Pharmacological and Non-pharmacological Interventions in Patients Undergoing Nasal Surgeries for Prevention of Emergence Agitation: a Systematic Review and Network Meta-analysis

Overview

Journal Braz J Anesthesiol

Specialty Anesthesiology

Date 2024 Oct 18

PMID 39423915

Authors

Gustavo R M Wegner

Bruno F M Wegner

Henrik G Oliveira

Luis A Costa

Luigi W Spagnol

Valentine W Spagnol

Gilberto T F de Oliveira Filho

Affiliations

Soon will be listed here.

Abstract

Background: Emergence agitation is a common complication after nasal surgeries, marked by increased agitation and a heightened risk of injuries. Factors like urinary catheter, endotracheal tube, postoperative pain, and younger age contribute to its occurrence. Due to the variety of preventive approaches reported in the literature, a network meta-analysis is essential.

Methods: This systematic review employs a network meta-analysis design, following Cochrane Handbook and PRISMA-NMA criteria. Inclusion criteria involve randomized controlled studies on pharmacological and non-pharmacological interventions for preventing emergence agitation in nasal surgeries. Electronic searches, including PubMed, Scopus, Embase, Cochrane Library, and Web of Science, without language or date restrictions, were conducted. Two independent reviewers selected studies, and data extraction was performed using standardized tables. Bayesian NMA, MetaInsight web app, and Cochrane Foundation Risk of Bias Assessment Tool were applied for data analysis and bias assessment.

Results: After a rigorous selection process, 17 Randomized Controlled Trials (RCTs) encompassing 2,122 patients and 14 interventions were included. The best ranked treatments identified were intraoperative dexmedetomidine (1 μg.kg- for 10 minutes as a bolus, followed by 0.4 μg.kg.h), bilateral nasociliary and maxillary nerve block, ketamine (0.5 mg.kg administered 20 minutes before the end of surgery), nasal compression for 40 minutes before anesthesia induction, and suction above the cuff of the endotracheal tube.

Conclusions: Both pharmacological and non-pharmacological interventions emerged as effective strategies in mitigating emergence agitation after nasal surgeries, offering clinicians valuable options for improving postoperative outcomes in this patient population.

References

Lee S, Sung T . Emergence agitation: current knowledge and unresolved questions. Korean J Anesthesiol. 2020; 73(6):471-485. PMC: 7714637. DOI: 10.4097/kja.20097. View

Parthasarathy S, Krishnapriyanka K, Saravanan B . Effectiveness of pre-emptive nerve block on opioid consumption in patients undergoing nasal surgery under general anaesthesia: A double-blinded randomised controlled study. Indian J Anaesth. 2022; 66(2):133-139. PMC: 8963222. DOI: 10.4103/ija.ija_813_21. View

Zhang X, Qi S, Lin Z, Zhang Y, Dai W, Tian W . Pre-operative administration of butorphanol mitigates emergence agitation in patients undergoing functional endoscopic sinus surgery: A randomized controlled clinical trial. Front Psychiatry. 2023; 13:1090149. PMC: 9887110. DOI: 10.3389/fpsyt.2022.1090149. View

Yang Y, Feng L, Ji C, Lu K, Chen Y, Chen B . Inhalational Versus Propofol-based Intravenous Maintenance of Anesthesia for Emergence Delirium in Adults: A Meta-analysis and Trial Sequential Analysis. J Neurosurg Anesthesiol. 2022; 35(2):177-186. DOI: 10.1097/ANA.0000000000000830. View

Owen R, Bradbury N, Xin Y, Cooper N, Sutton A . MetaInsight: An interactive web-based tool for analyzing, interrogating, and visualizing network meta-analyses using R-shiny and netmeta. Res Synth Methods. 2019; 10(4):569-581. PMC: 6973101. DOI: 10.1002/jrsm.1373. View

Liu Z . [Analysis of risk factors for emergence agitation in adults undergoing general anesthesia for nasal surgery]. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2016; 29(21):1881-5. View

