Incidence, Risk Factors and Consequences of Emergence Agitation in Adult Patients after Elective Craniotomy for Brain Tumor: A Prospective Cohort Study

Abstract

Emergence agitation is a frequent complication that can have serious consequences during recovery from general anesthesia. However, agitation has been poorly investigated in patients after craniotomy. In this prospective cohort study, adult patients were enrolled after elective craniotomy for brain tumor. The sedation-agitation scale was evaluated during the first 12 hours after surgery. Agitation developed in 35 of 123 patients (29%). Of the agitated patients, 28 (80%) were graded as very and dangerously agitated. By multivariate stepwise logistic regression analysis, independent predictors for agitation included male sex, history of long-term use of anti-depressant drugs or benzodiazepines, frontal approach of the operation, method and duration of anesthesia and presence of endotracheal intubation. Total intravenous anesthesia and balanced anesthesia with short duration were protective factors. Emergence agitation was associated with self-extubation (8.6% vs 0%, P = 0.005). Sedatives were administered more in agitated patients than non-agitated patients (85.7% vs 6.8%, P<0.001). In conclusion, emergence agitation was a frequent complication in patients after elective craniotomy for brain tumors. The clarification of risk factors could help to identify the high-risk patients, and then to facilitate the prevention and treatment of agitation. For patients undergoing craniotomy, greater attention should be paid to those receiving a frontal approach for craniotomy and those anesthetized under balanced anesthesia with long duration. More researches are warranted to elucidate whether total intravenous anesthesia could reduce the incidence of agitation after craniotomy.Trial RegistrationClinicalTrials.gov NCT00590499.

Emergence agitation: current knowledge and unresolved questions

“…All rights reserved. [2,3,8,18,21,[37][38][39][40][41][42][43][44] (Table 1). Here, we review some common risk factors and important issues presented in the literature.…”

“…Among these, although the RSAS and RASS have been commonly used and show high interrater reliability in adult intensive care unit patients [81,82], none of the scales have been validated in the operating room and/or the PACU. There have been few studies of EA in intensive care unit patients [37]; the majority of EA studies have been performed in PACUs or operating rooms [19,20,83].…”

“…Specifically, in a meta-analysis published in 2010 [86], prophylactic administration of midazolam showed no preventive effect against EA in children anesthetized with sevoflurane, desflurane, or both; in contrast, another meta-analysis (published in 2013) indicated that prophylactic administration of midazolam reduced sevoflurane-induced EA [124]. In adults, premedication with benzodiazepines or a patient history of long-term benzodiazepine use increased the risk of EA [18,21,37]. Avoidance of benzodiazepine premedication can be helpful for preventing EA in adults [125].…”

Emergence agitation during recovery from intracranial surgery under general anaesthesia: a protocol and statistical analysis plan for a prospective multicentre cohort study

“…Patients after intracranial operations are more vulnerable to the stress resulting from emergence agitation during the recovery from general anaesthesia. 2 3 In our previous pilot study with 123 cases, 4 we found that the incidence of agitation was 29% in patients admitted to the intensive care unit (ICU) after intracranial operations for brain tumours, and this incidence was higher than in those undergoing no intracranial operations. 5–8 Observational investigations in patients after intracranial surgeries have been scarce.…”

“… 11 The incidence of agitation reported in our pilot study was still much higher than these results. 4 9–11 These discrepancies warrant a prospective cohort study with a large sample size to determine the precise incidence of emergence agitation in patients after intracranial surgery.…”