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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. Published online November 29, 2018. 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

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