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Li Y, Wang B, Zhang LL, He SF, Hu XW, Wong GTC, Zhang Y. Dexmedetomidine Combined with General Anesthesia Provides Similar Intraoperative Stress Response Reduction When Compared with a Combined General and Epidural Anesthetic Technique. Anesth Analg 2016; 122:1202-10. [DOI: 10.1213/ane.0000000000001165] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Li JY, Yi ML, Liao R. Dorsal Penile Nerve Block With Ropivacaine-Reduced Postoperative Catheter-Related Bladder Discomfort in Male Patients After Emergence of General Anesthesia: A Prospective, Randomized, Controlled Study. Medicine (Baltimore) 2016; 95:e3409. [PMID: 27082620 PMCID: PMC4839864 DOI: 10.1097/md.0000000000003409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Catheter-related bladder discomfort (CRBD) is a distressing symptom complex after surgery, especially in male patients who have had urinary catheterization under general anesthesia. In this prospective, randomized, controlled trial, we compared dorsal penile nerve block (DPNB) with 0.33% ropivacaine with intravenous tramadol 1.5 mg kg(-1) in prevention of CRBD, as well as the incidences of postoperative side effects. Fifty-eight male patients aged 18 to 50 years, undergoing elective liver surgery and limb surgery with urinary catheterization, were enrolled and divided randomly into 2 groups. In the DPNB group, patients were given dorsal penile nerve block with 15 mL of 0.33% ropivacaine, and in the tramadol intravenous administration (TRAM) group, patients were given 1.5 mg kg(-1) tramadol after the completion of surgery before extubation. The primary outcome was the incidence of CRBD, and the secondary outcomes included the severity of CRBD, postoperative side effects, postoperative pain, and the acceptance of urinary catheterization. Patients were evaluated upon arrival to postanesthetic care unit (PACU), at 0.5, 1, 2, 4, and 6 hours after patients' arrival in the PACU for outcomes. The incidence of CRBD was significantly lower in the DPNB group than in the TRAM group, either upon arrival to PACU (10.3% vs 37.9%, P = 0.015), or at 0.5 hours (3.4% vs 34.5%, P = 0.003), 1 hours (3.4% vs 37.9%, P = 0.001), 2 hours (6.9% vs 34.5%, P = 0.010), and 4 hours (6.9% vs 27.6%, P = 0.039) after patients' arrival in PACU. Compared with the TRAM group, the severity of postoperative CRBD upon arrival to PACU (P = 0.011) and at 0.5 hours (P = 0.005), 1 hours (P = 0.002), 2 hours (P = 0.005), 4 hours (P = 0.017), and 6 hours (P = 0.047) after patients' arrival in PACU were all significantly reduced in the DPNB group. The incidences of postoperative nausea, vomiting, dizziness, and sedation were decreased significantly in the DPNB group compared with the TRAM group (P < 0.05). The acceptance of urinary catheterization was 93.1% (27/29 patients) in the DPNB group and 58.6% (17/29 patients) in the TRAM group, respectively (P < 0.001).DPNB with ropivacaine has a better effect for CRBD reduction and less side effects than intravenous tramadol administration. The trial has been registered at www.clinicaltrials.gov (NCT01721031).
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Affiliation(s)
- Jing-Yi Li
- From the Department of Dermatovenereology (J-YL), West China Hospital, Sichuan University, Chengdu; Department of Anesthesiology (M-LY), the First People's Hospital of Neijang, Neijiang; and Department of Anesthesiology (RL), West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Feldheiser A, Aziz O, Baldini G, Cox BPBW, Fearon KCH, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytrebø LM, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60:289-334. [PMID: 26514824 PMCID: PMC5061107 DOI: 10.1111/aas.12651] [Citation(s) in RCA: 382] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/23/2015] [Accepted: 09/25/2015] [Indexed: 12/17/2022]
Abstract
Background The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Methods Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. Results This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. Conclusions Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.
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Affiliation(s)
- A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - O. Aziz
- St. Mark's Hospital Harrow Middlesex UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - B. P. B. W. Cox
- Department of Anesthesiology and Pain Therapy University Hospital Maastricht (azM) Maastricht The Netherlands
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - R. H. Kennedy
- St. Mark's Hospital/Imperial College Harrow, Middlesex/London UK
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - D. N. Lobo
- Gastrointestinal Surgery National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK
| | - T. Miller
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - F. F. Radtke
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - T. Ruiz Garces
- Anestesiologa y Reanimacin Hospital Clinico Lozano Blesa Universidad de Zaragoza Zaragoza Spain
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal Quebec Canada
| | - M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Surrey UK
| | - J. K. Thacker
- Department of Surgery Duke University Medical Center Durham North Carolina USA
| | - L. M. Ytrebø
- Department of Anaesthesiology University Hospital of North Norway Tromso Norway
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
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154
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Kim HC, Hong WP, Lim YJ, Park HP. The effect of sevoflurane versus desflurane on postoperative catheter-related bladder discomfort in patients undergoing transurethral excision of a bladder tumour: a randomized controlled trial. Can J Anaesth 2016; 63:596-602. [DOI: 10.1007/s12630-016-0600-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/12/2015] [Accepted: 01/25/2016] [Indexed: 11/25/2022] Open
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Scott MJ, Baldini G, Fearon KCH, Feldheiser A, Feldman LS, Gan TJ, Ljungqvist O, Lobo DN, Rockall TA, Schricker T, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand 2015; 59:1212-31. [PMID: 26346577 PMCID: PMC5049676 DOI: 10.1111/aas.12601] [Citation(s) in RCA: 232] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 06/18/2015] [Accepted: 07/23/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The present article has been written to convey concepts of anaesthetic care within the context of an Enhanced Recovery After Surgery (ERAS) programme, thus aligning the practice of anaesthesia with the care delivered by the surgical team before, during and after surgery. METHODS The physiological principles supporting the implementation of the ERAS programmes in patients undergoing major abdominal procedures are reviewed using an updated literature search and discussed by a multidisciplinary group composed of anaesthesiologists and surgeons with the aim to improve perioperative care. RESULTS The pathophysiology of some key perioperative elements disturbing the homoeostatic mechanisms such as insulin resistance, ileus and pain is here discussed. CONCLUSIONS Evidence-based strategies aimed at controlling the disruption of homoeostasis need to be evaluated in the context of ERAS programmes. Anaesthesiologists could, therefore, play a crucial role in facilitating the recovery process.
