Date of this Version

10-6-2025

Document Type

DNP Project

Rights

default

Abstract

Background: In a landmark study, Eckenhoff et al surveyed emergence delirium, highlighting a negative correlation between the incidence of emergence delirium and age. In this study, patients aged 3-9 had a 13% incidence of emergence delirium, leading to harm, caregiver distress, and increased healthcare costs. Despite the research, standardized guidelines have yet to be established to reduce emergence delirium in children. Midazolam has displayed inconsistent and adverse effects. Remimazolam, an ultra-short-acting benzodiazepine, offers anxiolysis without lingering adverse effects, making it a promising alternative for reducing emergence delirium in pediatric patients. This project explored intranasal remimazolam's effectiveness and safety profile versus intranasal midazolam in reducing delirium in pediatric patients undergoing outpatient surgery.

Methods: A search of the current literature utilizing PubMed, CENTRAL, and ProQuest was conducted to assess: “In pediatric patients aged 3-8 undergoing outpatient surgery, does the use of intranasal remimazolam compared to intranasal midazolam reduce the incidence of postoperative delirium?” Boolean operators (AND/OR) and the keywords emergence delirium, pediatric emergence, remimazolam, and midazolam were used. Over 2000 studies were screened, and 15 RCTs were selected based on publication dates from 2019 to 2024 after removing duplicates. This project aimed to inform clinical practice and guide future research in pediatric anesthesia by addressing knowledge gaps and comparing outcomes. After IRB exemption was obtained, pre and post-qualitative anonymous surveys were sent via Qualtrics to CRNAs over 8 weeks and aggregate data were analyzed by Qualtrics.

Results: The survey was distributed to 26 CRNAs via e-mail with a 0% response rate. A total of 15 CRNAs were recruited via QR code, with 15 (100%) participants consenting to participate in the study. Although 15 providers initially consented to participate in the project, 2 (13.33%) participants did not complete the post-test questionnaire, and 1 (6.67%) participant answered up until question 7 on the pre-test. The remaining 12 (80%) participants fully completed all components of the QI project; therefore, the attrition rate of this QI project is 3 (20%) participants. Post-survey results demonstrated an overall increase in provider knowledge regarding both current and emerging preoperative sedatives, as well as the management of pediatric emergence delirium. Question 7 and 8 reflected the greatest significance for increased knowledge (19% and 13% increase in correctness, respectively). Additionally, there was an increase in reported likelihood of utilizing remimazolam as a premedication in the post-survey.

Discussion: Remimazolam, offers an alternative due to its rapid onset, ultra-short-acting duration of action, and favorable safety profile; these characteristics make remimazolam safe for pediatric use, as it reduces the risk of lingering effects and cumulative overdose. Examined studies have demonstrated that children who received intraoperative remimazolam as a complement to general anesthesia revealed a quicker return to responsiveness and quickly achieved requirements for discharge, highlighting remimazolam’s minimal risk of adverse effects, suggesting a potential decrease in the incidence of emergence delirium. Although this project is generalizable, it is restricted to the pediatric population, participant selection was limited to CRNAs due to lack of willingness from other anesthesia providers, and it was confined to one facility. By enhancing provider knowledge and facilitating the implementation of EBP in clinical settings, this project transcends barriers and will promote optimal pediatric patient outcomes.

Keywords: Emergence delirium, pediatric emergence, remimazolam, midazolam

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