinberg ME, Wang SM, MacLaren JE, et al. Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial. Anesthesiology. 2007;106:65–74.

    Article  Google Scholar 

  21. 21.

    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;91:563–6.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Bong CL, Lim E, Allen JC, Choo WLH, Siow YN, Teo PBY, et al. A comparison of single dose dexmedetomidine or propofol on the incidence of emergence delirium in children undergoing general anaesthesia for magnetic resonance imaging. Anaesthesia. 2015;70:393–9.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    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 Anesth. 2010;104:216–23.

    CAS  Article  Google Scholar 

  24. 24.

    Hallen J, Rawal N, Gupta A. Postoperative recovery following outpatient pediatric myringotomy: a comparison between sevoflurane and halothane. J Clin Anesth. 2001;13:161–6.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Bae JH, Koo BW, Kim SJ, Lee DH, Lee ET, Kang CJ. The effects of midazolam administered postoperatively on emergence agitation in pediatric strabismus surgery. Korean J Anesthesiol. 2010;58:45–9.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Cravero JP, Beach M, Thyr B, Whalen K. The effect of small dose fentanyl on the emergence characteristics of pediatric patients after sevoflurane anesthesia without surgery. Anesth Analg. 2003;97:364–7.

    CAS  Article  Google Scholar 

  27. 27.

    • Rosen HD, Mervitz D, Cravero JP. Pediatric emergence delirium: Canadian pediatric anesthesiologists’ experience. Pediatr Anesth. 2016;26:207–12. of current practice patterns of emergence delirium treatment in the PACU.

    Article  Google Scholar 

  28. 28.

    Dahmani S, Mantz J, Veyckemans F. Case scenario: severe emergence agitation after myringotomy n a 3-yr-old child. Anesthesiology. 2012;117:399–406.

    Article  PubMed  Google Scholar 

  29. 29.

    D'Errico C, Voepel-Lewis TD, Siewert M, et al. Prolonged recovery stay and unplanned admission of the pediatric surgical outpatient; an observational study. J Clin Anesth. 1998;10:482–7.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Olutoye O, Watcha MF. Management of postoperative vomiting in pediatric patients. Int Anaesthesiol Clinics. 2003;41:99–117.

    Article  Google Scholar 

  31. 31.

    Baxter A, Watcha MF, Baxter WV, et al. Development and validation of a pictorial nausea rating scale for children. Pediatrics. 2011;127:e1542–e49.

    Article  PubMed  Google Scholar 

  32. 32.

    • Watcha MF, Lee AD, Medellin E, et al. Clinical use of the pictorial Baxter retching scale for measurement of postoperative nausea in children. Anesth Analg. 2018. study validated the BARF score used to identify nausea in the pediatric patient to facilitate treatment with antiemetics.

  33. 33.

    Lerman J. Surgical and patient factors involved in postoperative nausea & vomiting. Br J Anaesth. 1992;69(Suppl 1):24S–32S.

    CAS  Article  Google Scholar 

  34. 34.

    Eberhart LHJ, Geldner G, Kranke P, Morin AM, Schäuffelen A, Treiber H, et al. The development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients. Anesth Analg. 2004;99:1630–7.

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA, Watcha M, Chung F, Angus S, Apfel CC, Bergese SD, Candiotti KA, Chan MT, Davis PJ, Hooper VD, Lagoo-Deenadayalan S, Myles P, Nezat G, Philip BK, Tramèr MR, Society for Ambulatory Anesthesia. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2014;118:85–113. Doi:

  36. 36.

    •• Martin S, Baines D, Holtby H, et al. The Association of Paediatric Anaesthetists of Great Britain & Ireland: guidelines on the prevention of post-operative vomiting in children. 2016. Available at Accessed January 2019. These guidelines summarize the most recent literature for the prevention of postoperative nausea and vomiting in children.

  37. 37.

    Bolton CM, Myles PS, Nolan T, Sterne JA. Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis. Br J Anaesth. 2006;97:593–604.

    CAS  Article  PubMed  Google Scholar 

  38. 38.

    Mehta D, Sanatani S, Whyte SD. The effects of droperidol and ondansetron on dispersion of myocardial repolarization in children. Paediatr Anaesth. 2010;20:905–12.

    Article  PubMed  Google Scholar 

  39. 39.

    • Ashok V, Bala I, Bharti N, et al. Effects of intraoperative liberal fluid therapy on postoperative nausea and vomiting in children - a randomized controlled trial. Paediatr Anaesth. 2017;27:810–5. study showed that liberal fluid management (30 mL/kg) intraoperatively decreases the incidence of postoperative nausea and vomiting.

    Article  PubMed  Google Scholar 

  40. 40.

    Schreiner MS, Nicolson SC, Martin T, Whitney L. Should children drink before discharge from day surgery? Anesthesiology. 1992;76:528–33.

    CAS  Article  Google Scholar 

  41. 41.

    Ho KY, Gan TJ. Pharmacology, pharmacogenetics, and clinical efficacy of 5-hydroxytyptamine type 3 receptor antagonists for postoperative nausea and vomiting. Curr Opin Anaesth. 2006;19:606–11.

