Incidence and factors associated with emergence agitation among children following general anaesthesia: a prospective observational study from an LMIC tertiary hospital

Emergence agitation (EA) is a frequent disturbance during recovery from general anaesthesia in children, with widely varying reported incidence. Data from low- and middle-income countries are limited. This study estimated the incidence of EA after elective general anaesthesia in children and identified associated perioperative and psychological factors. A single-centre prospective observational study was conducted at a tertiary hospital over one year. Children aged 1 to 18 years undergoing elective general anaesthesia were assessed. EA was defined as a Paediatric Anaesthesia Emergence Delirium score of 12 or higher, and incidence is reported with a 95% confidence interval (CI). Postoperative pain was assessed using the FLACC scale or a numerical rating scale according to age. Preoperative anxiety was screened across generalised anxiety, social phobia and separation anxiety domains using age- and gender-normed T-scores. Group comparisons used chi-square, Fisher exact and Mann-Whitney U tests, and factors associated with EA were examined using multivariable modified Poisson regression with robust error variance. Crude and adjusted relative risks with 95% confidence intervals (CI) were reported. The study was sized to estimate incidence, and the analysis of associated factors was exploratory. Among 119 children, EA occurred in 19 (16.0%, 95% CI 10.5 to 23.6). Incidence was 19.7% at 1 to 6 years and 11.3% at 7 to 18 years. Social phobia, shorter fasting, postoperative pain, anaesthesia-naïve status and surgical specialty were associated with EA on univariable analysis. On multivariable modified Poisson regression, postoperative pain (aRR 3.72, 95% CI 1.47 to 9.42, p = 0.006), shorter fasting duration (aRR 0.81 per hour, 95% CI 0.68 to 0.97, p = 0.021) and surgery in the combined orthopaedic, ophthalmic and oral maxillofacial category (aRR 2.54, 95% CI 1.14 to 5.65, p = 0.022) remained associated with EA. Social phobia was associated in the crude analysis but not after adjustment. Age, gender, volatile agent and airway device showed no association. EA affected 16% (95% CI 10.5 to 23.6) of children following elective general anaesthesia. Postoperative pain, shorter preoperative fasting and surgery in a combined orthopaedic, ophthalmic and oral maxillofacial category were associated with EA after adjustment, whereas social phobia was significant only before adjustment. Pain was recorded concurrently with the outcome, so this association is concurrent rather than predictive, and the inverse association with fasting duration remains unexplained. These exploratory findings require confirmation in adequately powered multicentre studies.