Risk factors of inadequate emergence following general anesthesia with an emphasis on patients with substance dependence history

Risk Factors for Postanesthetic Emergence Delirium in Adults: A Systematic Review and Meta-analysis

Emergence delirium (ED) is delirium that occurs during or immediately after emergence from general anesthesia or sedation. Effective pharmacological treatments for ED are lacking, so preventive measures should be taken to minimize the risk of ED. However, the risk factors for ED in adults are unclear. In this systematic review and meta-analysis, we evaluated the evidence for risk factors for ED in adults. The PubMed, Scopus, Cochrane Library, Google Scholar, and Embase databases were searched for observational studies reporting the risk factors for ED in adults from inception to July 31, 2023. Twenty observational studies reporting 19,171 participants were included in this meta-analysis. Among the preoperative factors identified as risk factors for ED were age <40 or ≥65 years, male sex, smoking history, substance abuse, cognitive impairment, anxiety, and American Society of Anesthesiologists physical status score III or IV. Intraoperative risk factors for ED were the use of benzodiazepines, inhalational anesthetics, or etomidate, and surgical factors including abdominal surgery, frontal craniotomy (vs. other craniotomy approaches) for cerebral tumors, and the length of surgery. Postoperative risk factors were indwelling urinary catheters, the presence of a tracheal tube in the postanesthetic care unit or intensive care unit, the presence of a nasogastric tube, and pain. Knowledge of these risk factors may guide the implementation of stratified management and timely interventions for patients at high risk of ED. The majority of studies included in this review investigated only hyperactive ED and further research is required to determine risk factors for hypoactive and mixed ED types.

Dexmedetomidine versus remifentanil in nasal surgery: a systematic review and meta-analysis

BACKGROUND

Nasal surgeries, addressing anatomical variations for form and function, require careful anesthesia administration, including dexmedetomidine and remifentanil. This meta-analysis evaluates their safety and efficacy variations in nasal surgeries, emphasizing patient comfort and optimal outcomes.

METHODS

Four electronic databases (PubMed, Scopus, Web of Science, and CINAHL Complete) were searched for records in English. Studies that measure the effect of dexmedetomidine versus remifentanil on patients underwent nasal surgery were included. The Cochrane Collaboration's tool was used to assess the quality of the included studies. A random-effect model was preferred and statistical analysis was performed by Stata software version 17.

RESULTS

Out of an initial pool of 63 articles, five studies were selected for this analysis. All of these chosen studies were Randomized Controlled Trials (RCTs). The meta-analysis involved a total of 302 participants, with 152 in the remifentanil group and 150 in the dexmedetomidine group. The analysis aimed to compare the effects of Dexmedetomidine and Remifentanil on heart rate (HR) and mean arterial pressure (MAP) during surgery. Both groups exhibited similar MAP and HR, with the exception of a slightly lower HR in the remifentanil group at the 15th minute of surgery (Standardized Mean Difference: -0.24 [-0.83, 0.34]). Furthermore, when evaluating the impact of these medications on post-surgery outcomes, including pain levels, the use of pain relief medications, patient-surgeon satisfaction, agitation scores, and recovery time, no significant differences were observed between the two medications in any of these aspects.

CONCLUSION

In summary, the study compared Dexmedetomidine and Remifentanil in nasal surgeries anesthesia. No significant differences were found in heart rate, blood pressure, satisfaction, pain, agitation, or recovery time. The study had limitations, and future research should establish standardized protocols and consider various surgical factors.

Risk factors for emergence agitation during the awakening period in elderly patients after total joint arthroplasty: a retrospective cohort study

OBJECTIVES

This study aimed to explore the incidence and risk factors for emergence agitation (EA) in elderly patients who underwent total joint arthroplasty (TJA) under general anaesthesia, and to assess their predictive values.

DESIGN

Single-centre retrospective cohort study.

SETTING

A 1600-bed general tertiary hospital in China.

PARTICIPANTS

This study enrolled 421 elderly patients scheduled for elective primary TJA under general anaesthesia.

PRIMARY AND SECONDARY OUTCOME MEASURES

EA was assessed using the Richmond Agitation Sedation Scale during the awakening period after surgery in the post-anaesthesia care unit. Risk factors for EA were identified using univariate and multivariable logistic analyses. The receiver operating characteristic (ROC) curve was used to assess the predictive values of the risk factors for EA.

RESULTS

The incidence of EA in elderly patients who underwent TJA was 37.6%. According to the multivariable logistic analysis, postoperative pain (95% CI: 1.951 to 3.196), male sex (95% CI: 1.781 to 6.435), catheter-related bladder discomfort (CRBD) (95% CI: 4.001 to 15.392) and longer fasting times for solids (95% CI: 1.260 to 2.301) and fluids (95% CI: 1.263 to 2.365) were independent risk factors for EA. As shown by the ROC analysis, postoperative pain and fasting times for solids and fluids had good predictive values, with areas under the ROC curve equalling 0.769, 0.753 and 0.768, respectively.

CONCLUSIONS

EA is a common complication after TJA in elderly patients. Some risk factors, including postoperative pain, male sex, CRBD and longer fasting times, can increase the incidence of EA. These risk factors may contribute to identifying high-risk patients, which facilitates the development of effective strategies to prevent and treat EA.

TRIAL REGISTRATION NUMBER

ChiCTR1800020193.

