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Golmohammadi M, Sane S, Ghavipanjeh Rezaei S, Hosseini R, Alwaily ER, Hussien BM, Mohammadpour R, Rahmani N, Kazemi Haki B. Investigating the Effect of Dexmedetomidine in Controlling Postoperative Emergence Agitation in Children under Sevoflurane Anesthesia. Anesthesiol Res Pract 2024; 2024:6418429. [PMID: 39105128 PMCID: PMC11300049 DOI: 10.1155/2024/6418429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 05/15/2024] [Accepted: 07/03/2024] [Indexed: 08/07/2024] Open
Abstract
Introduction Emergence agitation (EA) is one of the common problems during recovery from general anesthesia, especially in children. In this study, we investigated the effect of dexmedetomidine on the control of agitation after anesthesia with sevoflurane in children. Method This randomized control-placebo, double-blind prospective clinical trial was conducted on seventy-six children between 2 and 7 years with ASA (American Society of Anesthesiologists) class I who were candidates for elective adenoidectomy surgery and tonsillectomy. Participants were selected by an available sampling method. Patients were randomly placed in one of the two groups D (dexmedetomidine 0.5 μg/kg infusion within ten minutes) or P (placebo: normal saline infusion within ten minutes). A four-point scale evaluated agitation. Pain evaluation was done by FLACC (faces, legs, activity, cry, and consolability). The statistical software was SPSS version 23. P < 0.05 was considered statistically significant. Results The level of agitation was significantly lower in the intervention group (P < 0.05), except after 40 minutes in the PACU (Post Anesthesia Care Unit) (P=1.00). Patients in the control group experienced high pain scores when admitted at PACU, 10, 20, and 30 minutes after admission at PACU (P < 0.05). Pethidine and metoclopramide prescriptions in the intervention group were lower than in the control group (P < 0.05). Shivering occurred in five patients in the intervention group and nine in the control groups (P=0.032). Hypotension that required intervention occurred in 3 patients in the intervention group and one in the control group (P=0.024). Conclusion Our trial demonstrated that the prescription of 0.5 μg/kg of dexmedetomidine within ten minutes after intubation significantly reduced the EA frequency, pain severity, analgesic consumption, and PONV (postoperative nausea and vomiting). However, it caused delays in the emergence from anesthesia. This trial is registered with IRCT20160430027677N14.
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Affiliation(s)
- Mitra Golmohammadi
- Department of AnesthesiologyUrmia University of Medical Sciences, Urmia, Iran
| | - Shahryar Sane
- Department of AnesthesiologyUrmia University of Medical Sciences, Urmia, Iran
| | - Somayeh Ghavipanjeh Rezaei
- Department of NursingSchool of Nursing and MidwiferyMaragheh University of Medical Sciences, Maragheh, Iran
| | - Rana Hosseini
- Department of Social MedicineUrmia University of Medical Sciences, Urmia, Iran
| | - Enas R. Alwaily
- Microbiology Research GroupCollege of PharmacyAl-Ayen University, Thi-Qar, Nasiriyah, Iraq
| | - Beneen M. Hussien
- Medical Laboratory Technology DepartmentCollege of Medical TechnologyThe Islamic University, Najaf, Iraq
| | - Ramin Mohammadpour
- Department of AnesthesiologyUrmia University of Medical Sciences, Urmia, Iran
| | - Nazila Rahmani
- College of MedicalVeterinary and Life ScienceUniversity of Glasgow, Glasgow, UK
| | - Behzad Kazemi Haki
- Department of AnesthesiologyUrmia University of Medical Sciences, Urmia, Iran
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Kapil S, Jain D, Ganesh V, Panda NB, Arya VK, Grover VK, Mukherjee KK, Bhagat H. Comparison of Response First Technique with Reversal First Technique for Quality of Extubation in Patients Undergoing Transsphenoidal Pituitary Surgery: A Randomized Clinical Trial. Neurol India 2024; 72:528-533. [PMID: 39041968 DOI: 10.4103/neurol-india.neurol-india-d-23-00528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/22/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND AND OBJECTIVE Early and smooth extubation following anesthesia is an important concern in patients undergoing transsphenoidal pituitary surgery to permit early neurological evaluation and prevent complications. The aim was to compare the RESPONSE FIRST and REVERSAL FIRST techniques for quality of extubation (QOE) in patients undergoing endoscopic transsphenoidal pituitary surgery. METHODS Fifty-six patients aged 18-60 years, with American Society of Anesthesiologists Physical Statuses I-II, and undergoing transsphenoidal surgery for pituitary tumors were randomized into either the RESPONSE FIRST group, in which neuromuscular reversal was given following the patient's response to oral commands, or the REVERSAL FIRST group, in which reversal of neuromuscular blockade (NMB) was given at the return of spontaneous respiration. QOE was the primary outcome. Hemodynamic response, jugular venous oxygen saturation (SjVO2), time to extubation, and awareness during emergence were assessed as secondary outcomes. RESULTS The QOE in the RESPONSE FIRST group was significantly better than the REVERSAL FIRST group (mean (interquartile range (IQR)), 18 (17-19) vs 14 (12-14.75), P < 0.001). Heart rate (HR) and mean arterial pressure (MAP) were better in the RESPONSE FIRST group when compared to the REVERSAL FIRST group at the time of extubation, at 5 minutes, and 15 minutes following extubation (P < 0.05). SjVO2values were higher in the REVERSAL FIRST group as compared to the RESPONSE FIRST group during extubation and at 5 minutes after extubation (P < 0.01). There was no significant difference in the time to extubation between the groups (P = 0.73). CONCLUSION The RESPONSE FIRST technique is associated with better QOE and preservation of systemic and cerebral hemodynamics during extubation in patients undergoing transsphenoidal pituitary surgery when compared to the REVERSAL FIRST technique.
