INTRODUCTION- Emergence
agitation (EA) occurs in the early recovery stage after general anesthesia and
is determined by restlessness, excitement, confusion, non-purposeful movement,
inconsolability, thrashing, & incoherence. The range of EA incidence is
roughly 0.25 to 90.5% [1]. It can turn dangerous at any time, with
potentially dangerous outcomes for the patient, including bleeding, self-extubation, self-harm, increased post-operative pain, &
catheter removal necessitating physical or medication restriction. Moreover, EA
worries recovery room workers & anesthesiologists, increasing hospital
expenses [2]. Self-extubation or catheter
removal due to emergent agitation following general anesthesia may result in
major problems such as hypoxia, aspiration pneumonia, hemorrhage, or the need
for reoperation [2]. Emergence agitation is more common following
ear, nose, & throat (ENT) surgery [3]. Due to blood
contamination of the airway & surgical pack obstruction of the nasal airway
during nasal surgery, conscious extubation is
recommended [4]. Extubation when awake,
however, might exacerbate emerging agitation. Usually, EA has a brief lifespan &
ends on its own. Managing emerging agitation mostly involves removing things
that cause it, such as pain, worry, or the presence of intrusive equipment.
Preferred therapeutic pharmacological therapies for emerging agitation,
according to several research are sedatives (like propofol & midazolam) and
opioids (like fentanyl & morphine) [1].
Dexmedetomidine
is a highly selective α2 agonist that reduces sympathetic central nervous
system activity to cause sedation & anxiolysis. Its association with low
respiratory depression is one of its main advantages over other sedatives [5].
Dextmedetomidine used during surgery reduces the number
of opioids used after surgery, the severity of pain, & the need for
antiemetic medication [6 9]. Furthermore, it has been demonstrated
that intra-operative dex infusion improves the recovery
quality following major spine surgery by reducing stress response [10].
There is little information on adult patients' emerging agitation; most
research on this topic has been done on pediatric patients. We conducted this
trial to determine the impact of intra-operative dexmedetomidine on emerging
agitation in adult patients following pharyngeal & nasal surgery.
MATERIALS & METHODS- This
prospective, randomized, double-blind study was undertaken at Nobel Medical
College Teaching Hospital, Biratnagar, from February 05, 2023, to December 05,
2023. The study involved 100 patients. These patients were assigned to two
groups based on computer-generated random numbers. The dexmedetomidine group
(Group D; n=50) received 0.4 g kg-1 h-1 from anesthesia
induction to extubation, while the control group
(Group C; n=50) received volume-matched normal saline infusion as a placebo.
Inclusion criteria- The
study included ASA class 1-2 patients (aged 20-60 yrs)
undergoing nasal and pharyngeal surgery and surgery not lasting more than two
hours.
Exclusion criteria- The
trial excluded patients who were unwilling to participate, allergic to the
study drug, had coagulopathies, or were classified as ASA-III or above.
Methodology- Routine
preanaesthetic check-up and counselling were done a
day before the surgery. Patients were kept nil per oral for at least 8 hours before
surgery. All patients were crystalloid-preloaded & given intravenous
Midazolam 0.04 mg/kg 30 min after intravenous access with 18G cannula before
anesthesia was administered. Routine monitors were employed & monitored at
5-minute intervals, including the ECG, non-invasive blood pressure, pulse,
oxygen saturation (SpO2), & end-tidal CO2 (E'CO2).
Fentanyl (1 mg kg-1) and propofol 1.5 mg kg-1 were used
to induce general anesthesia following the loading of 4 ml kg-1 of
crystalloid solution. Before orotracheal intubation, rocuronium bromide (0.8
mg/kg) was administered intravenously and then a 7-7.5 mm tube was inserted for
females and males, respectively. The ETCO2 was maintained between
30-40 mm hg in 50% oxygen/air by adjusting the ventilation frequency and
setting the mechanical ventilation to 6ml/kg tidal volume. Isoflurane was
utilized to keep the anesthetic at 1-1.5 volume % for maintenance of
anaesthesia. Reversal medications were administered after surgery to restore
neuromuscular function (glycopyrrolate 0.004 mg/kg & neostigmine 0.02
mg/kg). After that, manual ventilation using 100% oxygen at an 8 L/min rate was
substituted for mechanical ventilation. Group D patients received
dexmedetomidine until they were extubated. Other than being repeatedly asked to
open their eyes verbally, the patients were not disturbed. We avoided any other
stimuli.
We
measured each patient's degree of agitation using the RICKER sedation-agitation
scale [11], with the highest possible agitation score noted. 1:
little or no reaction to unpleasant stimuli; 2: arousal to physical stimuli but
lack of communication; 3: difficult arousal but awakening to verbal stimuli or
light shaking; 4: composure & obedience to commands; 5: anxiety or physical
agitation & calming to spoken instructions; 6: necessity for restraint &
frequent verbal reminders of boundaries; & 7: pulling at tracheal tube,
trying to remove catheters, or hitting staff. A score of 5 or higher on the
sedation-agitation scale indicated emergent agitation. Dangerous agitation was
defined as a score of 7 on the sedation-agitation scale [2,11].
