Effect of Total Intravenous Anesthesia vs Volatile Induction With Maintenance Anesthesia on Emergence Agitation After Nasal Surgery: A Randomized Clinical Trial | Anesthesiology | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Figure 1.  CONSORT Flow Diagram
CONSORT Flow Diagram

TIVA indicates total intravenous anesthesia; VIMA, volatile induction and maintenance of anesthesia.

Figure 2.  Occurrence Rate of Emergence Agitation
Occurrence Rate of Emergence Agitation

Findings are based on the Richmond Agitation–Sedation Scale (RASS) and the Riker Sedation–Agitation Scale (RSAS). TIVA indicates total intravenous anesthesia; VIMA, volatile induction and maintenance of anesthesia. Each group included 40 patients.

Table 1.  Demographics of the Study Population
Demographics of the Study Population
Table 2.  Intraoperative Data
Intraoperative Data
Table 3.  Postoperative Complications
Postoperative Complications
1.
Eckenhoff  JE, Kneale  DH, Dripps  RD.  The incidence and etiology of postanesthetic excitement: a clinical survey.  Anesthesiology. 1961;22:667-673. doi:10.1097/00000542-196109000-00002PubMedGoogle ScholarCrossref
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Kim  SY, Kim  JM, Lee  JH, Song  BM, Koo  BN.  Efficacy of intraoperative dexmedetomidine infusion on emergence agitation and quality of recovery after nasal surgery.  Br J Anaesth. 2013;111(2):222-228. doi:10.1093/bja/aet056PubMedGoogle ScholarCrossref
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Yu  D, Chai  W, Sun  X, Yao  L.  Emergence agitation in adults: risk factors in 2,000 patients.  Can J Anaesth. 2010;57(9):843-848. doi:10.1007/s12630-010-9338-9PubMedGoogle ScholarCrossref
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Dahmani  S, Delivet  H, Hilly  J.  Emergence delirium in children: an update.  Curr Opin Anaesthesiol. 2014;27(3):309-315. doi:10.1097/ACO.0000000000000076PubMedGoogle ScholarCrossref
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Kim  HJ, Kim  DK, Kim  HY, Kim  JK, Choi  SW.  Risk factors of emergence agitation in adults undergoing general anesthesia for nasal surgery.  Clin Exp Otorhinolaryngol. 2015;8(1):46-51. doi:10.3342/ceo.2015.8.1.46PubMedGoogle ScholarCrossref
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Lepousé  C, Lautner  CA, Liu  L, Gomis  P, Leon  A.  Emergence delirium in adults in the post-anaesthesia care unit.  Br J Anaesth. 2006;96(6):747-753. doi:10.1093/bja/ael094PubMedGoogle ScholarCrossref
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Riker  RR, Picard  JT, Fraser  GL.  Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.  Crit Care Med. 1999;27(7):1325-1329. doi:10.1097/00003246-199907000-00022PubMedGoogle ScholarCrossref
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Radtke  FM, Franck  M, Hagemann  L, Seeling  M, Wernecke  KD, Spies  CD.  Risk factors for inadequate emergence after anesthesia: emergence delirium and hypoactive emergence.  Minerva Anestesiol. 2010;76(6):394-403.PubMedGoogle Scholar
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Altman  D, Machin  D, Bryant  T, Gardner  M, eds. Statistics with Confidence: Confidence Intervals and Statistical Guidelines. 2nd ed. London, United Kingdom: BMJ Books; 2000.
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Cohen  IT, Finkel  JC, Hannallah  RS, Hummer  KA, Patel  KM.  Rapid emergence does not explain agitation following sevoflurane anaesthesia in infants and children: a comparison with propofol.  Paediatr Anaesth. 2003;13(1):63-67. doi:10.1046/j.1460-9592.2003.00948.xPubMedGoogle ScholarCrossref
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Yasui  Y, Masaki  E, Kato  F.  Sevoflurane directly excites locus coeruleus neurons of rats.  Anesthesiology. 2007;107(6):992-1002. doi:10.1097/01.anes.0000291453.78823.f4PubMedGoogle ScholarCrossref
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Chen  L, Xu  M, Li  GY, Cai  WX, Zhou  JX.  Incidence, risk factors and consequences of emergence agitation in adult patients after elective craniotomy for brain tumor: a prospective cohort study.  PLoS One. 2014;9(12):e114239. doi:10.1371/journal.pone.0114239PubMedGoogle ScholarCrossref
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Sessler  CN, Gosnell  MS, Grap  MJ,  et al.  The Richmond Agitation–Sedation Scale: validity and reliability in adult intensive care unit patients.  Am J Respir Crit Care Med. 2002;166(10):1338-1344. doi:10.1164/rccm.2107138PubMedGoogle ScholarCrossref
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Riker  RR, Fraser  GL, Simmons  LE, Wilkins  ML.  Validating the Sedation–Agitation Scale with the Bispectral Index and visual analog scale in adult ICU patients after cardiac surgery.  Intensive Care Med. 2001;27(5):853-858. doi:10.1007/s001340100912PubMedGoogle ScholarCrossref
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Simmons  LE, Riker  RR, Prato  BS, Fraser  GL.  Assessing sedation during intensive care unit mechanical ventilation with the Bispectral Index and the Sedation–Agitation Scale.  Crit Care Med. 1999;27(8):1499-1504. doi:10.1097/00003246-199908000-00016PubMedGoogle ScholarCrossref
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Brandl  KM, Langley  KA, Riker  RR, Dork  LA, Quails  CR, Levy  H.  Confirming the reliability of the Sedation–Agitation Scale administered by ICU nurses without experience in its use.  Pharmacotherapy. 2001;21(4):431-436. doi:10.1592/phco.21.5.431.34487PubMedGoogle ScholarCrossref
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Jo  JY, Choi  SS, Yi  JM,  et al.  Differential postoperative effects of volatile anesthesia and intraoperative remifentanil infusion in 7511 thyroidectomy patients: a propensity score matching analysis.  Medicine (Baltimore). 2016;95(7):e2764. doi:10.1097/MD.0000000000002764PubMedGoogle ScholarCrossref
Original Investigation
November 29, 2018