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Affiliation(s)
- Sonia Kapil
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Divya Jain
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Venkata Ganesh
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi B Panda
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra K Arya
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vinod K Grover
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kanchan K Mukherjee
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Hemant Bhagat
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Su YH, Luo DC, Pang Y. Effects of intraoperative Magnesium sulfate infusion on emergency agitation during general anesthesia in patients undergoing radical mastectomy: a randomized controlled study. BMC Anesthesiol 2023; 23:326. [PMID: 37749511 PMCID: PMC10521581 DOI: 10.1186/s12871-023-02288-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/18/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Emergency agitation is a common postoperative complication in patients under general anesthesia, which can lead to unpredictable damages such as shedding of drainage tube and bleeding from the wound. The purpose of the study is to investigate whether intraoperative infusion of Magnesium Sulfate reduces the incidence of emergency agitation (EA) in patients undergoing radical mastectomy, and to evaluate its safety and efficacy. METHODS A total of 70 patients were randomly assigned to two groups: the Magnesium group (M group) and the control group (C group). After a routine intravenous anesthetic induction, patients in the M group received a 30 mg/kg bolus of intravenous magnesium during the first hour and then a continuous infusion of 10 mg/kg ×h until the end of the surgery, patients in the C group received 0.9% saline at the same volume and rate. The sedation-agitation scale (SAS) and the visual analogue scale were used to assess agitation and pain, respectively. RESULTS Compared to the C group, the M group reduced the incidence of EA significantly (odds ratio 0.26, 95% confidence interval 0.09-0.71, P = 0.009). The postoperative pain score of the magnesium sulfate group(0(0,1)) was lower than that of the control group(2(0,3)) at T0 (P = 0.011). Additionally, the M group required a lower dosage of remifentanil during surgery compared to the C group(300.4 ± 84 versus 559.3 ± 184 µg, respectively, P<0.001). CONCLUSIONS the intraoperative infusion of magnesium sulfate is a safe and effective method for reducing the incidence of emergency agitation in patients undergoing radical mastectomy. TRAIL REGISTRATION The study was registered in Chictr.org with the identifier: ChiCTR2300070595 on 18/04/2023.
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Affiliation(s)
- Yan-Hong Su
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637000, China
| | - De-Cai Luo
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637000, China
| | - Yong Pang
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637000, China.
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Taylor M, Pileggi W, Boland M, Boudreaux-Kelly M, Julian D, Beckstead A. A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veterans Affairs Medical Center. PATIENT SAFETY 2022. [DOI: 10.33940/med/2022.12.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Emergence delirium (ED) is a temporary condition associated with a patient awakening from an anesthetic and/or adjunct agent (e.g., sedatives and analgesics). During the condition, patients risk harming themselves or staff by engaging in dangerous behavior, which may include thrashing, kicking, punching, and attempting to exit the bed/table.
A multidisciplinary team at Veterans Affairs Pittsburgh Healthcare System (VAPHS) developed and implemented a multicomponent intervention to reduce the severity and occurrence of ED. The intervention consists of a training component and 21 clinical components. The 21 clinical components are implemented on a patient-by-patient basis and include routine screening for risk factors, enhanced communication among staff, adjusting the environment, following a specific medication strategy, and application of manual restraint (hands-on). The authors provide 15 online Supplemental Materials (S1–S15) to promote replication of the intervention.
To our knowledge, this is the first manuscript that describes this type of multicomponent intervention in sufficient detail to allow others to replicate it. Following implementation of the intervention at VAPHS, perioperative staff reported that they observed a substantial reduction in the occurrence and severity of ED, ED-related patient and staff injuries, and ED-related loss of intravenous access and airway patency. Despite staff’s reported success of the intervention, rigorous research is needed to evaluate the efficacy of the intervention.
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Affiliation(s)
| | | | | | | | - David Julian
- VA Pittsburgh Healthcare System; University of Pittsburgh Medical Center Altoona
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Taylor M, Pileggi W, Boland M, Boudreaux-Kelly M, Julian D, Beckstead A. Online Supplement to “A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veteran Affairs Medical Center”. PATIENT SAFETY 2022. [DOI: 10.33940/supplement/2022.12.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
This supplementary material was provided by the authors to give readers additional information and resources to replicate their work.
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Affiliation(s)
| | | | | | | | - David Julian
- VA Pittsburgh Healthcare System; University of Pittsburgh Medical Center Altoona
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Liu W, Luo T, Wang F, Zhang D, Liu T, Huang J, Xu S. Effect of Preoperative Thoracic Paravertebral Blocks on Emergence Agitation During Tracheal Extubation: A Randomized Controlled Trial. Front Med (Lausanne) 2022; 9:902908. [PMID: 35814746 PMCID: PMC9257130 DOI: 10.3389/fmed.2022.902908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/19/2022] [Indexed: 11/13/2022] Open
Abstract
Objective This study aims to compare the effects of preoperative thoracic paravertebral blocks (TPVB) with intercoastal nerve blocks (ICNB) on emergence agitation (EA) during tracheal extubation in patients who underwent thoracoscopic lobectomy. Design, Setting, and Participants A randomized clinical trial was conducted in patients undergoing thoracoscopic lobectomy at Beijing Chest Hospital between June 2019 and December 2020. Interventions Patients were randomly assigned 1:1 to receive either ultrasound-guided preoperative TPVB or ICNB. Main Outcomes and Measures The primary outcome was the occurrence of emergency agitation, which was evaluated by Aono’s four-point scale (AFPS). Secondary outcomes included hemodynamics [mean arterial pressure (MAP) and heart rate (HR)]; and post-operative pain intensity [visual analog scale (VAS), Ramsay sedation score (RSS), and patient-controlled analgesia (PCA) demand times]. Results Among the 100 patients aged 55–75 years old, 50 were randomized to each group; 97 patients completed the trial. Compared to the ICNB group, the occurrence of EA in the TPVB group was significantly lower [31.3% (15/48) vs. 12.2% (6/49), relative risk = 1.276, 95% CI: 1.02–1.60, P = 0.028]. For patients in the TPVB group, the MAP and HR at 5, 10, and 30 min after extubation were significantly lower; the intraoperative details including emergence time, extubation time, and consumption of sufentanil were significantly shorter than that in the ICNB group. Additionally, patients in the TPVB group showed significantly lower VAS at rest or coughing and significantly lower RSS at 60 and 240 min after extubation than patients in the ICNB group (all P < 0.05). Conclusion Preoperative TPVB was associated with less EA during tracheal extubation when compared with ICNB in patients undergoing thoracoscopic lobectomy. Clinical Trial Registration [http://www.chictr.org.cn/index.aspx], identifier [ChiCTR1900023852].
