To identify the incidence and the risk factors of emergence agitation in adults undergoing general anesthesia for nasal surgery.
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.
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 (
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.
Emergence agitation is a postanesthetic phenomenon that develops in the early phase of general anesthesia recovery, and is characterized by agitation, confusion, disorientation, and possible violent behavior [
While its pathogenesis remains unclear, previous studies [
With the approval of Institutional Review Board of Samsung Medical Center (IRB No.: 2013-09-030, approval date: October 1, 2013), we retrospectively examined the records of 792 patients aged ≥18 years who underwent general anesthesia for elective nasal surgery from July 2012 to August 2013 at our institution. This study was registered with Clinical Research Information Service of Korean National Institute of Health (CRIS;
To obtain a pure comparison regarding emergence agitation, patients who underwent concurrent surgeries other than nasal surgery (e.g., adenoidectomy or tonsillectomy) or closed reduction for nasal bone fracture were excluded from the study. Patients admitted directly to the intensive care unit (ICU) were also excluded.
In every patient admitted to the PACU following general anesthesia at our institution, a serial Richmond Agitation Sedation Scale (RASS) assessments [
In all cases, anesthesia was induced by intravenous (IV) propofol or thiopental and rocuronium to provide neuromuscular blockade for endotracheal intubation. Anesthesia was maintained with total intravenous anesthesia (TIVA) using propofol and remifentanil or inhalational anesthesia with sevoflurane. Muscle relaxation was maintained by IV vecuronium (0.02 mg/kg) at regular intervals. IV opioids (meperidine or hydromorphone) or ketolorac is routinely given 30 minutes prior to the end of surgery for postoperative pain.
Three attending otolaryngologists performed the operations with residents assisting to their ability level. Upon surgery completion, the decision whether or not to perform nasal packing was made based on the surgeon's assessment of postoperative hemorrhage. For nasal packing, gauze or saline-soaked Merocel (Medtronic Xomed, Jacksonville, FL, USA) was applied and removed the following day. Merocel is composed of expandable hydroxylated polyvinyl acetate. The surgical procedures were grouped into four categories: septoplasty or/and rhinoplasty without osteotomies, septoplasty or/and rhinoplasty with osteotomies, endoscopic sinus surgery (ESS), and ESS with other nasal surgeries.
In the PACU, all patients were routinely managed using the following standardized postoperative protocol: (1) serial assessments of pain with an 11-point numerical rating scale (NRS), emergence agitation by RASS, and the presence of postnasal drip (PND, at admission, every 15 minutes thereafter, and at discharge from the PACU); (2) rescue analgesic administration of meperidine or hydromorphone in patients with a pain score≥5, and physical restraint or intermittent midazolam administration in severe cases of emergence agitation based on the decision of attending anesthesiologists; (3) antiemetic treatment with IV ramosetrone or granisetrone in patients with intolerable postoperative nausea and vomiting (PONV); and (4) PACU discharge criteria based on a modified Aldrete score (scores of 9 or greater were deemed appropriate for discharge).
Patients in the PACU with a RASS≥+1 at any time were considered to have emergence agitation. For patients with emergence agitation, we also noted the highest RASS score while in the PACU and whether of physical restraints or midazolam administration. For each patient, the following variables were noted: demographic data, American Society of Anesthesiologists (ASA) physical status (classification 1 vs. ≥2), current smokers (individuals having smoked at least 10 cigarettes per day for more than 1 year within at least 1 week before surgery), alcohol abuse (individuals having on average 3-4 drinks a day at least four or more times a week), surgery type and length, type of nasal packing (no packing, unilateral, or bilateral packing), premedication with midazolam, anesthesia type (sevoflurane anesthesia vs. TIVA) and length, analgesics used for postoperative pain (ketorolac, meperidine, or hydromorphone), presence of postoperative pain (patients were considered to have pain if they had a NRS≥5 while in the PACU), presence of PONV requiring antiemetics, presence of PND, presence of a tracheal tube or urinary catheter on PACU admission, and length of stay in the PACU.