Effect of Total Intravenous Anesthesia vs Volatile Induction With Maintenance Anesthesia on Emergence Agitation After Nasal Surgery: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
JAMA Otolaryngol Head Neck Surg. 2019;145(2):117-123. doi:10.1001/jamaoto.2018.3097
Key Points

Question  Does the occurrence rate of emergence agitation differ between patients who underwent nasal surgery under volatile induction and maintenance of anesthesia or total intravenous anesthesia?

Findings  In this randomized clinical trial of 80 patients undergoing nasal surgery, emergence agitation after nasal surgery under total intravenous anesthesia occurred in fewer patients than under volatile induction and maintenance of anesthesia when assessed with the Richmond Agitation–Sedation Scale score (1 of 40 [2.5%] vs 8 of 40 [20.0%], respectively) and the Riker Sedation-Agitation Scale score (1 of 40 [2.5%] vs 10 of 40 [25.0%], respectively).

Meaning  The occurrence of emergence agitation after nasal surgery under general anesthesia can be reduced by using total intravenous anesthesia rather than inhalation anesthesia.

Abstract

Importance  Emergence agitation is common after nasal surgery under general anesthesia and may lead to serious consequences for the patient, including an increased risk of injury, pain, hemorrhage, and self-extubation. Despite decades of research, studies on the incidence, risk factors, and prevention of emergence agitation in adult patients are ongoing, and opinions differ on the different effects of inhalation and intravenous anesthesia.

Objective  To investigate the effect of anesthetic method on the occurrence of emergence agitation after nasal surgery.

Design, Setting, and Participants  This prospective, randomized, single-blind, clinical trial included 80 patients undergoing open rhinoplasty, septoplasty, turbinoplasty, endoscopic sinus surgery, and functional endoscopic sinus surgery under general anesthesia who were randomized to receive total intravenous anesthesia (TIVA) with remifentanil hydrochloride and propofol (n = 40) or volatile induction and maintenance of anesthesia (VIMA) with sevoflurane and nitrous oxide (n = 40) in Asan Medical Center, a tertiary referral center in Seoul, Republic of Korea. Data were collected from August 24 through October 14, 2016, and analyzed from October 26, 2016, through September 14, 2017.

Main Outcomes and Measures  The occurrence of emergence agitation defined by the following 2 individual criteria: a Richmond Agitation–Sedation Scale score of at least 1 and a Riker Sedation–Agitation Scale score of at least 5 immediately after extubation.