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Affiliation(s)
- Wei Liu
- Department of Anesthesiology, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Taijun Luo
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, China
| | - Fei Wang
- Department of Anesthesiology, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Ding Zhang
- Department of Anesthesiology, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Tao Liu
- Department of Anesthesiology, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, United States
- Department of Anesthesia, Jewish Hospital, Louisville, KY, United States
| | - Shaofa Xu
- Department of Thoracic Surgery, Beijing Chest Hospital, Capital Medical University, Beijing, China
- *Correspondence: Shaofa Xu,
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Zhao L, Sun Z, Shen W, Zeng Y. Clinical application of dexmedetomidine combined with dezocine in local anesthesia for endoscopic dacryocystorhinostomy. EAR, NOSE & THROAT JOURNAL 2022:1455613221108366. [PMID: 35699398 DOI: 10.1177/01455613221108366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the clinical effect of dexmedetomidine combined with dezocine in local anesthesia for endoscopic dacryocystorhinostomy (DCR). METHODS Ninety patients undergoing elective endoscopic DCR were randomly divided into two groups, local anesthesia group (LA group n = 45) and general anesthesia group (GA group, n = 45). These subjects were all American Society of Anesthesiologists (ASA)-Physical Status I-II patients. The changes of mean arterial pressure (MAP) and heart rate (HR) were observed and recorded before anesthesia (T0), after anesthesia (T1), at the beginning of surgery (T2), and at the end of surgery (T3). The visual analogue scale (VAS) score was observed and recorded immediately after awakening from anesthesia and at 1, 2, 6, and 12 h after surgery. Additionally, the occurrence of adverse reactions after surgery and the sedation-agitation scale (SAS) score after awakening were recorded. RESULTS Compared with the LA group, the MAP and HR of the GA group were significantly lower at T1 and T2, but significantly higher at T3. Local anesthesia was associated with lower VAS score immediately after awakening and at 1, 2, 6, and 12 h after surgery. Also, local anesthesia caused a lower incidence of postoperative agitation, nausea, and vomiting. The SAS score in the LA group was markedly higher than that in the GA group. CONCLUSION Local anesthesia with dexmedetomidine and dezocine as adjuvants in endoscopic DCR has more stable hemodynamics and reduces the stress response during perioperative period. Also, this anesthesia achieves better postoperative sedation and analgesia effects, reduces postoperative complications, and improves the quality of awakening from anesthesia. Collectively, local anesthesia is a comfortable and safe option for patients with high risks of general anesthesia and those unwilling to receive general anesthesia.
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Affiliation(s)
- Lu Zhao
- Eye Institute of Shandong First Medical University, Qingdao Eye Hospital of Shandong First Medical University
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthamology
- School of Ophthamology, Shandong First Medical University
| | - Zuojun Sun
- Eye Institute of Shandong First Medical University, Qingdao Eye Hospital of Shandong First Medical University
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthamology
- School of Ophthamology, Shandong First Medical University
| | - Wenting Shen
- Eye Institute of Shandong First Medical University, Qingdao Eye Hospital of Shandong First Medical University
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthamology
- School of Ophthamology, Shandong First Medical University
| | - Yongheng Zeng
- Eye Institute of Shandong First Medical University, Qingdao Eye Hospital of Shandong First Medical University
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthamology
- School of Ophthamology, Shandong First Medical University
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Sin JCK, Tabah A, Campher MJJ, Laupland KB, Eley VA. The Effect of Dexmedetomidine on Postanesthesia Care Unit Discharge and Recovery: A Systematic Review and Meta-Analysis. Anesth Analg 2022; 134:1229-1244. [PMID: 35085107 DOI: 10.1213/ane.0000000000005843] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Current evidence on the effect of dexmedetomidine in early postoperative recovery is limited. We conducted a systematic review to evaluate the effect of dexmedetomidine on the length of stay (LOS) and recovery profile in postanesthesia care unit (PACU) patients. METHODS The study protocol is registered on International Prospective Register of Systematic Reviews (PROSPERO; CRD42021240559). No specific funding or support was received. We conducted searches in MEDLINE, Embase, PubMed, and Cochrane Library to March 31, 2021 for peer-reviewed randomized controlled studies comparing adult patients who received intravenous dexmedetomidine and placebo undergoing noncardiac, nonneurosurgical procedures under general anesthesia. All studies reporting statistics relating to the duration of stay in the recovery ward or PACU, the primary outcome, were included. We performed individual random-effect meta-analysis on the primary and secondary outcomes (time to extubation, emergence agitation, cough, pain, postoperative nausea and vomiting, shivering, residual sedation, bradycardia, and hypotension) using Stata version 17.0. Evidence was synthesized as mean difference (MD) and risk ratio (RR) for continuous and dichotomous variables, respectively. The quality of evidence was assessed using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS Thirty-three studies including 2676 patients were eligible for analysis. All studies had low risk or some concerns of overall bias and provided low-to-high certainty evidence for all studied outcomes. Dexmedetomidine was not associated with a significantly increased PACU LOS (MD, 0.69 minute; 95% confidence interval [CI], -1.42 to 2.81 minutes). It was associated with a statistically but not clinically significant prolonged time to extubation (MD, 1 minute; 95% CI, 0.32-1.68 minutes). Dexmedetomidine was associated with significantly reduced incidence of emergence agitation (RR, 0.38; 95% CI, 0.29-0.52), cough (RR, 0.69; 95% CI, 0.61-0.79), pain (RR, 0.50; 95% CI, 0.32-0.80), postoperative nausea and vomiting (RR, 0.54; 95% CI, 0.33-0.86), and shivering (RR, 0.24; 95% CI, 0.12-0.49) in PACU. There was an increased incidence of hypotension (RR, 5.39; 95% CI, 1.12-5.89) but not residual sedation (RR, 1.23; 95% CI, 0.20-7.56) or bradycardia (RR, 5.13; 95% CI, 0.96-27.47) in the dexmedetomidine group. CONCLUSIONS The use of dexmedetomidine did not increase the duration of PACU LOS but was associated with reduced emergence agitation, cough, pain, postoperative nausea and vomiting, and shivering in PACU. There was an increased incidence of hypotension but not residual sedation or bradycardia in PACU.