After that, the patients were taken to the post-anesthesia care unit (PACU),
where they were observed for any complications such as increased salivation,
nausea, vomiting, desaturation, & laryngospasm. Heart rate & blood
pressure were periodically checked.
Statistical
Analysis- Data was collected & recorded as per
working proforma. Observed data was entered in MS Excel sheet & analysis
was done using two-sample t-tests in SPSS software version 23. P value <0.05 was defined
as statistically significant.
Ethics approval and consent to participate- The
above study was approved by the Human Ethical Committee (Ethics Committee
approval number: IRC-NMCTH/741/2023 dated February 01 2023) of the Department
of Anaesthesiology, Nobel Medical College Teaching
Hospital, Biratnagar, Nepal and informed consent was obtained from the patients
before the study.
RESULTS- The study included a
total of 100 participants having pharyngeal & nasal surgery. Of these, 50
were assigned to the study group, the Dexmedetomidine group. Fifty people were
distributed to the control group, the non-dexmedetomidine group (normal
saline). The two groups' demographic profiles & surgical characteristics,
including age, gender, BMI, length of surgery, study drug infusion time, &
intraoperative fluid volume, were compared using the t-test (Table 1). The p-values for BMI, infusion duration of
study drug & amount of intraoperative fluid were p<0.05, which showed a
significant difference.
Table
1: Demographic
profile & operation details of patients.
|
|
Group
C (n=50) |
Group
D (n=50) |
p-value |
|
Age (Years) |
37.5 13.15 |
37.2 11.04 |
0.44 |
|
Sex
(Male/Female) |
35 15 |
37 13 |
0.48 |
|
Body Mass
Index (Kg/m2) |
23.12 1.32 |
22.05 1.20 |
0.0001 |
|
Duration of
Surgery (min) |
56 23 |
50 20 |
0.17 |
|
Infusion
Duration of Study Drug (min) |
58 25 |
62 20 |
0.005 |
|
Amount of
Intraoperative Fluid (ml) |
500 210 |
450 223 |
0.0005 |
Values
are mean SD. D=Dexmedetomidine; C=Control (normal saline)
As
shown in Fig. 1, there were fewer EA patients in Group D (n = 4; 8%) than in
Group C (n = 13; 26%) with a Ricker sedative agitation score of 5 to 7. Five
minutes after extubation, all patients' agitation
subsided. Three (6%) subjects in group C & one (2%) subjects in group D
suffered adverse effects such as post-operative nausea & vomiting. Neither
group experienced additional side effects, including bradycardia, desaturation,
hypersalivation, hypotension, or laryngospasm (Fig. 2).
.png)
Fig. 1: Distribution of Ricker
sedation agitation scale among study participants.
.png)
Fig. 2: Post-operative side effects &
complications in patients.
Table
2: Comparison of heart rate & blood
pressure between the study & control groups.
|
Time Intervals (Min) |
Mean Heart Rate |
p-value |
Mean Blood Pressure |
p-value |
||
|
Group C (n=50) |
Group D (n=50) |
Group C (n=50) |
Group D (n=50) |
|||
|
5 |
82.3 9.8 |
67.2 6.3 |
0.0001 |
85.7 7.4 |
67.4 6.1 |
<0.001 |
|
10 |
81.1 9 |
66.1 5.9 |
<0.001 |
83.4 7.2 |
65 5.4 |
|
|
15 |
78.1 7.5 |
66.1 6 |
<0.0001 |
83.1 7.9 |
64.9 4.9 |
|
|
30 |
77.9 7.1 |
65.5 5.7 |
<0.001 |
82.9 7.5 |
65.5 5 |
|
|
60 |
77.5 6.9 |
64.8 5.1 |
<0.001 |
79.6 6.4 |
65.3 4.7 |
|
|
90 |
76.4 6.4 |
67 5.5 |
0.06 |
81.3 6.2 |
65 4.6 |
|
|
120 |
79.5 6 |
64.4 4.8 |
<0.001 |
81.8 6 |
65.2 4.6 |
|
Data
is presented as mean SD. D=Dexmedetomidine; C=Control
(normal saline)
DISCUSSION- Dexmedetomidine
induces sleepiness & analgesia without impairing the respiratory system [12].
As a result, it has been used to avoid emerging agitation. In comparison to
control groups, intraoperative dexmedetomidine therapy reduced emergent
agitation in children by 57-70% [13-16]. Dexmedetomidine can also
produce hemodynamic abnormalities such as hypotension (30%), hypertension
(12%), & bradycardia (9%) [17]. Earlier studies of emerging
agitation used a variety of dexmedetomidine administration regimens (e.g., only
loading of 0.5 mg kg-1, only infusion of 0.2 mg kg-1 h-1,
or loading of 2 mg kg-1 followed by infusion of 0.7 mg kg-1 h-1)
[13-16].