Results  Among the 80 patients included in the analysis (68.8% men [n = 55]; mean [SD] age, 41.6 [17.9] years), emergence agitation measured by the Richmond Agitation Sedation Scale occurred in 8 of 40 patients (20.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 17.5 (95% CI, 3.6-31.4). Emergence agitation measured by the Riker Sedation–Agitation Scale score occurred in 10 of 40 patients (25.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 22.5 (95% CI, 7.3-37.7).

Conclusions and Relevance  The occurrence of emergence agitation after nasal surgery under general anesthesia can be significantly reduced by using TIVA rather than VIMA.

Trial Registration  CRIS identifier: KCT0002145

Introduction

Postanestheic emergence agitation, also called emergence delirium, was first described by Eckenhoff et al1 in 1961 as emergence excitement. In that clinical survey, the authors characterized emergence agitation as confusion, disorientation, crying, moaning, shouting, or screaming. The occurrence rate of emergence agitation was reported to range from 5% to 30%, depending on the distribution of patients and variables such as age, the presence of a urinary catheter or an endotracheal tube, or pain intensity. Although emergence agitation occurs infrequently, it is a clinically significant complication because patients can injure themselves or the medical staff.2 The precise mechanism of emergence agitation has not yet been elucidated, but risk factors have been revealed through various retrospective and prospective studies.3 The most common known risk factors are the presence of a urinary catheter or an endotracheal tube, postoperative pain, and younger age. The occurrence rate of emergence agitation is significantly higher in school-aged children, especially in those who receive volatile anesthesia with sevoflurane or desflurane.3-6

Despite decades of research, studies on the occurrence rate, risk factors, and prevention of emergence agitation in adult patients are still ongoing. In particular, opinions differ on the different effects of inhalation and intravenous anesthesia.3-6 In a prospective study of 1359 adult patients,6 multivariate analysis showed that the method of anesthesia did not affect the occurrence of emergence agitation. Another prospective observational study of about 2000 adults3 reported that the use of volatile anesthetic agents was associated with a higher occurrence rate of emergence agitation. In a 2015 retrospective study that investigated risk factors of emergence agitation after nasal surgery,5 the use of sevoflurane was reported to increase the risk of emergence agitation by more than 2-fold. Therefore, we designed a prospective, single-blind, randomized study to compare the occurrence of emergence agitation in patients who underwent nasal surgery under volatile induction and maintenance of anesthesia (VIMA) or total intravenous anesthesia (TIVA).

Methods
Patients

This prospective, randomized, single-blind clinical trial evaluated patients undergoing open rhinoplasty, septoplasty, turbinoplasty, endoscopic sinus surgery, and functional endoscopic sinus surgery under general anesthesia. The trial protocol can be found in Supplement 1. This study was approved by the institutional review board of the Asan Medical Center, Seoul, Republic of Korea. Written informed consent was obtained from all participants before enrollment.

Patients were included if they were aged 20 to 79 years with an American Society of Anesthesiologists physical status of 1 to 3. Patients were excluded from the study if they had a diagnosis of mental illness according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) or if they had taken a neuroleptic or benzodiazepine for longer than 2 weeks within 1 month of surgery. Patients who were allergic to opioids or nonsteroidal anti-inflammatory drugs or who were diagnosed with asthma or nasal polyps were also excluded. Eligible patients were randomly assigned to receive TIVA or VIMA by an online randomization program (http://www.randomization.com).

Study Design and Anesthesia

In the TIVA group, anesthesia was induced with propofol, 2 mg/kg, before starting a target-controlled infusion with propofol and remifentanil hydrochloride using an Orchestra pump (Fresenius Kabi AG). The effect-site concentration was controlled at 2.0 to 2.5 µg/mL to maintain a Bispectral Index Score of 40 to 60 (range, 0-100). The remifentanil infusion was titrated to maintain the patient’s blood pressure within 20% of the preoperative measurement. In the VIMA group, anesthesia was induced with inhaled sevoflurane and nitrous oxide and maintained with sevoflurane and 50% nitrous oxide in oxygen. After removal of the pharyngeal packing gauze at the end of surgery, administration of the anesthetic agents was immediately discontinued (time T0). After sufficient oral suctioning, the inhaled oxygen fraction was increased to 100% and the fresh gas flow rate to 8 L to facilitate emergence. Neuromuscular blocking was reversed with 0.4 mg of glycopyrrolate and 15 mg of pyridostigmine and confirmed using a train-of-four monitor. Patients received no simulation by investigators other than verbal stimulation performed every 30 seconds; patients were extubated once they regained consciousness and were able to obey an oral command (time T1).