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Affiliation(s)
- Jeremy Cheuk Kin Sin
- From the Department of Anaesthesia, Redcliffe Hospital, Redcliffe, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Matthys J J Campher
- From the Department of Anaesthesia, Redcliffe Hospital, Redcliffe, Queensland, Australia.,Department of Anaesthesia, The Tweed Hospital, Tweed Heads, New South Wales, Australia
| | - Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Victoria A Eley
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Taylor M, Pileggi W. Perioperative Delirium/Agitation Associated With the Use of Anesthetics and/or Adjunct Agents: A Study of Patient Behaviors, Injuries, and Interventions to Mitigate Risk. PATIENT SAFETY 2021. [DOI: 10.33940/med/2021.12.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Anesthetics and adjunct agents have a long history of being associated with patients engaging in delirious or agitated behavior in a perioperative setting. Prior to this study, few have explored the topic with a focus on safety for both the patient and staff. We explored the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for event reports to identify bouts of delirium/ agitation associated with anesthetics and/or adjunct agents that occurred during the pre-, intra-, or postoperative period. We identified 97 event reports from 63 healthcare facilities over a two-year period. Patients’ ages ranged from 1 to 91 years and 66% of the patients were reported as male. Also, 8% of the delirium/agitation occurred preoperatively, 8% intraoperatively, and 84% postoperatively. Across all three operative periods, 62% of the reports described dangerous/nonviolent behavior and 26% described dangerous/violent behavior. Additionally, 40% of the event reports described one or more patient injuries (e.g., cardiopulmonary arrest, asphyxiation, hematoma, prolapse/dehiscence, progressive ischemia) and 36% of the patients required additional healthcare services or monitoring (e.g., intra- or interfacility transfer, additional surgical procedure). Finally, 54% of the event reports described patient behavior that created an immediate and high risk of staff harm. Overall, the current study provides novel insight into how delirium/agitation has varying safety implications depending on the operative period. We encourage readers to review Table 5, which proposes a four-phase intervention package to prevent, treat, and de-escalate bouts of delirium/agitation.
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Feng Z, Shi X, Yan X, Zhu Y, Gu J, Zhu H, Yu W, Zhang S. Comparing the effects of dexmedetomidine versus propofol on the treatment of emergence agitation in adult patients after general anesthesia: study protocol for a randomized, superiority, controlled trial (DP-TEA Trial). Trials 2021; 22:811. [PMID: 34784941 PMCID: PMC8593636 DOI: 10.1186/s13063-021-05743-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 10/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergence agitation (EA) after general anesthesia is a common complication in the post-anesthesia care unit (PACU). Once EA occurs, there are still no guidelines established for the treatment in adults. Propofol is excessively used in managing agitated patients in the PACU, but it lacks analgesia and can result in apnea. Intraoperative infusion of dexmedetomidine has been proven to have a preventive effect on EA, but the treatment effect of dexmedetomidine on EA remains unknown. This study aims to compare the effects between dexmedetomidine and propofol on relieving EA in adult patients after general anesthesia in the PACU. METHODS In this randomized, superiority, controlled clinical study, a total of 120 adult patients aged 18-65 years of both genders, with American Society of Anesthesiologists (ASA) classification I or II developing EA in the PACU after general anesthesia, will be enrolled. Patients will be randomized at a 1:1 ratio into two groups, receiving either a single dose of dexmedetomidine (0.7μg/kg) or propofol (0.5 mg/kg). The primary outcome is the proportion of patients having a recurrent EA within 15 min after intervention in the PACU. DISCUSSION Previous studies have focused on premedication for preventing EA, while therapeutics for reliving EA have rarely been reported. To our knowledge, this study is the first randomized, superiority, controlled trial to compare a bolus of dexmedetomidine with the current routine care for this indication. TRIAL REGISTRATION ClinicalTrials.gov NCT04142840 . Registered on October 26, 2019.
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Affiliation(s)
- Zhaoyan Feng
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, No. 160 Pujian Road, Shanghai, 200127, China.,Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, China
| | - Xiao Shi
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, No. 160 Pujian Road, Shanghai, 200127, China
| | - Xue Yan
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, No. 160 Pujian Road, Shanghai, 200127, China
| | - Yamin Zhu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, No. 160 Pujian Road, Shanghai, 200127, China
| | - Juan Gu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, No. 160 Pujian Road, Shanghai, 200127, China
| | - Hao Zhu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, No. 160 Pujian Road, Shanghai, 200127, China
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, No. 160 Pujian Road, Shanghai, 200127, China.
| | - Song Zhang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, No. 160 Pujian Road, Shanghai, 200127, China.