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Affiliation(s)
- M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Guildford UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal QC Canada
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charit Mitte and Campus Virchow‐Klinikum Charit University Medicine Berlin Germany
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal QC Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham NY USA
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Orebro University Orebro Sweden
| | - D. N. Lobo
- Division of Gastrointestinal Surgery Nottingham Digestive Diseases Centre National Institute for Health Research Biomedical Research Unit Nottingham University Hospitals Queen's Medical Centre Nottingham UK
| | - T. A. Rockall
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Guildford UK
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal QC Canada
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal QC Canada
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156
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Kim DJ, Kim SH, So KY, Jung KT. Effects of dexmedetomidine on smooth emergence from anaesthesia in elderly patients undergoing orthopaedic surgery. BMC Anesthesiol 2015; 15:139. [PMID: 26446479 PMCID: PMC4597422 DOI: 10.1186/s12871-015-0127-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 10/03/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intraoperative dexmedetomidine may decrease postoperative emergence agitation in elderly patients due to its sedative effect. In this study, we evaluated the effect of adjuvant dexmedetomidine on smooth emergence from anaesthesia after orthopaedic surgery in elderly patients. METHODS A total 115 patients (ASA I-II, aged over 65 years) were randomly allocated into four groups. Anaesthesia was maintained with either sevoflurane or total intravenous anaesthesia (TIVA) comprising propofol and remifentanil. Patients were also administered either dexmedetomidine (0.4 μg kg(-1) hr(-1); SD and TD) intraoperatively or normal saline (SN or TN) as a control. The bispectral index (BIS) score was maintained from 40-60 intraoperatively. All anaesthetics and dexmedetomidine were discontinued at surgical conclusion, and the recovery times (durations to a BIS = 60, 70, and 80; eye opening; and extubation) were measured. The mean arterial pressure, heart rate, Ricker's agitation-sedation scale (RSAS), visual analogue scale (VAS) for pain, and incidences of emergence agitation and postoperative nausea and vomiting (PONV) were measured in the recovery room. RESULTS Dexmedetomidine significantly decreased the RSAS score in the SD and TD groups, and a calm state postoperatively occurred more frequently in these groups than in the control groups. The heart rate and incidence of emergence agitation were lower in the dexmedetomidine groups. Recovery time was higher in the SD group than in the SN group, and no significant differences occurred between the TN and TD groups. The VAS score was lower in the SD group than in the SN group, and the PONV did not differ regardless of the use of dexmedetomidine. CONCLUSIONS Dexmedetomidine may be an effective intraoperative adjuvant for a reducing emergence agitation and smooth emergence from anaesthesia after orthopaedic surgery in elderly patients. TRIAL REGISTRATION Current Controlled Trials NCT01851005 .
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Affiliation(s)
- Dong Jun Kim
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju, 501-717, South Korea.
| | - Sang Hun Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, 365 Pilmun-daero, Dong-gu, Gwangju, 501-717, South Korea.
| | - Keum Young So
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, 365 Pilmun-daero, Dong-gu, Gwangju, 501-717, South Korea.
| | - Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, 365 Pilmun-daero, Dong-gu, Gwangju, 501-717, South Korea.
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157
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Polat R, Peker K, Baran I, Bumin Aydın G, Topçu Gülöksüz Ç, Dönmez A. Comparison between dexmedetomidine and remifentanil infusion in emergence agitation during recovery after nasal surgery: A randomized double-blind trial. Anaesthesist 2015; 64:740-6. [PMID: 26329913 DOI: 10.1007/s00101-015-0077-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 07/12/2015] [Accepted: 07/15/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Postoperative emergency agitation (EA) is a common problem. Dexmedetomidine and remifentanil may be used to prevent this problem. Our primary aim was to compare dexmedetomidine, remifentanil, and placebo with respect to their effectiveness in preventing postoperative EA. MATERIAL AND METHODS Ninety patients undergoing nasal surgery were randomized into three groups. The dexmedetomidine group (group D, n = 30) received dexmedetomidine infusion at a rate of 0.4 μg kg(-1 ) h(-1); the remifentanil group (group R, n = 30) received remifentanil infusion at a rate of 0.05 μg kg(-1) min(-1) from induction of anesthesia until extubation; and the control group (group S, n = 30) received a volume-matched normal saline infusion as a placebo. Propofol (1.5-2 mg kg(-1)) and fentanyl (1 μg kg(-1)) were used to initiate anesthesia, and desflurane was used to maintain anesthesia. The incidence of agitation, hemodynamic parameters, and recovery characteristics were evaluated during emergence. RESULTS The incidence of EA was significantly higher in group S (46.7%) compared with groups R and D (3.3 and 20%, respectively; p < 0.001). The lowest incidence of EA was detected in group R (p = 0.046). Residual sedation in the post-anesthesia care unit (PACU) was similar in all groups (p = 0.947). The incidence of nausea or vomiting was significantly lower in group D than in groups R and S (p = 0.043). Administration of analgesics in the PACU was higher in group R than in groups S and D (p = 0.015). CONCLUSION Anesthetic maintenance with either remifentanil or dexmedetomidine infusion until extubation provided a more smooth and hemodynamically stable emergence, without complications after nasal surgery. While remifentanil was superior to dexmedetomidine with regard to avoiding EA, dexmedetomidine was more effective than remifentanil regarding vomiting and pain.
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Affiliation(s)
- R Polat
- Ministry of Health, Department of Anesthesiology Diskapi, Diskapi Yildirim Beyazit Research and Training Hospital, Ankara, Turkey.
| | - K Peker
- Ministry of Health, Department of Anesthesiology Diskapi, Diskapi Yildirim Beyazit Research and Training Hospital, Ankara, Turkey
| | - I Baran
- Ministry of Health, Department of Anesthesiology Diskapi, Diskapi Yildirim Beyazit Research and Training Hospital, Ankara, Turkey
| | - G Bumin Aydın
- Ministry of Health, Department of Anesthesiology Diskapi, Diskapi Yildirim Beyazit Research and Training Hospital, Ankara, Turkey
| | - Ç Topçu Gülöksüz
- Fen Faculty Statistics Department, Bartin University, Bartin, Turkey
| | - A Dönmez
- Ministry of Health, Department of Anesthesiology Diskapi, Diskapi Yildirim Beyazit Research and Training Hospital, Ankara, Turkey
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158
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Tirlapur N. Should all critically ill ventilated patients receive muscle relaxants for intrahospital transfers? Br J Hosp Med (Lond) 2015; 76:550. [DOI: 10.12968/hmed.2015.76.9.550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Nikhil Tirlapur
- is Specialist Registrar in Anaesthesia and Intensive Care (Dual Accreditation) in the Section for Anaesthetics, Pain Medicine and Intensive Care, Faculty of Medicine, Imperial College London, London SW10 9NH
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159
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The effect of intraoperative dexmedetomidine on postoperative catheter-related bladder discomfort in patients undergoing transurethral bladder tumour resection. Eur J Anaesthesiol 2015; 32:596-601. [DOI: 10.1097/eja.0000000000000196] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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160
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Effect of glycopyrrolate versus atropine coadministered with neostigmine for reversal of rocuronium on postoperative catheter-related bladder discomfort in patients undergoing transurethral resection of bladder tumor: a prospective randomized study. J Anesth 2015; 29:831-5. [DOI: 10.1007/s00540-015-2064-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/21/2015] [Indexed: 10/23/2022]
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161
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Man Y, Guo Z, Cao J, Mi W. Efficacy of perioperative dexmedetomidine in postoperative neurocognitive function: a meta-analysis. Clin Exp Pharmacol Physiol 2015; 42:837-42. [PMID: 26016826 DOI: 10.1111/1440-1681.12432] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/21/2015] [Accepted: 05/19/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Yuanyuan Man
- Anaesthesia and Operation Centre; Chinese PLA General Hospital; Beijing China
| | - Zhenggang Guo
- Department of Anaesthesiology; The First Hospital Affiliated to the Chinese PLA Hospital; Beijing China
| | - Jiangbei Cao
- Anaesthesia and Operation Centre; Chinese PLA General Hospital; Beijing China
| | - Weidong Mi
- Anaesthesia and Operation Centre; Chinese PLA General Hospital; Beijing China
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162
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Dextroamphetamine (but Not Atomoxetine) Induces Reanimation from General Anesthesia: Implications for the Roles of Dopamine and Norepinephrine in Active Emergence. PLoS One 2015; 10:e0131914. [PMID: 26148114 PMCID: PMC4492624 DOI: 10.1371/journal.pone.0131914] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 06/08/2015] [Indexed: 11/23/2022] Open
Abstract
Methylphenidate induces reanimation (active emergence) from general anesthesia in rodents, and recent evidence suggests that dopaminergic neurotransmission is important in producing this effect. Dextroamphetamine causes the direct release of dopamine and norepinephrine, whereas atomoxetine is a selective reuptake inhibitor for norepinephrine. Like methylphenidate, both drugs are prescribed to treat Attention Deficit Hyperactivity Disorder. In this study, we tested the efficacy of dextroamphetamine and atomoxetine for inducing reanimation from general anesthesia in rats. Emergence from general anesthesia was defined by return of righting. During continuous sevoflurane anesthesia, dextroamphetamine dose-dependently induced behavioral arousal and restored righting, but atomoxetine did not (n = 6 each). When the D1 dopamine receptor antagonist SCH-23390 was administered prior to dextroamphetamine under the same conditions, righting was not restored (n = 6). After a single dose of propofol (8 mg/kg IV), the mean emergence times for rats that received normal saline (vehicle) and dextroamphetamine (1 mg/kg IV) were 641 sec and 404 sec, respectively (n = 8 each). The difference was statistically significant. Although atomoxetine reduced mean emergence time to 566 sec (n = 8), this decrease was not statistically significant. Spectral analysis of electroencephalogram recordings revealed that dextroamphetamine and atomoxetine both induced a shift in peak power from δ (0.1–4 Hz) to θ (4–8 Hz) during continuous sevoflurane general anesthesia, which was not observed when animals were pre-treated with SCH-23390. In summary, dextroamphetamine induces reanimation from general anesthesia in rodents, but atomoxetine does not induce an arousal response under the same experimental conditions. This supports the hypothesis that dopaminergic stimulation during general anesthesia produces a robust behavioral arousal response. In contrast, selective noradrenergic stimulation causes significant neurophysiological changes, but does not promote behavioral arousal during general anesthesia. We hypothesize that dextroamphetamine is more likely than atomoxetine to be clinically useful for restoring consciousness in anesthetized patients, mainly due to its stimulation of dopaminergic neurotransmission.
