Predicting pediatric emergence delirium using data-driven machine learning applied to electronic health record dataset at a quaternary care pediatric hospital

Abstract

Objectives: Pediatric emergence delirium is an undesirable outcome that is understudied. Development of a predictive model is an initial step toward reducing its occurrence. This study aimed to apply machine learning (ML) methods to a large clinical dataset to develop a predictive model for pediatric emergence delirium.

Materials and methods: We performed a single-center retrospective cohort study using electronic health record data from February 2015 to December 2019. We built and evaluated 4 commonly used ML models for predicting emergence delirium: least absolute shrinkage and selection operator, ridge regression, random forest, and extreme gradient boosting. The primary outcome was the occurrence of emergence delirium, defined as a Watcha score of 3 or 4 recorded at any time during recovery.

Results: The dataset included 54 776 encounters across 43 830 patients. The 4 ML models performed similarly with performance assessed by the area under the receiver operating characteristic curves ranging from 0.74 to 0.75. Notable variables associated with increased risk included adenoidectomy with or without tonsillectomy, decreasing age, midazolam premedication, and ondansetron administration, while intravenous induction and ketorolac were associated with reduced risk of emergence delirium.

Conclusions: Four different ML models demonstrated similar performance in predicting postoperative emergence delirium using a large pediatric dataset. The prediction performance of the models draws attention to our incomplete understanding of this phenomenon based on the studied variables. The results from our modeling could serve as a first step in designing a predictive clinical decision support system, but further optimization and validation are needed.

Clinical trial number and registry url: Not applicable.

Figure 1.

Study flow diagram.

Figure 2.

Receiver operating characteristic curves and precision versus sensitivity plots for the 4 studied machine learning models. Abbreviation: FPR = false positive rate; PPV = positive predictive value; RF = random forest; XGB = Extreme Gradient Boost.

Figure 3.

Top 10 variables associated with increased and decreased likelihood of emergence delirium, ordered based on LASSO regression model coefficient.

Figure 4.

LASSO model predictions for 4 clinical scenarios. (Scenario A) A 3-year-old male, tonsillectomy/adenoidectomy, admit after surgery observation, midazolam premedication, preoperative blood pressure absent, inhaled anesthesia induction, moderate induction behavior. (Scenario B) A 5-year-old female, minor general surgery/urology procedure, day surgery, midazolam premedication, preoperative blood pressure present, inhaled anesthesia induction, moderate induction behavior. (Scenario C) A 5-year-old male, minor general surgery/urology procedure, day surgery, no premedication, preoperative blood pressure present, inhaled anesthesia induction, calm induction behavior. (Scenario D) A 9-year-old male, orthopedic extremity procedure, day surgery, midazolam premedication, preoperative blood pressure present, inhaled anesthesia induction, calm induction behavior.