    Article  Google Scholar 

  42. 42.

    Cammu G, De Witte J, De Veylder J, et al. Postoperative residual paralysis in outpatients versus inpatients. Anesth Analg. 2006;102:426–9.

    Article  PubMed  Google Scholar 

  43. 43.

    Fuchs-Buder T, Fink H, Hofmockel R, et al. Application of neuromuscular monitoring in Germany. Anaesthetist. 2008;57:908–14.

    CAS  Article  Google Scholar 

  44. 44.

    Grayling M, Sweeney BP. Recovery from neuromuscular blockade: a survey of practice. Anaesthesia. 2007;62:806–9.

    CAS  Article  PubMed  Google Scholar 

  45. 45.

    Meretoja OA. Neuromuscular blockade and current treatment strategies for its reversal in children. Paediatr Anaesth. 2010;20(7):591–604.

    Article  PubMed  Google Scholar 

  46. 46.

    Meretoja OA. Neuromuscular blocking agents in paediatric patients: influence of age on the response. Anaesth Intensive Care. 1990;18:440–8.

    CAS  Article  Google Scholar 

  47. 47.

    Hayes AH, Mirakhur RK, Breslin DS, Reid JE, McCourt KC. Postoperative residual block after intermediate-acting neuromuscular blocking drugs. Anaesthesia. 2001;56:312–8.

    CAS  Article  PubMed  Google Scholar 

  48. 48.

    Plaud B, Debaene B, Donati F, Marty J. Residual paralysis after emergence from anesthesia. Anesthesiology. 2010;112:1013–22.

    Article  PubMed  Google Scholar 

  49. 49.

    Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg. 2008;107:130–7.

    Article  PubMed  Google Scholar 

  50. 50.

    Ploeger BA, Smeets J, Strougo A, Drenth HJ, Ruigt G, Houwing N, et al. Pharmacokinetic-pharmacodynamic model for the reversal of neuromuscular blockade by sugammadex. Anesthesiology. 2009;110:95–105.

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    • Tobias JD. Current evidence for the use of sugammadex in children. Pediatr Anesth. 2017;27:118–25. reviews the literature of sugammadex in children.

    Article  Google Scholar 

  52. 52.

    Syed F, Trifa M, Uffman JC, et al. Monitoring of sugammadex dosing at a large tertiary care pediatric hospital. Pediatr Qual Saf. 2018;3:e113.

    Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    De Boer HD, van Esmond J, Booij LH, et al. Reversal of rocuronium-induced profound neuromuscular block by sugammadex in Duchenne muscular dystrophy. Paediatr Anaesth. 2009;19:1226–8.

    Article  PubMed  Google Scholar 

  54. 54.

    Williams R, Bryant H. Sugammadex advice for women of childbearing age. Anaesthesia. 2018;73:133–4.

    CAS  Article  PubMed  Google Scholar 

  55. 55.

    Lucier MM, Brisson D. Extubation of pediatric patients by PACU nurses. J Perianesth Nurs. 2003;18:91–5.

    Article  PubMed  Google Scholar 

  56. 56.

    • Kako H, Corridore M, Seo S, et al. Tracheal extubation practices following adenotonsillectomy in children: effects on operating room efficiency between two institutions. Paediatr Anaesth. 2017;27:591–5. study compares the safety and effect on operating room efficiency of tracheal extubation in the operating room versus the postanesthesia care unit at two tertiary care children's hospitals.

    Article  PubMed  Google Scholar 

  57. 57.

    House LM, Calloway NH, Sandberg WS, Ehrenfeld JM. Prolonged patient emergence time among clinical anesthesia resident trainees. J Anaesthesiol Clin Pharmacol. 2016;32:446–52.

    Article  PubMed  PubMed Central  Google Scholar 

  58. 58.

    Asai T, Koga K, Vaughan RS. Respiratory complications associated with tracheal intubation and extubation. Br J Anaesth. 1998;80:767–75.

    CAS  Article  PubMed  Google Scholar 

  59. 59.

    Pop RS. Extubation of pediatric patients: can nurses safely pull the tube? J Perianesth Nurs. 2009;24:313–8.

    Article  PubMed  Google Scholar 

  60. 60.

    von Ungern-Sternberg BS, Erb TO, Reber A, et al. Opening the upper airway-airway maneuvers in pediatric anesthesia. Paediatr Anaesth. 2005;15:181–9.

    Article  Google Scholar 

  61. 61.

    Adler AC, Chandrakantan A. Nursing initiated tracheal extubation in the PACU, the risk of delegating critical anesthesiology tasks in the interest of speed. Pediatr Anesth. 2017;27:1165–6.

    Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Francine S. Yudkowitz.

Ethics declarations

Conflict of Interest

Francine S. Yudkowitz and Renee L. Davis declare they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Pediatric Anesthesia

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Yudkowitz, F.S., Davis, R.L. Pediatric Post-anesthesia Care Unit Challenges Update. Curr Anesthesiol Rep 9, 92–99 (2019).

Download citation


  • Post-anesthesia care unit
  • Emergence delirium
  • Postoperative nausea and vomiting
  • Residual neuromuscular blockade
  • Extubation in post-anesthesia care unit