Garg A, Kamal M, Mohammed S, Singariya G, Chouhan D, Biyani G . Efficacy of dexmedetomidine for prevention of emergence agitation in patients posted for nasal surgery under desflurane anaesthesia: A prospective double-blinded randomised controlled trial. Indian J Anaesth. 2018; 62(7):524-530. PMC: 6053886. DOI: 10.4103/ija.IJA_788_17. View

Riker R, Fraser G, Simmons L, Wilkins M . 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):853-8. DOI: 10.1007/s001340100912. View

Nevill C, Cooper N, Sutton A . A multifaceted graphical display, including treatment ranking, was developed to aid interpretation of network meta-analysis. J Clin Epidemiol. 2023; 157():83-91. DOI: 10.1016/j.jclinepi.2023.02.016. View

10.

Choi H, Jung S, Hong J, Joo Y, Kim Y, Hong S . Effects of Bilateral Infraorbital and Infratrochlear Nerve Block on Emergence Agitation after Septorhinoplasty: A Randomized Controlled Trial. J Clin Med. 2019; 8(6). PMC: 6616642. DOI: 10.3390/jcm8060769. View

11.

Beliveau A, Boyne D, Slater J, Brenner D, Arora P . BUGSnet: an R package to facilitate the conduct and reporting of Bayesian network Meta-analyses. BMC Med Res Methodol. 2019; 19(1):196. PMC: 6805536. DOI: 10.1186/s12874-019-0829-2. View

12.

Riker R, Picard J, Fraser G . Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999; 27(7):1325-9. DOI: 10.1097/00003246-199907000-00022. View

13.

Flukiger J, Hollinger A, Speich B, Meier V, Tontsch J, Zehnder T . Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis. Ann Intensive Care. 2018; 8(1):92. PMC: 6148680. DOI: 10.1186/s13613-018-0437-z. View

14.

Sterne J, Savovic J, Page M, Elbers R, Blencowe N, Boutron I . RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019; 366:l4898. DOI: 10.1136/bmj.l4898. View

15.

Jacob Y, Schneider B, Spies C, Heinrich M, Von Haefen C, Kho W . In a secondary analysis from a randomised, double-blind placebo-controlled trial Dexmedetomidine blocks cholinergic dysregulation in delirium pathogenesis in patients with major surgery. Sci Rep. 2023; 13(1):3971. PMC: 9998872. DOI: 10.1038/s41598-023-30756-z. View

16.

Kim S, Kim J, Lee J, Song B, Koo B . Efficacy of intraoperative dexmedetomidine infusion on emergence agitation and quality of recovery after nasal surgery. Br J Anaesth. 2013; 111(2):222-8. DOI: 10.1093/bja/aet056. View

17.

Sessler C, Gosnell M, Grap M, Brophy G, ONeal P, Keane K . The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002; 166(10):1338-44. DOI: 10.1164/rccm.2107138. View

18.

Yuzkat N, Demir C . Effect of using the Suction Above Cuff Endotracheal Tube (SACETT) on postoperative respiratory complications in rhinoplasty: a randomized prospective controlled trial. Ther Clin Risk Manag. 2019; 15:571-577. PMC: 6489680. DOI: 10.2147/TCRM.S200662. View

19.

Cerejeira J, Nogueira V, Luis P, Vaz-Serra A, Mukaetova-Ladinska E . The cholinergic system and inflammation: common pathways in delirium pathophysiology. J Am Geriatr Soc. 2012; 60(4):669-75. DOI: 10.1111/j.1532-5415.2011.03883.x. View

20.

Khan B, Guzman O, Campbell N, Walroth T, Tricker J, Hui S . Comparison and agreement between the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale in evaluating patients' eligibility for delirium assessment in the ICU. Chest. 2012; 142(1):48-54. PMC: 3610594. DOI: 10.1378/chest.11-2100. View