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163
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Beydon L, Rouxel A, Camut N, Schinkel N, Malinovsky JM, Aveline C, Marret E, Bildea A, Dupoiron D, Liu N, Daniel V, Darsonval A, Chrétien JM, Rault L, Bruna J, Alberti C. Sedative premedication before surgery – A multicentre randomized study versus placebo. Anaesth Crit Care Pain Med 2015; 34:165-71. [DOI: 10.1016/j.accpm.2015.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 01/21/2015] [Indexed: 10/23/2022]
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164
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Yan LM, Chen H, Yu RG, Wang ZH, Zhou GH, Wang YJ, Zhang X, Xu M, Chen L, Zhou JX. Emergence agitation during recovery from intracranial surgery under general anaesthesia: a protocol and statistical analysis plan for a prospective multicentre cohort study. BMJ Open 2015; 5:e007542. [PMID: 25900467 PMCID: PMC4410113 DOI: 10.1136/bmjopen-2014-007542] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Emergence agitation after intracranial surgery is an important clinical issue during anaesthesia recovery. The aim of this multicentre cohort study is to investigate the incidence of emergence agitation, identify the risk factors and determine clinical outcomes in adult patients after intracranial surgery under general anaesthesia. Additionally, we will deliberately clarify the relationship between postoperative pneumocephalus and agitation. METHODS AND ANALYSIS The present study is a prospective multicentre cohort study. Five intensive care units (ICUs) in China will participate in the study. Consecutive adult patients admitted to the ICUs after intracranial surgery will be enrolled. Sedation-Agitation Scale (SAS) or Richmond Agitation-Sedation Scale (RASS) will be used to evaluate the patients 12 h after the enrolment. Agitation is defined as an SAS score of 5-7, or an RASS score of +2 to +4. According to the maximal SAS and RASS score, patients will be divided into two cohorts: the agitation group and the non-agitation group. Factors potentially related to emergence agitation will be collected at study entry, during anaesthesia and operation, during postoperative care. Univariate analyses between the agitation and the non-agitation groups will be performed. The stepwise backward logistic regression will be carried out to identify the independent predictors of agitation. Patients will be followed up for 72 h after the operation. Accidental self-extubation of the endotracheal tube and removal of other catheters will be documented. The use of sedatives and analgesics will be collected. ETHICS AND DISSEMINATION Ethics approval has been obtained from each of five participating hospitals. Study findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT02318199.
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Affiliation(s)
- Li-Mei Yan
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Critical Care Medicine, Inner Mongolia People's Hospital, Hohhot, Inner Mongolia, China
| | - Han Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Rong-Guo Yu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Zhu-Heng Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Critical Care Medicine, Daxing Teaching Hospital, Capital Medical University, Beijing, China
| | - Guan-Hua Zhou
- Department of Critical Care Medicine, Daxing Teaching Hospital, Capital Medical University, Beijing, China
| | - Yong-Jin Wang
- Department of Critical Care Medicine, Bethune International Peace Hospital, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xia Zhang
- Department of Critical Care Medicine, Bethune International Peace Hospital, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lu Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Li B, Wang H, Wu H, Gao C. Neurocognitive dysfunction risk alleviation with the use of dexmedetomidine in perioperative conditions or as ICU sedation: a meta-analysis. Medicine (Baltimore) 2015; 94:e597. [PMID: 25860207 PMCID: PMC4554047 DOI: 10.1097/md.0000000000000597] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Many studies have reported the beneficial effects of dexmedetomidine on postoperative neurocognitive function but overall evidence is not as clear. We examined this conundrum by meta-analyzing studies that used dexmedetomidine in perioperative conditions or as intensive care unit (ICU) sedation and utilized reliable neurocognitive assessment tests. The literature search was undertaken across several electronic databases including EBSCO, Embase, Google Scholar, Ovid SP, PubMed, Scopus, and Web of Science. Literature search was carried out across several electronic databases and relevant studies were selected after following précised inclusion criteria. Meta-analysis of risk differences (RDs) was carried out and subgroup analyses were performed. Twenty studies were selected from which data of 2612 individuals were used. Initial dexmedetomidine dose was 0.68 ± 0.27 and maintenance dose was 0.54 ± 0.32 in the trials. Dexmedetomidine treatment was associated with significantly lower risk of postoperative/postanesthesia neurocognitive dysfunction both in comparison with saline-treated controls (RD [95% confidence interval, CI]: -0.17 (-0.30, -0.04); P = 0.008) and comparators (-0.16 [-0.28, -0.04]; P = 0.009). In the subgroups analyses, however, there was no significant differences between dexmedetomidine and controls/comparators when studies with confusion assessment method for ICU only (RD: -0.10 (-0.22, 0.02); P = 0.1) or midazolam as comparator only (RD: -0.26 (-0.60, 0.07); P = 0.12) were meta-analyzed. Dexmedetomidine use in the perioperative conditions or as ICU sedation is associated with lower risk of neurocognitive dysfunction. There can be some impact of neurocognitive assessment method, drug interactions, and clinical heterogeneity on the overall outcomes of this meta-analysis.