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A Comparison of Dexmedetomidine and Propofol on Emergence Delirium in Children Undergoing Cleft Palate Surgery With Sevoflurane-Based Anesthesia. J Craniofac Surg 2021; 33:650-653. [PMID: 34739450 DOI: 10.1097/scs.0000000000008343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
ABSTRACT Emergence delirium is a common complication after sevoflurane-anesthesia and have a serious impact on children undergoing cleft palate surgery. The aim of this study was to compare the effect of propofol and dexmedetomidine on emergence delirium in children. Ninety children aged 8 to 24 months, underwent cleft palate repair, were enrolled in the study. Children were randomly assigned to 3 groups after the induction: Group C (intravenous infusion 0.9% saline), Group P (intravenous infusion 2 mg/kg/hour propofol), and Group D (intravenous infusion 0.5 μg/kg/hour dexmedetomidine). Emergence delirium was diagnosed using the pediatric anesthesia emergence delirium scale and pain using the face, legs, activity, cry, consolability scale. Heart rate, mean arterial pressure, respiratory recovery time, extubation time, post anesthesia care unit observation time, and adverse events were also evaluated. A total of 86 patients were analyzed. The incidence of emergence delirium was 20.1% in group D, 58.6% in group P and 85.7% in group C (P < 0.05). A lower face, legs, activity, cry, consolability score was seen in group D than in group P and group C (3.9 + 1.1 versus 6.1 ± 0.9 and 7.1 ± 1.0, P < 0.05). The value of heart rate and mean arterial pressure during emergence in group P and group C were significantly higher than that in group D (All P < 0.05). These findings suggest that dexmedetomidine as a sedative, analgesic, and sympatholytic agent was superior to propofol in reducing the incidence of emergence delirium in children undergoing cleft palates surgery with sevoflurane-based anesthesia.
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Xu S, Wang S, Hu S, Ju X, Li Q, Li Y. Effects of lidocaine, dexmedetomidine, and their combination infusion on postoperative nausea and vomiting following laparoscopic hysterectomy: a randomized controlled trial. BMC Anesthesiol 2021; 21:199. [PMID: 34348668 PMCID: PMC8336323 DOI: 10.1186/s12871-021-01420-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/22/2021] [Indexed: 12/03/2022] Open
Abstract
Background A few studies have reported that administration of lidocaine and dexmedetomidine relieves the incidence of postoperative nausea and vomiting (PONV). We explored whether combined infusion of lidocaine plus dexmedetomidine had lower occurrence of PONV undergoing laparoscopic hysterectomy with general anesthesia. Methods A total of 248 women undergoing elective laparoscopic hysterectomy were allocated into the following four groups: the control group (group C, n = 62) received an equal volume of saline, the lidocaine group (group L, n = 62) received intravenous lidocaine (bolus infusion of 1.5 mg/kg over 10 min, 1.5 mg/kg/h continuous infusion), the dexmedetomidine group (group D, n = 62) received dexmedetomidine administration (bolus infusion of 0.5 µg/kg over 10 min, 0.4 µg/kg/h continuous infusion), and the lidocaine plus dexmedetomidine group (group LD, n = 62) received combination of lidocaine (bolus infusion of 1.5 mg/kg over 10 min, 1.5 mg/kg/h continuous infusion) and dexmedetomidine administration (bolus infusion of 0.5 µg/kg over 10 min, 0.4 µg/kg/h continuous infusion). The primary outcome was the incidence of nausea, vomiting, and PONV during the first 48 h after surgery. The secondary outcomes included the incidence of total 24 h PONV after surgery, intraoperative remifentanil requirement, postoperative pain visual analogue scale (VAS) scores and fentanyl consumption, the incidence of bradycardia, agitation, shivering, and mouth dry during post-anesthesia care unit (PACU) stay period. Results The occurrence of nausea and PONV in group LD (5.0 and 8.3%) at 0–2 h after operation was lower than group C (21.7 and 28.3%) (P < 0.05). There was no statistically significant difference with respect to occurrence of nausea and PONV in groups L (13.3 and 20.0%) and D (8.3 and 13.3%) at 0–2 h after operation compared to group C (21.7 and 28.3%). The incidence of nausea, vomiting, and PONV at 2–24 and 24–48 h after surgery in all four groups was not statistically significant. The incidence of total 24 h PONV in group LD (33.3%) was significantly decreased compared to group C (60.0%) (P < 0.05). The cumulative consumption of fentanyl at 6 and 12 h after surgery was significantly reduced in group LD compared to other three groups (P < 0.05). The pain VAS scores were significantly decreased at 2, 6, and 12 h after operation in group LD compared to other three groups (P < 0.05). Remifentanil dose in the intraoperative period was significantly lower in groups LD and D compared with groups C and L (P < 0.05). The number of mouth dry, bradycardia, and over sedation during the PACU stay period was markedly increased in group LD (28.3, 30.0, and 35.0%, respectively) compared with groups C (1.7, 1.7, and 3.3%, respectively) and L (3.3, 5.0, and 6.7%, respectively) (P < 0.05). Conclusions Lidocaine combined with dexmedetomidine infusion markedly decreased the occurrence of nausea and PONV at 0–2 h as well as the total 24 h PONV. However, it significantly increased the incidence of mouth dry, bradycardia, and over sedation during the PACU stay period after laparoscopic hysterectomy with general anesthesia. Trial registration ClinicalTrials.gov (NCT03809923), registered on January 18, 2019.
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Affiliation(s)
- Siqi Xu
- Department of Anesthesiology, The Affiliated Anqing Hospital of Anhui Medical University, Anqing, 246000, China
| | - Shengbin Wang
- Department of Anesthesiology, The Affiliated Anqing Hospital of Anhui Medical University, Anqing, 246000, China.