Emergence is defined as the interval within 2 minutes after extubation. Sedation and agitation were assessed immediately after extubation using the following 2 scales: the Riker Sedation–Agitation Scale (RSAS)7 and the Richmond Agitation–Sedation Scale (RASS).8 The RASS and RSAS are tools for measuring the degree of agitation and delirium in stages. Although they are similar in content, they have slightly different scales (from fully sedative state to highly agitated state). The RASS is divided into 10 levels (range of scores, −5 to 4, with higher scores indicating greater agitation) and the RSAS into 7 levels (range of scores, 1-7, with higher scores indicating greater agitation). The agitation scores were assessed by independent anesthesiologists who were blinded to the anesthetic methods administered in this study. The patients recovered for 1 hour in the postanesthesia care unit. A well-trained nurse blinded to randomized study group evaluated pain intensity by using the Numeric Rating Scale (range, 0-10, with higher scores indicating worse pain) immediately after arrival, 30 minutes after arrival, and 60 minutes after arrival to the recovery room. Rescue analgesics, such as nonsteroidal anti-inflammatory drugs and opioids, were administered when the Numeric Rating Scale score exceeded 5.

Outcomes

The primary outcome of this study was the occurrence of emergence agitation. The definition of emergence agitation was based on an RASS score of at least 1 or an RSAS score of at least 5 immediately after extubation. The secondary outcomes were pain intensity and the need for rescue analgesics as well as the occurrence of immediate postoperative complications, including postoperative nausea and vomiting, itching or urticaria, desaturation, and shivering.

Sample Size and Statistical Analysis

Data were analyzed from October 26, 2016, through September 14, 2017. The PS power and sample size calculations (version 3.1.2; 2014) developed by the Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, were used to calculate the sample size.9 For the calculation of the sample size, a previous study by Yu et al3 was used as reference. In their study, the anticipated occurrence rate of emergence agitation was 27.8% and 7.5% in the VIMA and TIVA groups, respectively, and a 10% screen failure rate was assumed.3 Thus, we estimated that 120 patients (60 in each group) would be required to achieve a study power of 80% and detect a 75% lower risk of the primary end point with VIMA vs TIVA using a 2-sided χ2 test at a significance level of .05. Although no formal interim analysis was planned, the difference in the occurrence rate of emergence agitation between the 2 groups was very high. Therefore, a sample size recalculation was performed based on pooled data from the first 74 patients that did not affect the type I error rate. Surprisingly, the occurrence rate of emergence agitation in the TIVA group was only 2.8%, instead of the initially expected 7.5%, and that in the TIVA group was 26.3%. Because of this lower occurrence rate observed in the TIVA group, the sample size was recalculated, raising the study power to 85%. Nevertheless, the recalculated total sample size was reduced (40 in each group, for a total of 80). Therefore, we stopped enrollment at 86 patients.

All continuous variables are expressed as mean (SD), and categorical variables are expressed as frequencies and percentages. To compare perioperative data, an unpaired, 2-tailed t test was used for continuous variables and a χ2 test was used for categorical variables. The risk difference and its 95% CI are calculated according to Altman et al.10 All data manipulations and statistical analysis were performed using SPSS for Windows (version 21; IBM Corporation) and Stata software (version 13.1; StataCorp LP). Statistical significance was evaluated at the 2-sided α level of .05. The effect size and the corresponding 95% CIs are reported.

Results

A total of 86 patients were assessed for eligibility from August 24 through October 14, 2016. Five patients declined to participate, and 1 was excluded because of a diagnosed psychological disorder. Consequently, 80 patients (55 [68.8%] men and 25 [31.2%] women; mean [SD] age, 41.6 [17.9] years) were included and randomized to the TIVA group (n = 40) or the VIMA group (n = 40) (Figure 1). The baseline characteristics and intraoperative data of the study population are summarized in Table 1 and Table 2. There were no significant differences between groups. The types of operation included endoscopic sinus surgery, endoscopic endonasal resection, septoplasty, turbinoplasty, and open rhinoplasty. In most cases, endonasal packing was performed for hemostasis. Sixty-three patients underwent bilateral endonasal packing (31 patients in the TIVA group and 32 patients in the VIMA group). We found no significant difference in the duration of anesthesia (mean [SD], 150.5 [89.3] vs 138.0 [72.1] minutes) or surgery (mean [SD], 102.6 [57.8] vs 112.7 [66.0] minutes) between the 2 groups (Table 2).