A prospective observational single center study evaluating emergence agitation in the early postoperative period in adult patients undergoing elective craniotomies under general anesthesia

Background and Aims

Emergence agitation is a significant clinical issue during recovery from general anesthesia. Patients after intracranial operations are even more vulnerable to the stress resulting from emergence agitation. Due to the limited data available in neurosurgical patients, we evaluated the incidence, risk factors, and complications of emergence agitation.

Material and Methods

317 consenting eligible patients undergoing elective craniotomies were recruited. The preoperative Glasgow Coma Scale (GCS)) and pain score were recorded. Bispectral Index (BIS) guided balanced general anesthesia was administered and reversed. Immediate postoperatively, the GCS and the pain score were noted. The patients were observed for 24 hours following extubation. The levels of agitation and sedation were evaluated by the Riker's Agitation-Sedation Scale. Emergence Agitation was defined as Riker's Agitation score of 5 to 7.

Results

In our subset of the patient population, the incidence was 5.4%, mildly agitated in the first 24 hours and none required sedative medication as therapy. The sole risk factor identified was prolonged surgery beyond 4 hours. None of the patients in the agitated group had any complications.

Conclusion

Early objective assessment of risk factors in the preoperative period with objective validated tests and shorter duration of surgery maybe the way forward in patients at high risk for emergence agitation, to reduce the incidence and mitigate the undesirable consequences.

Transparency considerations for describing statistical analyses in research

Researchers who use the results of statistical analyses to draw conclusions about collected data must write a statistical analysis section in their manuscript. Describing statistical analyses in precise detail is as important as presenting the dosages of drugs and methodology of interventions. It is also essential for scientific accuracy and transparency in scientific research. We evaluated the quality of the statistical analysis sections of clinical research articles published in the Korean Journal of Anesthesiology between February 2020 and February 2021. Using a Likert scale where 1, 2, and 3 represented “not described at all,” “partially described,” and “fully described,” respectively, the following 6 items were assessed: 1) stating of the statistical analysis methods used, 2) rationale for and detailed description of the statistical analysis methods used, 3) parameters derived from the statistical analyses, 4) type and version of the statistical software package used, 5) significance level, and 6) sidedness of the test (one-sided vs. two-sided). The first 3 items evaluate issues directly related to the statistical analysis methods used and last 3 are indirectly related items. In all the included articles, the statistical analysis methods used were stated (score of 3). However, only 4 articles (12.9%) fully described the sidedness of the test (score of 3). Authors tend not to describe the sidedness of statistical analysis tests in the methodology section of clinical research articles. It is essential that the sidedness be described in research studies.

The principles of presenting statistical results: Table

General medical journals such as the Korean Journal of Anesthesiology (KJA) receive numerous manuscripts every year. However, reviewers have noticed that the tables presented in various manuscripts have great diversity in their appearance, resulting in difficulties in the review and publication process. It might be due to the lack of clear written instructions regarding reporting of statistical results for authors. Therefore, the present article aims to briefly outline reporting methods for several table types, which are commonly used to present statistical results. We hope this article will serve as a guideline for reviewers as well as for authors, who wish to submit a manuscript to the KJA.

Delayed Emergence from Anesthesia: What We Know and How We Act

The emergence from anesthesia is the stage of general anesthesia featuring the patient’s progression from the unconsciousness status to wakefulness and restoration of consciousness. This complex process has precise neurobiology which differs from that of induction. Despite the medications commonly used in anesthesia allow recovery in a few minutes, a delay in waking up from anesthesia, called delayed emergence, may occur. This phenomenon is associated with delays in the operating room, and an overall increase in costs. Together with the emergence delirium, the phenomenon represents a manifestation of inadequate emergence. Nevertheless, in delayed emergence, the transition from unconsciousness to complete wakefulness usually occurs along a normal trajectory, although slowed down. On the other hand, this awakening trajectory could proceed abnormally, possibly culminating in the manifestation of emergence delirium. Clinically, delayed emergence often represents a challenge for clinicians who must make an accurate diagnosis of the underlying cause to quickly establish appropriate therapy. This paper aimed at presenting an update on the phenomenon, analyzing its causes. Diagnostic and therapeutic strategies are addressed. Finally, therapeutic perspectives on the “active awakening” are reported.

Emergence agitation: current knowledge and unresolved questions

Emergence agitation (EA), also referred to as emergence delirium, can have clinically significant consequences. The mechanism of EA remains unclear. The proposed risk factors of EA include age, male sex, type of surgery, emergency operation, use of inhalational anesthetics with low blood-gas partition coefficients, long duration of surgery, anticholinergics, premedication with benzodiazepines, voiding urgency, postoperative pain, and the presence of invasive devices. If preoperative or intraoperative objective monitoring could predict the occurrence of agitation during emergence, this would help to reduce its adverse consequences. Several tools are available for assessing EA. However, there are no standardized clinical research practice guidelines and its incidence varies considerably with the assessment tool or definition used. Total intravenous anesthesia, propofol, μ-opioid agonists, N-methyl-D-aspartate receptor antagonists, nefopam, α2-adrenoreceptor agonists, regional analgesia, multimodal analgesia, parent-present induction, and preoperative education for surgery may help in preventing of EA. However, it is difficult to identify patients at high risk and apply preventive measures in various clinical situations. The risk factors and outcomes of preventive strategies vary with the methodologies of studies and patients assessed.This review discusses important outcomes of research on EA and directions for future research.