| | - Shenghong Hu
- Department of Anesthesiology, The Affiliated Anqing Hospital of Anhui Medical University, Anqing, 246000, China
| | - Xia Ju
- Department of Anesthesiology, The Affiliated Anqing Hospital of Anhui Medical University, Anqing, 246000, China
| | - Qing Li
- Department of Gynaecology and Obstetrics, The Affiliated Anqing Hospital of Anhui Medical University, Anqing, 246000, China
| | - Yuanhai Li
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China
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Xing J, Wu R, Liang L, Fang H, Chen L, Luo C. Comparison of the Analgesic Effects of Intravenous Infusion of Dexmedetomidine Versus Bilateral Superficial Cervical Plexus Block After Thyroidectomy: A Randomized Controlled Trial. Clin J Pain 2021; 37:623-628. [PMID: 34155159 DOI: 10.1097/ajp.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/04/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Dexmedetomidine (DEX) is widely used in clinical practice because of its safety and effectiveness. Superficial cervical plexus block (SCPB) can reduce pain in thyroid surgery. The objective of this study was to investigated whether intravenous DEX has an equivalent analgesic effect and patients' satisfaction to SCPB for thyroid surgery. MATERIALS AND METHODS Ninety patients who had been scheduled for thyroidectomy under general anesthesia with endotracheal intubation were randomly divided into 3 groups. Group D: DEX was administered intravenously at an initial dose of 1 µg/kg over 10 minutes; then induction and endotracheal intubation performed, and then a continuous intravenous infusion of DEX was administered at a rate of 0.4 μg/kg/h until 30 minutes before the end of surgery. Group B: ultrasound-guided bilateral SCPB was performed, with 10 mL of 0.375% ropivacaine injected on each side. Group C: intravenous saline was administered at the same rate and dose as in group D. Patients' perioperative status, visual analog scale scores, complications and patients' satisfaction were recorded. RESULTS The pain at rest at 1 hour after extubation and the movement-evoked pain within 24 hours after extubation were significantly lower in groups D and B than in group C. Patients' satisfaction was significantly higher in groups D and B than in group C. There was no difference in pain at rest, movement-evoked pain and patients' satisfaction between group D and B. CONCLUSIONS Perioperative intravenous infusion of DEX can effectively reduce wound pain after thyroidectomy, and the analgesic effect is equivalent to that of bilateral SCPB.
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Affiliation(s)
- Jibin Xing
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Ranliang Wu
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Ling Liang
- Department of Anesthesiology, The People's Hospital of Gaoming, Foshan, China
| | - Hongyi Fang
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Liubing Chen
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Chenfang Luo
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou
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Guthrie DB, Boorin MR, Sisti AR, Epstein RH, Romeiser JL, Lam DK, Gan TJ, Bennett-Guerrero E. Retrospective Comparison of Intramuscular Admixtures of Ketamine and Dexmedetomidine Versus Ketamine and Midazolam for Preoperative Sedation. Anesth Prog 2021; 68:3-9. [PMID: 33827122 DOI: 10.2344/anpr-67-04-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 06/19/2020] [Indexed: 11/11/2022] Open
Abstract
Precooperative children and patients with intellectual disabilities often require intramuscular (IM) sedation prior to the induction of general anesthesia (GA). Ketamine is an effective preinduction sedative but can produce significant adverse side effects. Dexmedetomidine, a sedative with sympatholytic and analgesic properties, may provide advantages when used in combination with ketamine. This retrospective study evaluated the efficacy and safety of IM ketamine with dexmedetomidine for preoperative sedation. We conducted a chart review of all patients (n = 105) treated for dental rehabilitation who received either IM ketamine and dexmedetomidine (study group, n = 74) or IM ketamine and midazolam (control group, n = 31) prior to induction of GA. No significant difference (p = .14) was observed in the time interval from IM administration to operating room entry (median [interquartile range]) between the study and control groups (5 [4-8] vs 5 [2-7] minutes). Patients who received IM dexmedetomidine exhibited significantly lower mean arterial pressures throughout the induction (p = .004) and had lower heart rates (p = .01) throughout the intraoperative period compared with patients who did not receive dexmedetomidine. The combination of dexmedetomidine and ketamine may provide effective and safe IM sedation prior to the induction of GA.
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Affiliation(s)
- David B Guthrie
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York.,Division of Dental Anesthesiology, Department of Oral and Maxillofacial Surgery, Stony Brook School of Dental Medicine, Stony Brook, New York
| | - Martin R Boorin
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York.,Division of Dental Anesthesiology, Department of Oral and Maxillofacial Surgery, Stony Brook School of Dental Medicine, Stony Brook, New York
| | - Andrew R Sisti
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York.,Division of Dental Anesthesiology, Department of Oral and Maxillofacial Surgery, Stony Brook School of Dental Medicine, Stony Brook, New York
| | - Ralph H Epstein
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York.,Division of Dental Anesthesiology, Department of Oral and Maxillofacial Surgery, Stony Brook School of Dental Medicine, Stony Brook, New York
| | - Jamie L Romeiser
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - David K Lam
- Division of Dental Anesthesiology, Department of Oral and Maxillofacial Surgery, Stony Brook School of Dental Medicine, Stony Brook, New York.,Department of Surgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Tong J Gan
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Elliott Bennett-Guerrero
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
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Zhang X, Bai Y, Shi M, Ming S, Jin X, Xie Y. Effect of different administration and dosage of dexmedetomidine in the reduction of emergence agitation in children: a meta-analysis of randomized controlled trials with sequential trial analysis. Transl Pediatr 2021; 10:929-957. [PMID: 34012842 PMCID: PMC8107879 DOI: 10.21037/tp-21-105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Beneficial effects of dexmedetomidine (DEX) against emergence agitation (EA) in children remain controversial. We performed a more comprehensive meta-analysis to evaluate the protective effect of different administration routes, timing, patterns, and doses of DEX on EA in children. METHODS The randomized controlled trials about DEX preventing EA in children were searched in PubMed, Cochrane Library, Embase, and Web of Sciences up to October 7, 2020. The traditional meta-analysis and subgroup analysis were performed to study the influence of DEX on EA in children. The sequential trial analysis (TSA) further analyzed the pooled results to evaluate meta-analyses' robustness. Grading of recommendation, assessment, development, and evaluation (GRADE) was used to assess evidence quality. RESULTS Sixty-seven studies with 5,688 pediatric patients were included. DEX significantly decreased EA in children compared to placebo [RR 0.29, 95% confidence intervals (CI): 0.25-0.34] and midazolam (RR 0.34, 95% CI: 0.25-0.45), with firm evidence from TSA. Notably, using DEX significantly reduced severe EA incidence (RR 0.23, 95% CI: 0.16-0.32), with firm evidence by TSA and high quality of GRADE. Pre-specified subgroup analyses revealed firm and high-quality evidence for a reduction of EA, only if the perineural route administers DEX (RR 0.24, 95% CI: 0.14-0.41), as premedication (RR 0.27, 95% CI: 0.20-0.36), as continuous dosage (RR 0.25, 95% CI: 0.18-0.33), at high dose (RR 0.24, 95% CI: 0.18-0.31). The pooled results also showed that DEX reduced the incidence of PONV compared to placebo (RR 0.43, 95% CI: 0.33-0.55). Evidence for DEX's influence on other secondary outcomes (emergence time, time in PACU, rescue analgesia, hypotension, and bradycardia) is insufficient to draw any conclusion. CONCLUSIONS Our findings confirm the beneficial effects of DEX on EA, severe EA, and PONV in children. There was firm and high-quality evidence for the efficacy of DEX in preventing EA in children when perineural routes administered DEX, as premedication, as continuous dosage, and at a high dose. The best dose, route, patterns, and timing of DEX and influence on other outcomes call for further studies.
