Adult Emergence Agitation: A Veteran-Focused Narrative Review

Abstract

Emergence agitation (EA) is a self-limited state of psychomotor excitement during awakening from general anesthesia. EA is confined to the emergence period as consciousness is restored, which sharply distinguishes it from other postoperative delirium states. Sporadic episodes of EA may become violent with the potential for harm to both patients and caregivers, but the long-term consequences of such events are not fully understood. Current literature on EA in adults is limited to small-scale studies with inconsistent nomenclature, variable time periods that define emergence, a host of different surgical populations, and conflicting diagnostic criteria. Therefore, true incidence rates and risk factors are unknown. In adult noncardiac surgery, the incidence of EA is approximately 19%. Limited data suggest that young adults undergoing otolaryngology operations with volatile anesthetic maintenance may be at the highest risk for EA. Currently suggested EA mechanisms are theoretical but might reflect underblunted sympathetic activation in response to various internal (eg, flashbacks or anxiety) or external (eg, surgical pain) stimuli as consciousness returns. Supplemental dexmedetomidine and ketamine may be utilized for EA prevention. Compared to the civilian population, military veterans may be more vulnerable to EA due to high rates of posttraumatic stress disorder (PTSD) manifesting as violent flashbacks; however, confirmatory data are limited. Nonetheless, expert military medical providers suggest that use of patient-centered rapport tactics, PTSD trigger identification and avoidance, and grounding measures may alleviate hyperactive emergence phenomena. Future research is needed to better characterize EA in veterans and validate prophylactic measures to optimize care for these patients. This narrative review provides readers with an important framework to distinguish EA from delirium. Furthermore, we summarize current knowledge of EA risk factors, mechanisms, and adult management strategies and specifically revisit them in the context of veteran perioperative health. The anesthesiology care team is ideally positioned to further explore EA and develop effective prevention and treatment protocols.

Predictive Value of Preoperative Profiling of Serum Metabolites for Emergence Agitation After General Anesthesia in Adult Patients

“…After alignment of the metabolites with the MS database and screening, 31 significantly altered metabolites were selected to analyze the different metabolite patterns between the EA group and the non-EA group ( Table 3 ). The differentially regulated metabolites were classified into several “superclasses”: “Lipids and lipid-like molecules” (11 metabolites), “Organoheterocyclic compounds” ( Kanaya, 2016 ), “Organic acids and derivatives” ( Munk et al, 2016 ), “Nucleosides, nucleotides, and analogs” ( Wei et al, 2020 ), “Organic oxygen compounds” ( Wei et al, 2020 ), “Organic nitrogen compounds” ( Tolly et al, 2020 ), “Phenylpropanoids and polyketides” ( Tolly et al, 2020 ), and “Alkaloids and derivatives” ( Tolly et al, 2020 ). After alignment with the KEGG and MetaboAnalyst databases, altered metabolites were found to participate mainly in “purine metabolism,” “glycerophospholipid metabolism and nicotinate,” and “nicotinamide metabolism pathways.” We also analyzed the pathway enrichment of the 31 significantly altered metabolites, and 14 KEGG pathways were included ( Figure 4 ), which were mainly associated with “Glycerophospholipid metabolism,” “Phenylalanine, yrosine, and tryptophan biosynthesis,” and “Phenylalanine metabolism” ( Supplementary Table S1 ).…”

“…The mechanism of EA pathogenesis is not known. A common hypothesis is that excessive reactions may occur due to internal or external stimuli as consciousness returns during the recovery from anesthesia ( Brown et al, 2010 ; Tolly et al, 2020 ). It has been reported that several factors contribute to EA occurrence, including preoperative concomitant diseases and excessive sympathetic activation ( Kim et al, 2019 ) from indwelling catheters and tubes ( Kwon et al, 2016 ; Fields et al, 2018 ).…”

“…Calculation of the RAAS score was conducted by well-trained nursing staff. EA was defined as a RASS ≥ + 2 or dexmedetomidine utilization during the PACU stay ( Tolly et al, 2020 ). If EA occurred, appropriate measures were taken immediately.…”

“…In the clinical setting, EA represents a fluctuating state of mental excitement and involuntary physical activity and may precipitate several clinical problems including dislodgement of indwelling catheters, self/staff injury, falling off in the operating theater/transport stretcher, etc. ( Lee and Sung, 2020 ; Tolly et al, 2020 ). In particular, self-extubation may lead to serious consequences, that is, hypoxia and aspiration, if EA occurs and is not treated in a timely manner ( Wei et al, 2020 ).…”

Perioperative Delirium/Agitation Associated With the Use of Anesthetics and/or Adjunct Agents: A Study of Patient Behaviors, Injuries, and Interventions to Mitigate Risk

“…1 In a majority of literature, the condition is referred to as emergence delirium, agitation, or excitation. 2,3 The condition often begins with awakening or emergence from the anesthetic and/or adjunct agent and is followed by a return to baseline behavior after a short time period (typically less than 30 minutes). [2][3][4][5][6] During the bout of delirium/agitation, the patient may engage in a wide range of behavior that includes one or more of the following: violence (e.g., punching, kicking, hitting, biting), thrashing movement, aggression, combativeness, screaming, disconnect with current time and place (e.g., flashbacks, hallucinating, disoriented), attempting to exit bed/table, and attempting to remove medical apparatuses.…”