Emergence agitation: current knowledge and unresolved questions

Abstract

This article is protected by copyright of Korean Journal of Anesthesiology. All rights reserved. Emergence agitation (EA), which is also referred to as emergence delirium, can lead to clinically significant consequences. The mechanism of EA remains unclear. Proposed contributors to EA include age, male sex, type of surgery, emergency operation, use of inhalational anesthetics with low blood-gas partition coefficients, long duration of surgery, anticholinergics, premedication with benzodiazepines, voiding urgency, postoperative pain, and the presence of invasive devices. If preor intraoperative objective monitoring could predict the occurrence of agitation during emergence, this would help to reduce the adverse consequences of EA. Several tools are available for assessing EA; however, its incidence varies considerably according to the assessment tool and definition of EA used, due to the absence of standardized clinical research practice guidelines. Total intravenous anesthesia, propofol, μ-opioid agonists, N-methyl-D-aspartate receptor antagonists, nefopam, α2adrenoreceptor agonists, regional analgesia, multimodal analgesia, parent-present induction, and preoperative education for surgery may contribute to prevention of EA. However, it is difficult to identify patients at high risk for EA and to properly apply EA prevention methods in various clinical situations, because both risk factors and preventive strategies often show inconsistent results depending on the methodology of the study and the patients assessed. This review discusses the most important research topics related to EA and directions for future research.

Emergence delirium is associated with increased postoperative delirium in elderly: a prospective observational study

“…The above results suggest that maintaining normothermia during anesthesia, preventing agitation during emergence and providing optimal analgesia may reduce emergence delirium and subsequent postoperative delirium but requires further demonstration. Contrary to some of the previous results [34], we found that male patients developed less emergence delirium; more studies are needed.…”

“…It is noteworthy that emergence agitation was identified as a risk factor of emergence delirium. As a matter of fact, the two terms have been used interchangeably in previous studies, and the same assessment tool (e.g., RASS or Riker Sedation-Agitation Scale) have been used for both conditions [4,5,9,10,13,34]. We also found that hypothermia at the PACU admission was associated with emergence delirium development.…”

Comparison of the effects of desflurane and sevoflurane on emergence characteristics in pediatric patients premedicated with ketamine

“…There are several reasons why EA occurs. Some studies have suggested that rapid recovery from GA might contribute to the occurrence of EA [14]. According to the meta-analysis [22], EA occurred more frequently with sevoflurane anesthesia than with halothane anesthesia in children.…”

“…Also, intravenous (IV) ketamine used as premedication can reduce EA compared to IV midazolam during sevoflurane anesthesia [13]. Lee et al [14] reported that lack of premedication with midazolam may be a risk factor for EA in children.…”

Butorphanol Mitigates Emergence Agitation in Patients Undergoing Functional Endoscopic Sinus Surgery: A Randomised Controlled Clinical Trail

“…This can lead to serious complications, such as hypoxia, aspiration pneumonia, bleeding, or re-operation [1,2,8]. Although many strategies had been proven helpful to the reduction of the incidence of EA, like α2-adrenoreceptor agonists [10,11], total intravenous anaesthesia [12], and multimodal analgesia [13], these preventive strategies often yielded inconsistent results depending on the methodology of the study and the patients assessed [14], and led to residual sedation and haemodynamic changes that resulted in prolonged post-anaesthesia care unit (PACU) stay.…”