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Affiliation(s)
- Bo Li
- From the Department of Anesthesiology (BL, HW, CG), Jinan General Hospital, PLA Jinan Military Area Command, Jinan; and Department of Anesthesiology (HW), The People's Hospital of Zhangqiu, Zhangqiu, Shandong, China
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Stamper MJ, Hawks SJ, Taicher BM, Bonta J, Brandon DH. Identifying pediatric emergence delirium by using the PAED Scale: a quality improvement project. AORN J 2015; 99:480-94. [PMID: 24674794 DOI: 10.1016/j.aorn.2013.08.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 07/11/2013] [Accepted: 08/19/2013] [Indexed: 02/08/2023]
Abstract
Pediatric emergence delirium is a postoperative phenomenon characterized by aberrant cognitive and psychomotor behavior, which can place the patient and health care personnel at risk for injury. A common tool for identifying emergence delirium is the Level of Consciousness-Richmond Agitation and Sedation Scale (LOC-RASS), although it has not been validated for use in the pediatric population. The Pediatric Anesthesia Emergence Delirium Scale (PAED) is a newly validated tool to measure emergence delirium in children. We chose to implement and evaluate the effectiveness and fidelity of using the PAED Scale to identify pediatric emergence delirium in one eight-bed postanesthesia care unit in comparison with the traditional LOC-RASS. The overall incidence of pediatric emergence delirium found by using the LOC-RASS with a retrospective chart review (3%) was significantly lower than the incidence found by using the LOC-RASS (7.5%) and PAED Scale (11.5%) during the implementation period. Our findings suggest that the PAED Scale may be a more sensitive measure of pediatric emergence delirium, and, in the future, we recommend that health care personnel at our facility use the PAED Scale rather than the LOC-RASS.
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Risk factors of emergence agitation in adults undergoing general anesthesia for nasal surgery. Clin Exp Otorhinolaryngol 2015; 8:46-51. [PMID: 25729495 PMCID: PMC4338091 DOI: 10.3342/ceo.2015.8.1.46] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 02/09/2014] [Accepted: 02/10/2014] [Indexed: 01/08/2023] Open
Abstract
Objectives To identify the incidence and the risk factors of emergence agitation in adults undergoing general anesthesia for nasal surgery. Methods We retrospectively examined 792 patients aged ≥18 years who underwent general anesthesia for elective nasal surgery between July 2012 and August 2013. Patients in the postanesthesia care unit with a Richmond Agitation Sedation Scale≥+1 at any time were considered to have emergence agitation. Results The overall incidence of emergence agitation is 22.2%. From multivariate regression analysis, the following six variables were found to be significantly associated with emergence agitation (P<0.05): younger age, recent smoking, sevoflurane anesthesia, postoperative pain on the numerical rating scale (NRS)≥5, presence of a tracheal tube, and presence of a urinary catheter. Presence of a tracheal tube was the greatest risk factor, increasing the risk of developing emergence agitation by approximately fivefold (odds ratio, 5.448; 95% confidence interval, 2.973 to 9.982). Younger age was also a strong risk factor (odds ratio, 0.975 for each 1-year increase; 95% confidence interval, 0.964 to 0.987). Current smoking, sevoflurane anesthesia, postoperative pain of NRS≥5, and the presence of a urinary catheter nearly doubled the risk of emergence agitation. Conclusion Emergence agitation following general anesthesia is a common complication in adult nasal surgery patients. To reduce the occurrence and consequences of agitation episodes, elimination of the associated risk factors is necessary, especially in at-risk patients.
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168
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CHOI GJ, BAEK CW, KANG H, PARK YH, YANG SY, SHIN HY, JUNG YH, WOO YC, LEE UL. Emergence agitation after orthognathic surgery: a randomised controlled comparison between sevoflurane and desflurane. Acta Anaesthesiol Scand 2015; 59:224-31. [PMID: 25395384 DOI: 10.1111/aas.12435] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 10/03/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND This study aimed to compare emergence agitation following sevoflurane and desflurane anaesthesia in adults undergoing orthognathic surgery. The hypothesis was that there might be a difference in the incidence of emergence agitation following sevoflurane and desflurane anaesthesia considering the difference in blood solubility and speed of recovery between the two. METHODS In this prospective randomised double-blind study, 144 adults undergoing orthognathic surgery were randomly allocated to either sevoflurane or desflurane anaesthesia. The incidence of emergence agitation and possible causative factors were then compared between the groups. RESULTS The incidence of emergence agitation was lower in the desflurane group than in the sevoflurane group (24% vs. 71%, P < 0.001). In addition, the time intervals between the discontinuation of anaesthetics and the first response, extubation, and discharge from post-anaesthesia care unit were significantly shorter in the desflurane group (P = 0.002, P < 0.001 and P = 0.003, respectively). The other variables were similar in the two groups. CONCLUSIONS In adults undergoing orthognathic surgery, desflurane anaesthesia was associated with less emergence agitation than was sevoflurane anaesthesia.
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Affiliation(s)
- G. J. CHOI
- Department of Anaesthesiology and Pain Medicine; Chung-Ang University College of Medicine; Seoul Korea
| | - C. W. BAEK
- Department of Anaesthesiology and Pain Medicine; Chung-Ang University College of Medicine; Seoul Korea
| | - H. KANG
- Department of Anaesthesiology and Pain Medicine; Chung-Ang University College of Medicine; Seoul Korea
| | - Y. H. PARK
- Department of Anaesthesiology and Pain Medicine; Chung-Ang University College of Medicine; Seoul Korea
| | - S. Y. YANG
- Department of Anaesthesiology and Pain Medicine; Chung-Ang University College of Medicine; Seoul Korea
| | - H. Y. SHIN
- Department of Anaesthesiology and Pain Medicine; Chung-Ang University College of Medicine; Seoul Korea
| | - Y. H. JUNG
- Department of Anaesthesiology and Pain Medicine; Chung-Ang University College of Medicine; Seoul Korea
| | - Y. C. WOO
- Department of Anaesthesiology and Pain Medicine; Chung-Ang University College of Medicine; Seoul Korea
| | - U. L. LEE
- Department of Oral and Maxillofacial Surgery, Dental Center; Chung-Ang University College of Medicine; Seoul Korea
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Kim HC, Kim E, Jeon YT, Hwang JW, Lim YJ, Seo JH, Park HP. Postanaesthetic emergence agitation in adult patients after general anaesthesia for urological surgery. J Int Med Res 2015; 43:226-35. [DOI: 10.1177/0300060514562489] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To investigate the incidence and risk factors for emergence agitation in the postanaesthetic care unit (PACU), in adult patients undergoing urological surgery. Methods Medical records were retrospectively reviewed. Preoperative, intraoperative and postoperative variables were evaluated. Emergence agitation was defined as a Riker sedation–agitation score ≥5. Logistic regression analysis was used to determine independent risk factors for emergence agitation. Results Emergence agitation was observed in 48/488 (9.8%) patients. Chronic lung disease (odds ratio [OR] 2.72, 95% confidence interval [CI] 1.03, 7.17), duration of surgery (OR 1.01, 95% CI 1.00, 1.01), history of social drinking (OR 2.48, 95% CI 1.25, 4.93), postoperative pain score (OR 1.32, 95% CI 1.14, 1.53), voiding urgency (OR 2.20, 95% CI 1.01, 4.77) and presence of gastric tube (OR 2.85, 95% CI 1.07, 7.54) were independent risk factors for emergence agitation. Conclusions Adequate postoperative pain management and prevention of catheter-related bladder discomfort may be helpful in reducing the incidence of emergence agitation in urology patients.