The occurrence rate of emergence agitation in each group is shown in Figure 2. Regardless of the method of anesthesia, 9 patients experienced emergence agitation (overall incidence, 11.2%) according to the RASS and 11 (overall incidence, 13.8%) according to the RSAS. Emergence agitation with an RASS score of at least 1 immediately after extubation occurred significantly less often in the TIVA group than in the VIMA group (1 of 40 [2.5%] vs 8 of 40 [20.0%]; risk difference, 17.5 [95% CI, 3.6-31.4]). The analysis based on the RSAS score yielded a similar result. Emergence agitation measured using the RSAS score occurred in 1 of 40 patients (2.5%) and 10 of 40 (25.0%) in the TIVA and VIMA groups, respectively. The risk difference was 22.5 (95% CI, 7.3-37.7). The agitation subsided within 5 minutes after extubation in all patients assessed as agitated. However, no significant difference occurred in the time between cessation of administration of anesthetic agents and extubation in the 2 groups (mean [SD], 11.75 [4.12] minutes in the TIVA group vs 11.18 [3.49] minutes in the VIMA group; mean difference, 0.58; 95% CI, −1.13 to 2.28). Moreover, no significant difference occurred between the 2 groups in the incidence of immediate postoperative complications such as cough, laryngospasm, and desaturation. Of note, no incidents of laryngospasm or desaturation occurred in either group (Table 3). However, 4 patients (10.0%) in the TIVA group and 8 (20.0%) in the VIMA group experienced severe cough immediately after extubation (Table 3). During their stay in the postanesthesia care unit, only 1 patient (in the TIVA group) of the 80 experienced shivering (Table 3). Postoperative pain intensity did not differ between the 2 groups, nor did the need for administration of rescue analgesics in the postanesthesia care unit (Table 3).

Discussion

The main finding of the present study was that adult patients who underwent nasal surgery under general anesthesia were more likely to experience emergence agitation if they received VIMA vs TIVA. However, no difference in the occurrence rate of acute perioperative complications or pain intensity between the 2 groups was found.

In children, the use of volatile anesthetic agents is a well-known risk factor of emergence agitation. However, a paucity of research on emergence agitation is available in adults, and opinions are divided on whether the type of anesthetic agent affects the occurrence of emergence agitation. Several prospective observational studies of patients who underwent various surgical procedures revealed that the occurrence of emergence agitation did not increase with the use of volatile agents compared with propofol and that those volatile agents were not a risk factor of emergence agitation.6,8 Conversely, Yu et al3 observed that patients who received inhalational anesthesia showed a higher occurrence rate of emergence agitation than patients who received anesthesia with propofol; those authors demonstrated that the use of volatile agents was a risk factor of emergence agitation, which is consistent with the results of our research. Even in children, the mechanism underlying the association between emergence agitation and the use of inhaled anesthetic agents has not been fully elucidated. In the past, some investigators3 argued that the occurrence rate of emergence agitation may be lower with TIVA because propofol and remifentanil can be eliminated from the body faster than inhaled anesthetic agents. However, although pediatric studies revealed that emergence from propofol was generally smoother and the occurrence rate of emergence agitation was lower compared with emergence from sevoflurane, the recovery times from propofol and sevoflurane were almost the same.11 One possible explanation can be found in mouse experiments that showed nerves within the locus ceruleus, a site involved in adrenergic excitation, were especially stimulated by sevoflurane.12