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Affiliation(s)
- Xu Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yan Bai
- Department of Anesthesiology, The Second Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Min Shi
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shaopeng Ming
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiaogao Jin
- Department of Anesthesiology, The Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Yubo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Kaur G, Kaur P, Gupta R, Kullar K, Bhangu GS, Sandhu SS. Discharge readiness after minor gynaecological surgeries comparing dexmedetomidine and ketamine premedication in bispectral index (BIS) guided propofol-based anaesthesia. Indian J Anaesth 2021; 65:S34-S40. [PMID: 33814588 PMCID: PMC7993037 DOI: 10.4103/ija.ija_998_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/30/2020] [Accepted: 01/23/2021] [Indexed: 11/05/2022] Open
Abstract
Background and Aims: Dexmedetomidine and ketamine are commonly used pre-medicants to propofol. Previous literature shows a delay in recovery with their use without any clarity on discharge. This study was planned to find out whether adding these premedicants to Bispectral index (BIS) guided propofol anaesthesia led to delayed discharge in minor gynaecological surgeries. Methods: Totally, 120 adult females belonging to American Society of Anesthesiologists (ASA) physical status I and II undergoing minor gynaecological surgeries under general anaesthesia were randomly allocated to receive 1 μg/kg dexmedetomidine (Group D), 0.5 mg/kg ketamine (Group K) and normal saline (Group P) as premedication. Propofol 1% was used for induction and maintenance of anaesthesia keeping BIS between 55 and 70. After the procedure, patients were assessed primarily for discharge readiness using Modified Post Anaesthesia Discharge Scoring System (MPADSS).The secondary outcomes were Modified Aldrete Score (MAS), total dose of propofol used and haemodynamics. Results: The percentage of patients ready for discharge were 22.5%, 30% and 15%at 1 hour in group D, K and P, respectively (p = 0.275). Median MAS was 5, 4 and 6 respectively for group D, K and P immediately post-surgery (p = 0.000). The mean dose of propofol used was 69.75 ± 12.56 mg in group D and 135.25 ± 9.2 mg in group P (p = 0.001). There were significant haemodynamic variations in group D (16.4% fall in heart rate at 5 minutes and 24.18% fall in mean arterial pressure at 15 minutes). Conclusion: Premedication with dexmedetomidine and ketamine in propofol anaesthesia does not delay discharge. However, stable haemodynamics and good analgesia with ketamine make it a better option.
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Affiliation(s)
- Gaganjot Kaur
- Department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
| | - Preetveen Kaur
- Department of Anaesthesia, Civil Hospital, Amritsar, Punjab, India
| | - Ruchi Gupta
- Department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
| | - Keerat Kullar
- Department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
| | - Gurpreet Singh Bhangu
- Department of Surgery, Sri Guru Ram Das Institute of Medical Sciences and Research, Punjab, India
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Tolly B, Waly A, Peterson G, Erbes CR, Prielipp RC, Apostolidou I. Adult Emergence Agitation: A Veteran-Focused Narrative Review. Anesth Analg 2021; 132:353-364. [PMID: 33177329 DOI: 10.1213/ane.0000000000005211] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Emergence agitation (EA) is a self-limited state of psychomotor excitement during awakening from general anesthesia. EA is confined to the emergence period as consciousness is restored, which sharply distinguishes it from other postoperative delirium states. Sporadic episodes of EA may become violent with the potential for harm to both patients and caregivers, but the long-term consequences of such events are not fully understood. Current literature on EA in adults is limited to small-scale studies with inconsistent nomenclature, variable time periods that define emergence, a host of different surgical populations, and conflicting diagnostic criteria. Therefore, true incidence rates and risk factors are unknown. In adult noncardiac surgery, the incidence of EA is approximately 19%. Limited data suggest that young adults undergoing otolaryngology operations with volatile anesthetic maintenance may be at the highest risk for EA. Currently suggested EA mechanisms are theoretical but might reflect underblunted sympathetic activation in response to various internal (eg, flashbacks or anxiety) or external (eg, surgical pain) stimuli as consciousness returns. Supplemental dexmedetomidine and ketamine may be utilized for EA prevention. Compared to the civilian population, military veterans may be more vulnerable to EA due to high rates of posttraumatic stress disorder (PTSD) manifesting as violent flashbacks; however, confirmatory data are limited. Nonetheless, expert military medical providers suggest that use of patient-centered rapport tactics, PTSD trigger identification and avoidance, and grounding measures may alleviate hyperactive emergence phenomena. Future research is needed to better characterize EA in veterans and validate prophylactic measures to optimize care for these patients. This narrative review provides readers with an important framework to distinguish EA from delirium. Furthermore, we summarize current knowledge of EA risk factors, mechanisms, and adult management strategies and specifically revisit them in the context of veteran perioperative health. The anesthesiology care team is ideally positioned to further explore EA and develop effective prevention and treatment protocols.