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Affiliation(s)
- Hyun-Chang Kim
- Department of Anaesthesia and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eugene Kim
- Department of Anaesthesia and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Tae Jeon
- Department of Anaesthesia and Pain Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jung-Won Hwang
- Department of Anaesthesia and Pain Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Young-Jin Lim
- Department of Anaesthesia and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hwa Seo
- Department of Anaesthesia and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee-Pyoung Park
- Department of Anaesthesia and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Card E, Pandharipande P, Tomes C, Lee C, Wood J, Nelson D, Graves A, Shintani A, Ely EW, Hughes C. Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit. Br J Anaesth 2014; 115:411-7. [PMID: 25540068 DOI: 10.1093/bja/aeu442] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Emergence from anaesthesia is often accompanied by signs of delirium, including fluctuating mental status and inattention. The evolution of these signs of delirium requires investigation since delirium in the post-anaesthesia care unit (PACU) may be associated with worse outcomes. METHODS Adult patients emerging from anaesthesia were assessed for agitated emergence in the operating room using the Richmond Agitation-Sedation Scale (RASS). The Confusion Assessment Method for the Intensive Care Unit was then used to evaluate delirium signs at PACU admission and during PACU stay at 30 min, 1 h, and discharge. Signs consistent with delirium were classified as hyperactive vs hypoactive based upon a positive CAM-ICU assessment and the concomitant RASS score. Multivariable logistic regression was utilized to assess potential risk factors for delirium during PACU stay including age, American Society of Anesthesiologists classification, and opioid and benzodiazepine exposure. RESULTS Among 400 patients enrolled, 19% had agitated emergence. Delirium signs were present at PACU admission, 30 min, 1 h, and PACU discharge in 124 (31%), 59 (15%), 32 (8%), and 15 (4%) patients, respectively. In patients with delirium signs, hypoactive signs were present in 56% at PACU admission and in 92% during PACU stay. Perioperative opioids were associated with delirium signs during PACU stay (P=0.02). CONCLUSIONS A significant proportion of patients develop delirium signs in the immediate postoperative period, primarily manifesting with a hypoactive subtype. These signs often persist to PACU discharge, suggesting the need for structured delirium monitoring in the PACU to identify patients potentially at risk for worse outcomes in the postoperative period.
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Affiliation(s)
- E Card
- Department of Anesthesiology, Perioperative Clinical Research Institute
| | - P Pandharipande
- Department of Anesthesiology, Perioperative Clinical Research Institute, Department of Anesthesiology, Division of Critical Care Department of Perioperative Services, Department of Urologic Surgery Department of Biostatistics and Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center and the VA Tennessee Valley Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - C Tomes
- Department of Perioperative Services
| | - C Lee
- Department of Perioperative Services
| | - J Wood
- Department of Perioperative Services
| | - D Nelson
- Department of Anesthesiology, Perioperative Clinical Research Institute
| | | | | | - E W Ely
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center and the VA Tennessee Valley Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - C Hughes
- Department of Anesthesiology, Division of Critical Care
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Chen L, Xu M, Li GY, Cai WX, Zhou JX. Incidence, Risk Factors and Consequences of Emergence Agitation in Adult Patients after Elective Craniotomy for Brain Tumor: A Prospective Cohort Study. PLoS One 2014; 9:e114239. [PMID: 25493435 PMCID: PMC4262354 DOI: 10.1371/journal.pone.0114239] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 11/04/2014] [Indexed: 12/11/2022] Open
Abstract
Emergence agitation is a frequent complication that can have serious consequences during recovery from general anesthesia. However, agitation has been poorly investigated in patients after craniotomy. In this prospective cohort study, adult patients were enrolled after elective craniotomy for brain tumor. The sedation-agitation scale was evaluated during the first 12 hours after surgery. Agitation developed in 35 of 123 patients (29%). Of the agitated patients, 28 (80%) were graded as very and dangerously agitated. By multivariate stepwise logistic regression analysis, independent predictors for agitation included male sex, history of long-term use of anti-depressant drugs or benzodiazepines, frontal approach of the operation, method and duration of anesthesia and presence of endotracheal intubation. Total intravenous anesthesia and balanced anesthesia with short duration were protective factors. Emergence agitation was associated with self-extubation (8.6% vs 0%, P = 0.005). Sedatives were administered more in agitated patients than non-agitated patients (85.7% vs 6.8%, P<0.001). In conclusion, emergence agitation was a frequent complication in patients after elective craniotomy for brain tumors. The clarification of risk factors could help to identify the high-risk patients, and then to facilitate the prevention and treatment of agitation. For patients undergoing craniotomy, greater attention should be paid to those receiving a frontal approach for craniotomy and those anesthetized under balanced anesthesia with long duration. More researches are warranted to elucidate whether total intravenous anesthesia could reduce the incidence of agitation after craniotomy. Trial Registration ClinicalTrials.gov NCT00590499.
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Affiliation(s)
- Lu Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, 100050, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, 100050, China
| | - Gui-Yun Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, 100050, China
| | - Wei-Xin Cai
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, 100050, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, 100050, China
- * E-mail:
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172
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Alterations in the functional connectivity of frontal lobe networks preceding emergence delirium in children. Anesthesiology 2014; 121:740-52. [PMID: 25057840 DOI: 10.1097/aln.0000000000000376] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to characterize the electroencephalogram in children who emerged with emergence delirium (ED) compared with children without ED using methods that involved the assessment of cortical functional connectivity. METHODS Children aged 5 to 15 yr had multichannel electroencephalographic recordings during induction and emergence from anesthesia during minor surgical procedures. Of these, five children displayed ED after sevoflurane anesthesia. Measures of cortical functional connectivity previously used to evaluate anesthetic action in adults were compared between ED and age-, sex-, and anesthetic-matched non-ED children during emergence from anesthesia. RESULTS At the termination of sevoflurane anesthesia, the electroencephalogram in both ED and control patients showed delta frequency slowing and frontally dominant alpha activity, followed by a prolonged state with low-voltage, fast frequency activity (referred to as an indeterminate state). In children with ED, arousal with delirious behavior and a variety of electroencephalogram patterns occurred during the indeterminate state, before the appearance of normal wake or sleep patterns. The electroencephalogram in children without ED progressed from the indeterminate state to classifiable sleep or drowsy states, before peaceful awakening. Statistically significant differences in frontal lobe functional connectivity were identified between children with ED and non-ED. CONCLUSIONS ED is associated with arousal from an indeterminate state before the onset of sleep-like electroencephalogram patterns. Increased frontal lobe cortical functional connectivity observed in ED, immediately after the termination of sevoflurane anesthesia, will have important implications for the development of methods to predict ED, the design of preventative strategies, and efforts to better understand its pathophysiology.
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Electrical stimulation of the ventral tegmental area induces reanimation from general anesthesia. Anesthesiology 2014; 121:311-9. [PMID: 24398816 DOI: 10.1097/aln.0000000000000117] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Methylphenidate or a D1 dopamine receptor agonist induces reanimation (active emergence) from general anesthesia. The authors tested whether electrical stimulation of dopaminergic nuclei also induces reanimation from general anesthesia. METHODS In adult rats, a bipolar insulated stainless steel electrode was placed in the ventral tegmental area (VTA, n = 5) or substantia nigra (n = 5). After a minimum 7-day recovery period, the isoflurane dose sufficient to maintain loss of righting was established. Electrical stimulation was initiated and increased in intensity every 3 min to a maximum of 120 µA. If stimulation restored the righting reflex, an additional experiment was performed at least 3 days later during continuous propofol anesthesia. Histological analysis was conducted to identify the location of the electrode tip. In separate experiments, stimulation was performed in the prone position during general anesthesia with isoflurane or propofol, and the electroencephalogram was recorded. RESULTS To maintain loss of righting, the dose of isoflurane was 0.9% ± 0.1 vol%, and the target plasma dose of propofol was 4.4 ± 1.1 µg/ml (mean ± SD). In all rats with VTA electrodes, electrical stimulation induced a graded arousal response including righting that increased with current intensity. VTA stimulation induced a shift in electroencephalogram peak power from δ (<4 Hz) to θ (4-8 Hz). In all rats with substantia nigra electrodes, stimulation did not elicit an arousal response or significant electroencephalogram changes. CONCLUSIONS Electrical stimulation of the VTA, but not the substantia nigra, induces reanimation during general anesthesia with isoflurane or propofol. These results are consistent with the hypothesis that dopamine release by VTA neurons, but not substantia nigra neurons, induces reanimation from general anesthesia.