Statistical analyses were performed with PASW ver. 18.0 (SPSS Inc., Chicago, IL, USA). First, univariate characteristics between patients with and without emergence agitation were compared using unpaired
A total of 792 patients were included in the study. The mean age was 41.8±16.2 years (range, 18 to 85 years); 26.9% of patients (n=213) were females. Emergence agitation occurred in 176 patients (22.2%) in the PACU. In agitated patients, eight patients needed physical restraint, and of these, two received benzodiazepines to control agitation. All patients regained normal cognitive status before discharge from the PACU. In agitated patients, the RASS level of agitation was: 3.4% combative agitated patients (n=6), 9.1% very agitated patients (n=16), and 87.5% restless or agitated patients (n=154).
The incidence of emergence agitation did not differ depending on the presence of nasal packing (
In univariate analyses, significant differences were observed between nonagitated and agitated patients when considering gender, age, smoking habits, ASA physical status, type of anesthesia, premedication with midazolam, presence of a tracheal tube, presence of a urinary catheter, postoperative pain, and PONV requiring antiemetic treatment (
In addition to these 10 variables, two variables associated with emergence agitation (
Presence of a tracheal tube was the greatest risk factor, increasing the risk of developing emergence agitation by about five times (OR, 5.448; 95% CI, 2.973 to 9.982;
Mean length of stay in the PACU was similar between those who experienced emergence agitation and those who did not (69.2±17.7 minutes vs. 68.6±13.9 minutes) (
The present study showed that emergence agitation was a common phenomenon occurring in 22.2% in adult patients undergoing general anesthesia for nasal surgery. Severe agitation necessitating use of sedatives or physical restraint was present in only 4.5% of those with agitation (1.0% of all patients). The overall incidence of emergence agitation in the present study is relatively low compared to the 52.0%-55.4% in the similar surgical cohorts of previous studies [
In the present study, six independent risk factors (younger age, recent smoking, sevoflurane anesthesia, postoperative pain of NRS≥5, presence of a tracheal tube, and presence of a urinary catheter) were identified. The most surprising finding of the present study is that nasal packing was not a risk for emergence agitation. Although the necessity for nasal packing following nasal surgeries is still a matter of debate, many surgeons prefer to use nasal packing to prevent synechiae, hematoma formation, and lateralization of the middle turbinate [
The most likely explanation for this unexpected result is that nasal packing could cause significant breathing difficulty on emergence from anesthesia in our patients. Because approximately one half of the respiratory airway resistance to airflow is provided by the nasal airway [
Another possible explanation is that either unilateral or bilateral nasal packing did not obstruct the corresponding nasal airway completely while in the PACU. In the present study, gauze (squeezed tightly after saline-soaking) or saline-soaked merocel was used as packing material. In the immediate postoperative period, nasal obstruction due to nasal packing may not be marked, although it becomes severe as the operation site swelling increases and nasal secretions accumulate over time. This assumption is supported by the previous study [
In the present study, sevoflurane anesthesia, postoperative pain of NRS≥5, presence of a tracheal tube, and presence of a urinary catheter were identified as independent risk factors of emergence agitation. These variables were repeatedly suggested as risk factors in previous studies for emergence agitation after general anesthesia for procedures other than nasal surgery [
For the first time, our study demonstrated that younger age and current smoking were associated with a higher incidence of emergence agitation. Radtke et al. [
Our results suggest that current smoking nearly doubles the risk of emergence agitation. To date, only one study [
There were several limitations to the present study. First, as the subjective or objective preoperative data on patients' nasal obstruction were absent, the impact of different nasal packing types on breathing difficulty could not be individually evaluated. Second, although two commonly used nasal packing materials were applied, many different commercially available packing materials are used with different degrees of nasal obstruction. An additional source of confounding may have been introduced through the inclusion of three surgeons in the study, although there is no difference in the occurrence of emergence agitation depending on the surgeon (
The present study describes a high incidence (22.2%) of emergence agitation in adult patients undergoing general anesthesia for nasal surgery, and identifies younger age, current smoking, sevoflurane anesthesia, postoperative pain of NRS≥5, presence of a tracheal tube, and presence of a urinary catheter as risk factors. The mainstay for management of emergence agitation is elimination of preventable causes, especially in at-risk patients. The following are the main strategies to reduce the occurrence and consequences of emergence agitation episodes: encouraging patients to quit smoking at least 1 week before surgery, selecting a TIVA rather than sevoflurane anesthesia, providing adequate postoperative analgesia, removing tracheal tubes and urinary catheters as early as possible following surgery, and more vigilant monitoring for emergence agitation in younger patients.