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Affiliation(s)
- Brian Tolly
- From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Anesthesiology, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Amr Waly
- From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Garrett Peterson
- From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Christopher R Erbes
- From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Richard C Prielipp
- Department of Anesthesiology, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Ioanna Apostolidou
- From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Anesthesiology, University of Minnesota School of Medicine, Minneapolis, Minnesota
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Ballesteros JJ, Briscoe JB, Ishizawa Y. Neural signatures of α2-Adrenergic agonist-induced unconsciousness and awakening by antagonist. eLife 2020; 9:57670. [PMID: 32857037 PMCID: PMC7455241 DOI: 10.7554/elife.57670] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/09/2020] [Indexed: 12/29/2022] Open
Abstract
How the brain dynamics change during anesthetic-induced altered states of consciousness is not completely understood. The α2-adrenergic agonists are unique. They generate unconsciousness selectively through α2-adrenergic receptors and related circuits. We studied intracortical neuronal dynamics during transitions of loss of consciousness (LOC) with the α2-adrenergic agonist dexmedetomidine and return of consciousness (ROC) in a functionally interconnecting somatosensory and ventral premotor network in non-human primates. LOC, ROC and full task performance recovery were all associated with distinct neural changes. The early recovery demonstrated characteristic intermediate dynamics distinguished by sustained high spindle activities. Awakening by the α2-adrenergic antagonist completely eliminated this intermediate state and instantaneously restored awake dynamics and the top task performance while the anesthetic was still being infused. The results suggest that instantaneous functional recovery is possible following anesthetic-induced unconsciousness and the intermediate recovery state is not a necessary path for the brain recovery.
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Affiliation(s)
- Jesus Javier Ballesteros
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Jessica Blair Briscoe
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Yumiko Ishizawa
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, United States
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Akhondzadeh R, Olapour A, Rashidi M, Elyasinia F. Comparison of Sedation with Dexmedetomidine Alfentanil Versus Ketamine-Alfentanil in Patients Undergoing Closed Reduction of Nasal Fractures. Anesth Pain Med 2020; 10:e102946. [PMID: 33134144 PMCID: PMC7539046 DOI: 10.5812/aapm.102946] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/06/2020] [Accepted: 07/26/2020] [Indexed: 12/21/2022] Open
Abstract
Objectives To compare the sedative effects of dexmedetomidine alfentanil versus ketamine-alfentanil in patients undergoing closed reduction of nasal fractures on the basis of intraoperative hemodynamic changes, satisfaction of patients and surgeons, and the adverse effects. Methods Sixty patients with ASA class 1 or 2 were randomized to either of two groups, a dexmedetomidine alfentanil group (DA group; n = 30) or a ketamine-alfentanil group (KA group; n = 30). Hemodynamic parameters, oxygenation status, adverse events, the satisfaction of patients and surgeons, and postoperative pain scores by visual analog scale (VAS) were recorded at specific time intervals during the trial. Results Systolic blood pressure was significantly lower in the DA group than in the KA group from T1 min to T15 min. The duration of the recovery ward stay was longer in the DA group; however, two groups were similar in terms of total anesthesia time and awakening time. Likewise, two groups were similar in terms of the patient and surgeon’s satisfaction, pain scores, and the occurrence of adverse effects. Conclusions Both sedation methods were safely performed, and dexmedetomidine-alfentanil is as effective as ketamine-alfentanil in patients undergoing short-term operations such as nasal fracture corrections.
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Affiliation(s)
- Reza Akhondzadeh
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Alireza Olapour
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mahboobe Rashidi
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Corresponding Author: Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Fahimeh Elyasinia
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Zhang W, Yu J, Guo M, Ren B, Tian Y, Hu Q, Xie Q, Xu C, Feng Z. Dexmedetomidine Attenuates Glutamate-Induced Cytotoxicity by Inhibiting the Mitochondrial-Mediated Apoptotic Pathway. Med Sci Monit 2020; 26:e922139. [PMID: 32419697 PMCID: PMC7251967 DOI: 10.12659/msm.922139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Glutamate (GLU) is the most excitatory amino acid in the central nervous system and plays an important role in maintaining the normal function of the nervous system. During cerebral ischemia, massive release of GLU leads to neuronal necrosis and apoptosis. It has been reported that dexmedetomidine (DEX) possesses anti-oxidant and anti-apoptotic properties. The objective of this study was to investigate the effects of DEX on GLU-induced neurotoxicity in PC12 cells. Material/Methods PC12 cells were treated with 20 mM GLU to establish an ischemia-induced injury model. Cell viability was accessed by MTT assay. MDA content and SOD activity were analyzed by assay kits. Apoptosis rate, ROS production, intracellular Ca2+ concentration, and MMP were evaluated by flow cytometry. Western blot analysis was performed to analyze expressions of caspase-3, caspase-9, cyt-c, bax, and bcl-2. Results PC12 cells treated with GLU exhibited reduced cell viability and increased apoptosis rates, which were ameliorated by pretreatment with DEX. DEX significantly increased SOD activity, reduced content of MDA, and decreased production of ROS in PC12 cells. In addition, DEX clearly reduced the level of intracellular Ca2+ and attenuated the decline of MMP. Moreover, DEX notably reduced expressions of caspase-3, caspase-9, cyt-c, and bax and increased expression of bcl-2. Conclusions Our findings suggest that DEX can protect PC12 cells against GLU-induced cytotoxicity, which may be attributed to its anti-oxidative property and reduction of intracellular calcium overload, as well as its ability to inhibit the mitochondria-mediated apoptotic pathway.
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Affiliation(s)
- Weidong Zhang
- Anesthesia and Operation Center, The First Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China (mainland).,Anesthesia and Operation Center, The Fifth Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Jun Yu
- Department of Anesthesiology, The Fourth Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Mengzhuo Guo
- Department of Anesthesiology, Beijing Tsinghua Changung Hospital, Beijing, China (mainland)
| | - Bo Ren
- Anesthesia and Operation Center, The Fifth Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Yanyan Tian
- Department of Anesthesiology, Air Force Characteristic Medical Center, Beijing, China (mainland)
| | - Qinggang Hu
- Department of Anesthesiology, The Fourth Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Qun Xie
- Department of Anesthesiology, The Fourth Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Chen Xu
- Anesthesia and Operation Center, The Fifth Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Zeguo Feng
- Anesthesia and Operation Center, The First Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
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