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Leung LS, Luo T, Ma J, Herrick I. Brain areas that influence general anesthesia. Prog Neurobiol 2014; 122:24-44. [PMID: 25172271 DOI: 10.1016/j.pneurobio.2014.08.001] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/03/2014] [Accepted: 08/19/2014] [Indexed: 10/24/2022]
Abstract
This document reviews the literature on local brain manipulation of general anesthesia in animals, focusing on behavioral and electrographic effects related to hypnosis or loss of consciousness. Local inactivation or lesion of wake-active areas, such as locus coeruleus, dorsal raphe, pedunculopontine tegmental nucleus, perifornical area, tuberomammillary nucleus, ventral tegmental area and basal forebrain, enhanced general anesthesia. Anesthesia enhancement was shown as a delayed emergence (recovery of righting reflex) from anesthesia or a decrease in the minimal alveolar concentration that induced loss of righting. Local activation of various wake-active areas, including pontis oralis and centromedial thalamus, promoted behavioral or electrographic arousal during maintained anesthesia and facilitated emergence. Lesion of the sleep-active ventrolateral preoptic area resulted in increased wakefulness and decreased isoflurane sensitivity, but only for 6 days after lesion. Inactivation of any structure within limbic circuits involving the medial septum, hippocampus, nucleus accumbens, ventral pallidum, and ventral tegmental area, amygdala, entorhinal and piriform cortex delayed emergence from anesthesia, and often reduced anesthetic-induced behavioral excitation. In summary, the concept that anesthesia works on the sleep-wake system has received strong support from studies that inactivated/lesioned or activated wake-active areas, and weak support from studies that lesioned sleep-active areas. In addition to the conventional wake-sleep areas, limbic structures such as the medial septum, hippocampus and prefrontal cortex are also involved in the behavioral response to general anesthesia. We suggest that hypnosis during general anesthesia may result from disrupting the wake-active neuronal activities in multiple areas and suppressing an atropine-resistant cortical activation associated with movements.
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Affiliation(s)
- L Stan Leung
- Department of Physiology and Pharmacology, The University of Western Ontario, London, Ontario, Canada N6A 5C1.
| | - Tao Luo
- Department of Anesthesiology, Peking University, Shenzhen Hospital, China
| | - Jingyi Ma
- Department of Physiology and Pharmacology, The University of Western Ontario, London, Ontario, Canada N6A 5C1
| | - Ian Herrick
- Department of Anaesthesiology and Perioperative Medicine, The University of Western Ontario, London, Ontario, Canada N6A 5C1
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A laparoscopic gastrectomy approach decreases the incidence and severity of emergence agitation after sevoflurane anesthesia. J Anesth 2014; 29:223-8. [DOI: 10.1007/s00540-014-1905-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 08/02/2014] [Indexed: 12/23/2022]
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Andersen LPH, Werner MU, Rosenberg J, Gögenur I. A systematic review of peri-operative melatonin. Anaesthesia 2014; 69:1163-71. [DOI: 10.1111/anae.12717] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2014] [Indexed: 12/23/2022]
Affiliation(s)
- L. P. H. Andersen
- Department of Surgery D; Herlev Hospital; University of Copenhagen; Copenhagen Denmark
| | - M. U. Werner
- Multidisciplinary Pain Center 7612; Neuroscience Center; Copenhagen Denmark
| | - J. Rosenberg
- Department of Surgery D; Herlev Hospital; University of Copenhagen; Copenhagen Denmark
| | - I. Gögenur
- Department of Surgery D; Herlev Hospital; University of Copenhagen; Copenhagen Denmark
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Neuropsychiatric Conditions Associated With Anesthesia Exposure. PSYCHOSOMATICS 2014; 55:21-8. [DOI: 10.1016/j.psym.2013.06.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 06/25/2013] [Accepted: 06/26/2013] [Indexed: 02/07/2023]
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Lorazepam does not improve the quality of recovery in day-case surgery patients. Eur J Anaesthesiol 2013; 30:743-51. [DOI: 10.1097/eja.0b013e328361d395] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
Emergence delirium (ED) is a well-known phenomenon in the postoperative period. However, the literature concerning this clinical problem is limited. This review evaluates the literature with respect to epidemiology and risk factors. Treatment strategies are discussed. The review concludes that there is a need for guidelines concerning diagnosis and treatment of ED. Risk factors should be investigated further in the clinical setting in the future.
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Affiliation(s)
- Louise Munk
- Department of Anaesthesiology I, Herlev Hospital, University of Copenhagen, DK-2730 Herlev, Denmark.
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Xará D, Silva A, Mendonça J, Abelha F. Inadequate emergence after anesthesia: emergence delirium and hypoactive emergence in the Postanesthesia Care Unit. J Clin Anesth 2013; 25:439-46. [PMID: 23965209 DOI: 10.1016/j.jclinane.2013.02.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 02/10/2013] [Accepted: 02/15/2013] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE To evaluate the frequency, determinants, and outcome of inadequate emergence after elective surgery in the Postanesthesia Care Unit (PACU). DESIGN Prospective observational study. SETTING 12-bed PACU of a tertiary-care hospital in a major metropolitan area. PATIENTS 266 adult patients admitted to the PACU. INTERVENTION To evaluate inadequate emergence, the Richmond Agitation and Sedation Scale (RASS) was administered to patients 10 minutes after their admission to the PACU. MEASUREMENTS Demographic data, perioperative variables, and postoperative length of stay (LOS) in the PACU and the hospital were recorded. MAIN RESULTS 40 (15%) patients showed symptoms of inadequate emergence: 17 patients (6.4%) screened positive for emergence delirium and 23 patients (8.6%) showed hypoactive emergence. Determinants of emergence delirium were longer duration of preoperative fasting (P = 0.001), higher visual analog scale (VAS) scores for pain (P = 0.002), and major surgical risk (P = 0.001); these patients had a higher frequency of postoperative delirium (P = 0.017) and had higher nausea VAS score 6 hours after surgery (P = 0.001). Determinants of hypoactive emergence were duration of surgery (P = 0.003), amount of crystalloids administered during surgery (P = 0.002), residual neuromuscular block (P < 0.001), high-risk surgery (P = 0.002), and lower core temperature on PACU admission (P = 0.028); these patients also had more frequent residual neuromuscular block (P < 0.001) postoperative delirium (P < 0.001), and more frequent adverse respiratory events (P = 0.02). Patients with hypoactive emergence had longer PACU and hospital LOS. CONCLUSIONS Preventable determinants for emergence delirium were higher postoperative pain scores and longer fasting times. Hypoactive emergence was associated with longer postoperative PACU and hospital LOSs.