No potential conflict of interest relevant to this article was reported.
Richmond Agitation Sedation Scale
Score | Term | Description |
---|---|---|
+4 | Combative | Overtly combative, violent, immediate danger to staff |
+3 | Very agitated | Pulls or removes tube(s) or catheter(s); aggressive |
+2 | Agitated | Frequent nonpurposeful movement, fights ventilator |
+1 | Restless | Anxious but movements not aggressive or vigorous |
0 | Alert and calm | |
–1 | Drowsy | Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (>10 seconds) |
–2 | Light sedation | Briefly awakens with eye contact to voice (<10 seconds) |
–3 | Moderate sedation | Movement or eye opening to voice (but no eye contact) |
–4 | Deep sedation | No response to voice, but movement or eye opening to physical stimulation |
–5 | Unarousable | No response to voice or physical stimulation |
Reprinted from Sessler et al. [
Univariate analyses: risk factors for emergence agitation after nasal surgery
Variable | Nonagitated (n=616) | Agitated (n=176) | |
---|---|---|---|
Gender, male/female | 437/179 | 142/34 | 0.013 |
Age (year) | 43.1±16.5 | 36.7±15.0 | <0.001 |
Current smokers/ex- or nonsmokers | 109/507 | 51/125 | 0.001 |
Alcohol abuse, yes/no | 66/550 | 15/161 | 0.481 |
Body mass index (kg/m2) | 24.1±3.4 | 24.0±3.3 | 0.651 |
ASA physical status, 1/≥2 | 386/230 | 128/48 | 0.017 |
Premedication with midazolam, yes/no | 542/74 | 136/40 | 0.001 |
Duration of surgery (minute) | 93.0±44.1 | 102.5±44.9 | 0.562 |
Duration of anesthesia (minute) | 142.6±47.2 | 150.7±47.8 | 0.642 |
Type of anesthesia, TIVA/sevoflurane anesthesia | 561/55 | 141/35 | <0.001 |
Type of surgery | 0.220 | ||
Septoplasty or/and rhinoplasty without osteotomies | 51 | 20 | |
Septoplasty or/and rhinoplasty with osteotomies | 171 | 55 | |
ESS only | 163 | 41 | |
ESS with other nasal surgeries | 231 | 60 | |
Nasal packing, none/unilateral/bilateral | 180/50/386 | 43/10/123 | 0.193 |
Analgesics used for postoperative pain, ketolorac/meperidine/hydromorphone | 19/377/220 | 5/122/49 | 0.132 |
Presence of tracheal tube, yes/no | 442/174 | 163/13 | <0.001 |
Presence of urinary catheter, yes/no | 21/595 | 14/162 | 0.017 |
Postoperative pain, NRS≥5/NRS<5 | 377/239 | 130/46 | 0.003 |
PONV requiring antiemetics, yes/no | 12/604 | 9/167 | 0.041 |
Core temperature, <36.0°C/36.0°C–37.5°C/>37.5°C | 33/570/13 | 7/166/3 | 0.800 |
Presence of postnasal drip, yes/no | 21/595 | 6/170 | 1.000 |
PACU stay time (minute) | 68.6±13.9 | 69.2±17.7 | 0.529 |
Values are presented as number or mean±SD.
ASA, American Society of Anesthesiologists; TIVA, total intravenous anesthesia; ESS, endoscopic sinus surgery; NRS, numerical rating scale; PONV, postanesthesia nausea and vomiting; PACU, postanesthesia care unit.
Multivariate logistic regression analysis: independent risk factors for emergence agitation
Variable | Odds ratio (95% CI) | |
---|---|---|
Age (year) | 0.975 (0.964–0.987) | <0.001 |
Recent smoking | 2.038 (1.350–3.075) | 0.001 |
Type of anesthesia, sevoflurane anesthesia vs. TIVA | 2.320 (1.414–3.807) | 0.001 |
Postoperative pain, NRS≥5 vs. NRS<5 | 1.813 (1.222–2.691) | 0.003 |
Presence of a tracheal tube | 5.448 (2.973–9.982) | <0.001 |
Presence of a urinary catheter | 2.416 (1.222–2.691) | 0.023 |
CI, confidence interval; TIVA, total intravenous anesthesia; NRS, numerical rating scale.