Well-known risk factors for emergence agitation are pain, presence of an endotracheal tube and/or a urinary catheter, younger age, current smoking, and male sex.3,5,13 In the present study, these risk factors were preadjusted to randomize the difference between the 2 groups. However, according to Tables 1 and 2, the 2 groups did not have identical distribution. In the case of sex, a noticeable difference of 17.5% was reported. Male patients are generally known to show more emergence agitation than female patients.3 In the present study, the occurrence rate of emergence agitation was lower in the TIVA group than in the VIMA group, despite the 17.5% more male patients included in the TIVA group. This difference reinforces the findings of the present study. Otorhinolaryngology surgery is also a known risk factor of emergence agitation, especially nasal surgery, possibly owing to the feeling of suffocation.1,2 Two recent studies2,5 evaluating adult patients who underwent nasal surgery showed the occurrence rates of emergence agitation were 22% and 50%. The first study2 used the RASS to evaluate the occurrence of emergence agitation, whereas the second study5 used the RSAS. In the present study, the overall occurrence rate of emergence agitation was 11.2% by the RASS and 13.8% by the RSAS. Although the occurrence rate of emergence agitation in the present study was similar to the overall occurrence rate of emergence agitation across patients who underwent different types of operations, this occurrence rate was relatively low for patients who underwent nasal surgery. This finding is probably due to the smoother emergence of patients in our study, as evidenced by the longer time between cessation of administration of anesthetic agents and extubation (11.75 and 11.18 minutes in our study vs 7.8 minutes in the study by Kim et al2). The presence of an endotracheal tube is another well-known risk factor of emergence agitation. Because our patients were allowed to emerge slowly with no arousal other than verbal stimulation, they were able to eliminate a substantial amount of the anesthetic agents from the body. This process may explain the lower occurrence rate of emergence agitation in our study.

Moreover, another strength of this study is that we used 2 different variables to evaluate the occurrence of emergence agitation. Previous studies have used a variety of agitation scales, such as the RSAS, RASS, or the New Sheffield Sedation Scale; however, to our knowledge, none of these scales has been validated for use in the recovery room. Moreover, the occurrence rate of emergence agitation varies depending on which scale is used, although the RSAS and RASS have been found to have excellent interrater reliability.6,14-17 Depending on which agitation assessment tool is used (RASS or RSAS), the occurrence rate of emergence agitation has been shown to vary from 20% to 60%. The present study used both assessment tools to examine these reported differences. The results showed a similar occurrence rate of emergence agitation between the evaluations performed using the RSAS and RASS.

According to previous studies,3,5 the difference in the occurrence rate of emergence agitation between the TIVA and inhalation anesthesia was similar to that of our study. For example, Yu et al3 showed that risk difference of postoperative emergence agitation between inhalation anesthesia and TIVA was 20.3%, although they used a different emergence agitation assessment tool from the present study and included all types of surgery. Another retrospective study for emergence agitation after nasal surgery5 showed that risk differences in the occurrence rate of emergence agitation by RASS between the groups of inhalation anesthesia and TIVA was about 17.3%. Although exact validation was not performed for clinically important difference in emergence agitation, the result of the present randomized clinical trial revealed a higher risk difference in emergence agitation measured by the RASS between the VIMA and TIVA groups than a previous report5 (Figure 2). Therefore, it was reasonable that the present results are clinically meaningful. Furthermore, the present study suggested that emergence agitation after nasal surgery under general anesthesia can be significantly reduced by using TIVA rather than VIMA.

As previously mentioned, the occurrence of emergence agitation after nasal surgery may increase owing to the feeling of suffocation. We hypothesized that emergence agitation would be more likely to occur in cases when both sides of the nose were congested owing to surgery or when both sides were packed. However, this hypothesis was not confirmed by the results of the study, which is consistent with previous studies that showed bilateral nasal packing was not a risk factor of emergence agitation.5 Moreover, the need for rescue analgesics and immediate postoperative pain intensity was not influenced by the type of anesthetic agents used. This finding contradicts a previous report18 that the use of remifentanil during thyroidectomy caused a higher intensity of immediate postoperative pain. One explanation for this discrepancy might be that nasal surgery is generally less painful than a thyroidectomy.

Strengths and Limitations

Despite some limitations, the findings of this study are important. Previous studies of emergence agitation in adult patients were mainly prospective observational or retrospective analysis. However, the present study was conducted as a prospective, randomized clinical trial and the anesthetic methods and emergence method were standardized across the study population. Moreover, patients in the present study only underwent a limited range of operation types, which further increases the objectivity of this analysis.