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Affiliation(s)
- Daniela Xará
- Department of Anesthesiology, Postanesthesia Care Unit, Centro Hospitalar de São João, Porto 4200-465, Portugal
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Kim S, Kim J, Lee J, Song B, Koo B. Efficacy of intraoperative dexmedetomidine infusion on emergence agitation and quality of recovery after nasal surgery. Br J Anaesth 2013; 111:222-8. [DOI: 10.1093/bja/aet056] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Nygren J, Thacker J, Carli F, Fearon KCH, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg 2013; 37:285-305. [PMID: 23052796 DOI: 10.1007/s00268-012-1787-6] [Citation(s) in RCA: 303] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Singh R, Kharbanda M, Sood N, Mahajan V, Chatterji C. Comparative evaluation of incidence of emergence agitation and post-operative recovery profile in paediatric patients after isoflurane, sevoflurane and desflurane anaesthesia. Indian J Anaesth 2012; 56:156-61. [PMID: 22701207 PMCID: PMC3371491 DOI: 10.4103/0019-5049.96325] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Emergence agitation (EA), although well documented in the clinical literature, still has uncertainties and confusion abound on this subject because of the absence of a clear definition and lack of reliable and valid assessment tools. AIM To compare the incidence and severity of EA and recovery characteristics in paediatric patients under isoflurane, sevoflurane or desflurane anaesthesia and evaluate the effect of age and duration of anaesthesia on the incidence of EA. SETTINGS AND DESIGN Randomized prospective double-blinded study. METHODS Seventy-five American Society of Anaesthesiologists I and II patients, aged between 4 months and 7 years, were included in the study. Patients were induced with sevoflurane and oxygen. Anaesthesia was maintained with O(2) + N(2)O and isoflurane, sevoflurane or desflurane according to randomization. Caudal block and paracetamol suppository was administered before the surgical incision. In the Post-Anesthesia Care Unit (PACU), degree of agitation was assessed using the Paediatric Anaesthesia Emergence Delirium Scale. Aldrette score, Face, Legs, Activity, Cry, Consolability score and any adverse events were noted. STATISTICAL ANALYSIS Chi-square/Fischer exact test was applied for categorical variables; for continuous variables, the analysis of variance/non-parametric Kruskall-Wallis test was applied. Two-sample t-test/non-parametric Wisconsin Mann-Whitney test was applied between the two groups. Statistical significance was determined at P<0.05. RESULTS Incidence and intensity of EA were comparable in all three groups. Age and duration of anaesthesia do not appear to have any bearing on the incidence of EA. Rapid emergence with sevoflurane and desflurane did not translate into early discharge from PACU. CONCLUSIONS EA is a multifactorial syndrome. More well-conducted studies using validated scales and standardized protocols should be carried out to better understand this phenomenon.
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Affiliation(s)
- Rahil Singh
- Department of Anaesthesiology and Critical Care, Indraprastha Apollo Hospital, Delhi, India
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Nygren J, Thacker J, Carli F, Fearon KCH, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:801-16. [PMID: 23062720 DOI: 10.1016/j.clnu.2012.08.012] [Citation(s) in RCA: 266] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/19/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol. METHODS Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate). CONCLUSIONS Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.
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Affiliation(s)
- J Nygren
- Department of Surgery, Ersta Hospital, Karolinska Institutet, Stockholm, Sweden.
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187
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Vasilevskis EE, Han JH, Hughes CG, Ely EW. Epidemiology and risk factors for delirium across hospital settings. Best Pract Res Clin Anaesthesiol 2012; 26:277-87. [PMID: 23040281 PMCID: PMC3580997 DOI: 10.1016/j.bpa.2012.07.003] [Citation(s) in RCA: 208] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 07/25/2012] [Indexed: 10/27/2022]
Abstract
Delirium is one of the most common causes of acute end-organ dysfunction across hospital settings, occurring in as high as 80% of critically ill patients that require intensive care unit (ICU) care. The implications of this acute form of brain injury are profound. Across many hospital settings (emergency department, general medical ward, postoperative and ICU), a patient who experiences delirium is more likely to experience increased short- and long-term mortality, decreases in long-term cognitive function, increases in hospital length of stay and increased complications of hospital care. With the development of reliable setting-specific delirium-screening instruments, researchers have been able to highlight the predisposing and potentially modifiable risk factors that place patients at highest risk. Among the large number of risk factors discovered, administration of potent sedative medications, most notably benzodiazepines, is most consistently and strongly associated with an increased burden of delirium. Alternatively, in both the hospital and ICU, delirium can be prevented with the application of protocols that include early mobility/exercise. Future studies must work to understand the epidemiology across settings and focus upon modifiable risk factors that can be integrated into existing delirium prevention and treatment protocols.
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Affiliation(s)
- Eduard E Vasilevskis
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, USA.
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188
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Tse L, Schwarz SKW, Bowering JB, Moore RL, Burns KD, Richford CM, Osborn JA, Barr AM. Pharmacological risk factors for delirium after cardiac surgery: a review. Curr Neuropharmacol 2012; 10:181-96. [PMID: 23449337 PMCID: PMC3468873 DOI: 10.2174/157015912803217332] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 04/10/2012] [Accepted: 04/30/2012] [Indexed: 12/29/2022] Open
Abstract
PURPOSE The objective of this review is to evaluate the literature on medications associated with delirium after cardiac surgery and potential prophylactic agents for preventing it. SOURCE Articles were searched in MEDLINE, Cumulative Index to Nursing and Allied Health, and EMBASE with the MeSH headings: delirium, cardiac surgical procedures, and risk factors, and the keywords: delirium, cardiac surgery, risk factors, and drugs. Principle inclusion criteria include having patient samples receiving cardiac procedures on cardiopulmonary bypass, and using DSM-IV-TR criteria or a standardized tool for the diagnosis of delirium. PRINCIPAL FINDINGS Fifteen studies were reviewed. Two single drugs (intraoperative fentanyl and ketamine), and two classes of drugs (preoperative antipsychotics and postoperative inotropes) were identified in the literature as being independently associated with delirium after cardiac surgery. Another seven classes of drugs (preoperative antihypertensives, anticholinergics, antidepressants, benzodiazepines, opioids, and statins, and postoperative opioids) and three single drugs (intraoperative diazepam, and postoperative dexmedetomidine and rivastigmine) have mixed findings. One drug (risperidone) has been shown to prevent delirium when taken immediately upon awakening from cardiac surgery. None of these findings was replicated in the studies reviewed. CONCLUSION These studies have shown that drugs taken perioperatively by cardiac surgery patients need to be considered in delirium risk management strategies. While medications with direct neurological actions are clearly important, this review has shown that specific cardiovascular drugs may also require attention. Future studies that are methodologically consistent are required to further validate these findings and improve their utility.