After general surgery, up to 20% of adult
patients have been reported to experience emergent agitation [2,3]. It
is notably common following ENT surgery, with 55.4% of subjects reporting
agitation [3]. There have been few studies on the relationship
between intraoperative dexmedetomidine infusion & emerging agitation in
adults. Only a few such trials have been conducted; one discovered that
dexmedetomidine reduced emergent agitation from 52% to 28% in people after nose
surgery (n=50 per group) [18]. The other study compared a
dexmedetomidine infusion group to two other groups (epidural & control,
each with 30 participants) after a gastrectomy & discovered that
dexmedetomidine reduced emergence agitation compared to the control (7% vs 27%)
[19]. Our findings support an earlier study, suggesting that
continuous dexmedetomidine infusion (0.4 g kg-1 h-1)
during nasal & pharyngeal surgery minimizes emerging agitation without
delaying extubation or worsening complications. In
contrast to the current study, Kim et al.
[18], Khurshid et al. [20]
found a slightly different incidence of emerging agitation, at 28% & 26%,
respectively. Furthermore, the incidence & severity of EA were higher in Abdellatif
and Ali et al. [21] than
in our study. The difference could be a single dosage of 0.3 g/kg
dexmedetomidine administered 5 minutes before the completion of surgery.
Adverse events such as post-operative
nausea & vomiting were reported in one (2%) patient in group D & three
(6%) in group C. Neither group had negative effects, such as laryngospasm,
desaturation, hypersalivation, hypotension, or bradycardia. In a comparable
trial, Kwon et al. [22]
found nausea & vomiting in 4 (17%) & 1 (3%), respectively. This could
be because the medications were administered at the same doses.
In the current study, we also found that
the study group had lower heart rate & blood pressure than the control
group. Although this difference was statistically significant, it was not
clinically meaningful & did not necessitate any intervention. The lower
heart rate & blood pressure seen in Group D could be attributed to
Dex-induced decreased sympathetic output & circulating catecholamine
levels. Unlike this discovery, Kim et al.
[18], Khurshid et al. [20],
Reddy et al. [23], &
Deepak et al. [24] did not
notice statistically significant alterations in heart rate & mean arterial
pressure during the procedure with dexmedetomidine (0.4 g/kg) infusion.
In our investigation, maintaining
dexmedetomidine until extubation resulted in more
stable hemodynamic alterations after emergence. A previous study demonstrated
that sustaining a dexmedetomidine infusion of 0.2 g kg-1 h-1
during extubation did not impact mean arterial
pressure (MAP) or heart rate (HR) in both the dexmedetomidine & control
groups [14]. The outcome discrepancies may be attributable to
patient age (adults vs children) or infusion concentration (0.4 g kg-1
h-1 vs 0.2 g kg-1 h-1).
CONCLUSIONS- Emergence
agitation can have serious consequences for patients, including self-injury,
increased post-operative pain, hemorrhage, self-extubation,
and removal of catheters. The study concluded that intraoperative
dexmedetomidine infusion can effectively reduce emergence agitation in patients
undergoing nasal and pharyngeal surgery without causing additional
complications. Dexmedetomidine infusion until extubation
provided more stable hemodynamic changes during emergence.
However,
further research is needed to explore the impact of different factors on the
efficacy of dexmedetomidine infusion and assess its long-term effects beyond 2
hours post-operatively. Additional studies could focus on comparing the
effectiveness of dexmedetomidine with other sedatives and opioids in managing
emergence agitation.
LIMITATIONS- The
study only included ASA class 1-2 patients aged between 20-60 years undergoing
nasal & pharyngeal surgery, so the findings may not apply to patients with
higher ASA classifications or different age groups. The study did not assess
the long-term outcomes or complications associated with dexmedetomidine use
beyond the immediate post-operative period. Also, the study did not compare
dexmedetomidine with other sedatives or opioids commonly used for emergence
agitation management, so the relative efficacy & safety of dexmedetomidine
compared to other pharmacological treatments could not be determined.
CONTRIBUTION OF
AUTHORS
Research
concept- Dr. Bandana Paudel
Research design- Dr.
Bandana Paudel
Supervision-Dr. Sanjay
Gautam
Materials- Dr. Sumitra
Paudel
Data collection- Dr.
Dinesh Bhandari, Dr. Sumitra Paudel
Data analysis and Interpretation- Dr.
Bandana Paudel and Dr. Sanjay Gautam
Literature search- Dr.
Bandana Paudel and Dr. Sanjay Gautam
Writing article- Dr.
Bandana Paudel and Dr. Sanjay Gautam
Critical review- Dr.
Bandana Paudel and Dr. Dinesh Bhandari
Article editing- Dr.
Bandana Paudel and Dr. Sumitra
Final approval- Dr.
Bandana Paudel
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