Several limitations of our present study should be noted. Although the results suggest that the use of VIMA increases the occurrence rate of emergence agitation compared with TIVA, we cannot be sure that this outcome is due to the volatile agents alone. Considering as many factors that may affect the occurrence of emergence agitation as possible, we attempted the randomization and tried to anesthetize the 2 groups in an identical manner. However, differences may be found in areas that were not investigated in this study. For example, although the American Society of Anesthesiologists physical status and anesthesia time seem to differ between the 2 groups, they are not well-known risk factors. To clarify whether volatile agents directly affect the occurrence of emergence agitation, a more limited and specific experiment should be performed. Second, we did not assess the hypoactive type of delirium. In our study, we defined delirium as a RASS score of at least 1 or an RSAS score of at least 5, which means that only agitated people were diagnosed with emergence agitation. However, delirium can manifest as the hypoactive type, which can be evaluated using a sedation scale or the opposite part of the agitation scale. In this study, we concentrated on the agitation element of emergence agitation because agitation poses the greatest risk of harm to patients and staff.

Conclusions

In conclusion, the occurrence of emergence agitation after nasal surgery can be reduced using TIVA instead of VIMA. No difference was found in the rate of immediate perioperative complications.

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Article Information

Accepted for Publication: September 17, 2018.

Corresponding Author: Seong-Soo Choi, MD, PhD, Department of Anesthesiology and Pain Medicine, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic–ro 43-gil, Songpa–gu, Seoul 05505, Republic of Korea (choiss@amc.seoul.kr).

Published Online: November 29, 2018. doi:10.1001/jamaoto.2018.3097

Author Contributions: Dr Choi had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jo, Jung, Kim, Ku.

Acquisition, analysis, or interpretation of data: Choi, Jo, S. Park, H. Park.

Drafting of the manuscript: Jo, Jung, Kim, S. Park, H. Park, Ku.

Critical revision of the manuscript for important intellectual content: Choi, Jo, Kim.

Statistical analysis: Choi, Jo.

Administrative, technical, or material support: Jung, Kim.

Supervision: Ku.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This study was presented in part at the International Anesthesia Research Society 2017 Annual Meeting and International Science Symposium; May 6, 2017; Washington, DC.

Additional Contributions: Yong Ju Jang, MD, PhD, Yoo-Sam Chung, MD, PhD, and Ji Heui Kim, MD, PhD, Department of Otorhinolaryngology, Asan Medical Center, Seoul, Republic of Korea, helped to prepare this study. Seong-Sik Cho, MD, PhD, Department of Occupational and Environmental Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea, assisted with data analysis. Hwanhee Yoo, MD, MS, Jinwook Lim, MD, MS, and Jaewon Baik, MD, MS, Department of Anesthesiology and Pain Medicine, Asan Medical Center, helped to perform the present study. None of these contributors was compensated for this work.

References
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Eckenhoff  JE, Kneale  DH, Dripps  RD.  The incidence and etiology of postanesthetic excitement: a clinical survey.  Anesthesiology. 1961;22:667-673. doi:10.1097/00000542-196109000-00002PubMedGoogle ScholarCrossref
2.
Kim  SY, Kim  JM, Lee  JH, Song  BM, Koo  BN.  Efficacy of intraoperative dexmedetomidine infusion on emergence agitation and quality of recovery after nasal surgery.  Br J Anaesth. 2013;111(2):222-228. doi:10.1093/bja/aet056PubMedGoogle ScholarCrossref
3.
Yu  D, Chai  W, Sun  X, Yao  L.  Emergence agitation in adults: risk factors in 2,000 patients.  Can J Anaesth. 2010;57(9):843-848. doi:10.1007/s12630-010-9338-9PubMedGoogle ScholarCrossref
4.
Dahmani  S, Delivet  H, Hilly  J.  Emergence delirium in children: an update.  Curr Opin Anaesthesiol. 2014;27(3):309-315. doi:10.1097/ACO.0000000000000076PubMedGoogle ScholarCrossref
5.
Kim  HJ, Kim  DK, Kim  HY, Kim  JK, Choi  SW.  Risk factors of emergence agitation in adults undergoing general anesthesia for nasal surgery.  Clin Exp Otorhinolaryngol. 2015;8(1):46-51. doi:10.3342/ceo.2015.8.1.46PubMedGoogle ScholarCrossref
6.
Lepousé  C, Lautner  CA, Liu  L, Gomis  P, Leon  A.  Emergence delirium in adults in the post-anaesthesia care unit.  Br J Anaesth. 2006;96(6):747-753. doi:10.1093/bja/ael094PubMedGoogle ScholarCrossref
7.
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