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Affiliation(s)
- Lurdes Tse
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, 2176 Health Sciences Mall, Vancouver, B.C., Canada, V6T 1Z3
| | - Stephan KW Schwarz
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, 2176 Health Sciences Mall, Vancouver, B.C., Canada, V6T 1Z3
| | - John B Bowering
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, 2176 Health Sciences Mall, Vancouver, B.C., Canada, V6T 1Z3
| | - Randell L Moore
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, 2176 Health Sciences Mall, Vancouver, B.C., Canada, V6T 1Z3
| | - Kyle D Burns
- Department of Psychiatry, The University of British Columbia, Canada
| | - Carole M Richford
- Department of Psychiatry, The University of British Columbia, Canada
| | - Jill A Osborn
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, 2176 Health Sciences Mall, Vancouver, B.C., Canada, V6T 1Z3
| | - Alasdair M Barr
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, 2176 Health Sciences Mall, Vancouver, B.C., Canada, V6T 1Z3
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McGuire JM. The Incidence of and Risk Factors for Emergence Delirium in U.S. Military Combat Veterans. J Perianesth Nurs 2012; 27:236-45. [DOI: 10.1016/j.jopan.2012.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 03/01/2012] [Accepted: 05/14/2012] [Indexed: 10/28/2022]
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Kim YS, Chae YK, Choi YS, Min JH, Ahn SW, Yoon JW, Lee SE, Lee YK. A comparative study of emergence agitation between sevoflurane and propofol anesthesia in adults after closed reduction of nasal bone fracture. Korean J Anesthesiol 2012; 63:48-53. [PMID: 22870365 PMCID: PMC3408515 DOI: 10.4097/kjae.2012.63.1.48] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 02/20/2012] [Accepted: 02/22/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergence agitation is associated with increased morbidity and hospital costs. However, there have been few reports in the medical literature on the occurrence of emergence agitation in adults. The aim of this study was to compare emergence agitation between sevoflurane and propofol anesthesia in adults after closed reduction of nasal bone fracture. METHODS Forty adults (ASA I-II, 20-60 yr) undergoing closed reduction of nasal bone fracture were randomly assigned to either sevoflurane or propofol group and anesthesia was maintained with sevoflurane or propofol. The bispectral index (BIS) was monitored and maintained within 40-60. At the end of surgery, patients were transported to the post anesthetic care unit (PACU) and agitation state scale was checked by Aono's four-point scale (AFPS). Emergence agitation was defined as and AFPS score of 3 or 4. Pain score were measured by numeric rating scale (NRS) on arrival and peak value at PACU. RESULTS Nine (45.0%) patients in the sevoflurane group and 2 (10.0%) patients in the propofol group developed emergence agitation in the PACU (P = 0.031). There was no correlation between peak NRS and Aono's four-point scale. CONCLUSIONS Propofol may decrease incidence of emergence agitation compared to sevoflurane in adults undergoing closed reduction of nasal bone fracture.
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Affiliation(s)
- Young-Shin Kim
- Department of Anesthesiology and Pain Medicine, Myongji Hospital, Kwandong University Medical School, Goyang, Korea
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191
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Low social support is associated with an increased risk of postoperative delirium. J Clin Anesth 2012; 24:126-32. [DOI: 10.1016/j.jclinane.2011.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 06/21/2011] [Accepted: 07/04/2011] [Indexed: 11/19/2022]
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Bilotta F, Doronzio A, Stazi E, Titi L, Zeppa IO, Cianchi A, Rosa G, Paoloni FP, Bergese S, Asouhidou I, Ioannou P, Abramowicz AE, Spinelli A, Delphin E, Ayrian E, Zelman V, Lumb P. Early postoperative cognitive dysfunction and postoperative delirium after anaesthesia with various hypnotics: study protocol for a randomised controlled trial--the PINOCCHIO trial. Trials 2011; 12:170. [PMID: 21733178 PMCID: PMC3155116 DOI: 10.1186/1745-6215-12-170] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 07/06/2011] [Indexed: 11/28/2022] Open
Abstract
Background Postoperative delirium can result in increased postoperative morbidity and mortality, major demand for postoperative care and higher hospital costs. Hypnotics serve to induce and maintain anaesthesia and to abolish patients' consciousness. Their persisting clinical action can delay postoperative cognitive recovery and favour postoperative delirium. Some evidence suggests that these unwanted effects vary according to each hypnotic's specific pharmacodynamic and pharmacokinetic characteristics and its interaction with the individual patient. We designed this study to evaluate postoperative delirium rate after general anaesthesia with various hypnotics in patients undergoing surgical procedures other than cardiac or brain surgery. We also aimed to test whether delayed postoperative cognitive recovery increases the risk of postoperative delirium. Methods/Design After local ethics committee approval, enrolled patients will be randomly assigned to one of three treatment groups. In all patients anaesthesia will be induced with propofol and fentanyl, and maintained with the anaesthetics desflurane, or sevoflurane, or propofol and the analgesic opioid fentanyl. The onset of postoperative delirium will be monitored with the Nursing Delirium Scale every three hours up to 72 hours post anaesthesia. Cognitive function will be evaluated with two cognitive test batteries (the Short Memory Orientation Memory Concentration Test and the Rancho Los Amigos Scale) preoperatively, at baseline, and postoperatively at 20, 40 and 60 min after extubation. Statistical analysis will investigate differences in the hypnotics used to maintain anaesthesia and the odds ratios for postoperative delirium, the relation of early postoperative cognitive recovery and postoperative delirium rate. A subgroup analysis will be used to categorize patients according to demographic variables relevant to the risk of postoperative delirium (age, sex, body weight) and to the preoperative score index for delirium. Discussion The results of this comparative anaesthesiological trial should whether each the three hypnotics tested is related to a significantly different postoperative delirium rate. This information could ultimately allow us to select the most appropriate hypnotic to maintain anaesthesia for specific subgroups of patients and especially for those at high risk of postoperative delirium. Registered at Trial.gov Number ClinicalTrials.gov: NCT00507195
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Affiliation(s)
- Federico Bilotta
- Department of Anaesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy.
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Hughes CG, Pandharipande PP. Review articles: the effects of perioperative and intensive care unit sedation on brain organ dysfunction. Anesth Analg 2011; 112:1212-7. [PMID: 21474659 DOI: 10.1213/ane.0b013e318215366d] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Analgesia and sedation are routinely administered to patients in procedural suites, operating rooms, and intensive care units to permit invasive procedures, prevent pain and anxiety, reduce stress and oxygen consumption, allow mechanical ventilation, and for numerous other patient comfort and safety reasons. Increasing research and evidence, however, has implicated commonly prescribed sedative medications as risk factors for untoward events and worse patient outcomes, including brain organ dysfunction manifested as delirium and coma. The effect of sedatives on outcomes is also influenced by the depth of sedation, making it imperative to reduce total exposure to this class of medications. Juxtaposing the widespread necessity and use of sedation with the cost of acute and long-term cognitive dysfunction to patients and society, physicians must now strive to balance patients' demands and requisite for comfort with their own oath to do no harm. Fortunately, our methods of sedation and choice of medications can likely mitigate this cognitive risk. In this review, we detail the effects of perioperative and intensive care unit sedation on the development of delirium and cognitive impairment and provide an evidence-based approach towards analgesia and sedation paradigms to improve patient outcomes.
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Affiliation(s)
- Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee 37212, USA
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Affiliation(s)
- Emery N Brown
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit St., GRJ 4, Boston, MA 02114, USA.
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McGuire JM, Burkard JF. Risk Factors for Emergence Delirium in U.S. Military Members. J Perianesth Nurs 2010; 25:392-401. [DOI: 10.1016/j.jopan.2010.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 07/14/2010] [Accepted: 07/25/2010] [Indexed: 10/18/2022]
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[Methods and madness: agitation, delirium, and postoperative cognitive dysfunction]. Can J Anaesth 2010; 57:799-803. [PMID: 20526707 DOI: 10.1007/s12630-010-9339-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Yu D, Chai W, Sun X, Yao L. Emergence agitation in adults: risk factors in 2,000 patients. Can J Anaesth 2010; 57:843-8. [DOI: 10.1007/s12630-010-9338-9] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 05/14/2010] [Indexed: 10/19/2022] Open
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