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  • Clinical Research Article
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Risk factors for emergence delirium in infant-toddlers undergoing sevoflurane anesthesia and its impact on negative postoperative behavioral changes

Pediatric Research (2025)Cite this article

Abstract

Background

Sevoflurane anesthesia is employed as the standard protocol for pediatric patients undergoing fundus examination. This study investigates the incidence of emergence delirium (ED) and its risk factors in this population, and explores the relationship between ED and negative postoperative behavioral changes (NPOBC).

Methods

A prospective observational study was conducted from May to September 2024, involving 155 children aged 0–3 years undergoing fundus examination under general anesthesia. Patient and surgery-related data were recorded. ED was assessed using the Pediatric Anesthesia Emergence Delirium (PAED) scale, with logistic regression identifying associated factors. Postoperative behaviors were evaluated one week later using the Post-Hospital Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS), with linear regression analyzing the relationship between ED and NPOBC.

Results

In 155 patients, ED incidence was 51%. In the 96 followed-up, NPOBC one week postoperatively was seen in 30.2%. Risk factors for ED included prenatal medical history (OR = 3.70, 95% CI 1.31–10.40, P = 0.013), anesthesia exposure (OR = 1.73, 95% CI 1.36–2.20, P < 0.001), preoperative anxiety (OR = 2.35, 95% CI 1.40–3.94, P = 0.001), and postoperative pain (OR = 1.69, 95% CI 1.31–2.19, P < 0.001). Increased negative behavioral scale scores were associated with anesthesia exposure (B = 0.260, 95% CI 0.123–0.396, P < 0.001) and ED occurrence (B = 1.420, 95% CI 0.598–2.234, P < 0.001).

Conclusion

Our study shows a high incidence of negative emotions and behaviors. Future research should focus on optimizing postoperative analgesia and preoperative anti-anxiety interventions for this high-risk group, and further exploring the connections among anesthesia exposure, ED and NPOBC.

Impact

  • Our study showed a high incidence of negative emotions and behaviors (emergence delirium and postoperative behavioral changes) in minimally invasive fundus examinations under total inhalation anesthesia.

  • Risk factors for emergence delirium are prenatal medical history, anesthesia exposure, preoperative anxiety and postoperative pain. Higher negative behavior scores were associated with anesthesia exposure and emergence delirium.

  • This is the first study to explore the incidence and risk factors of behavioral abnormalities in infants and preterm children after general anesthesia, making it easier to spot high-risk kids having fundus exams and to fine-tune anesthesia and perioperative care for short, minimally invasive procedures.

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Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors thank the surgeons and nurses working in the ophthalmic surgery units for their involvement and support.

Funding

This study received no financial support from gene-related projects, commercial entities, or public funding agencies.

Author information

Author notes

  1. These authors contributed equally: Wanlu Zhao, Kinji Hashimoto.

Authors and Affiliations

  1. Department of Anesthesiology, People’s Hospital, Peking University, Beijing, China

    Wanlu Zhao, Weisi Ding, Yunpeng Zhang, Chunyu Guo, Yi Feng & Haiyan An

  2. Department of Ophthalmology, Peking University People’s Hospital, Beijing, China

    Kinji Hashimoto

  3. Department of Pain Medicine, Peking University People’s Hospital, Beijing, China

    Yi Feng

  4. Key Laboratory for Neuroscience, Ministry of Education/National Health Commission, Peking University, Beijing, China

    Yi Feng

Authors
  1. Wanlu Zhao
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  2. Kinji Hashimoto
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  3. Weisi Ding
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  4. Yunpeng Zhang
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  5. Chunyu Guo
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  6. Yi Feng
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Contributions

Wanlu Zhao and HASHIMOTO KINJI have given substantial contributions to the conception or the design of the manuscript, Weisi Ding to collection of the data, Yunpeng Zhang and Chunyu Guo to analysis and interpretation of the data. All authors have participated in drafting the manuscript, and Yi Feng & Haiyan An revised it critically. All authors read and approved the final version of the manuscript.

Corresponding authors

Correspondence to Yi Feng or Haiyan An.

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Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Peking University People’s Hospital (Approval No. 2024PHB133 − 001). Written informed consent was obtained from the legal guardian of the children before they were enrolled in the study.

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Zhao, W., Hashimoto, K., Ding, W. et al. Risk factors for emergence delirium in infant-toddlers undergoing sevoflurane anesthesia and its impact on negative postoperative behavioral changes. Pediatr Res (2025). https://doi.org/10.1038/s41390-025-04608-7

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