Introduction
Anesthesia is a medicine that is given to prevent pain during a surgical procedure. They can be in various forms like injection, inhalation, topical lotion, spray, eye drops, or skin patches. They can either numb the area or make the patient lose consciousness so that they do not feel pain. Local or regional anesthesia numbs a particular area, while general anesthesia makes the patient lose consciousness. Recovery from general anesthesia can sometimes cause unexpected behaviors like aggression. The aggressive behavior following anesthesia is discussed in this article.
What Is Recovery After Anesthesia?
Recovery from anesthesia is also termed ‘emergence.’ While recovering consciousness from anesthesia, the patient will be placed in a recovery room called the post-anesthesia care unit (PACU). During this period, the clinical staff will closely monitor the patient. Vital signs (signs that show that the body is functioning properly), like blood pressure, pulse, oxygen levels, and breathing, will be observed. Signs of any complications or breathing difficulty will be checked.
The person's return to their old state of awareness after an anesthetic procedure is termed recovery from anesthesia. In most cases, recovering from anesthesia is smooth and does not have any major complications. However, in some cases, there can be some changes in returning back to proper consciousness.
Inadequate emergence is when the individual's activity level decreases immediately after anesthesia recovery. Another type of incomplete emergence is called emergence agitation. The patient may have hallucinations, delusions, and confusion. These may be expressed as involuntary physical activity, restlessness, moaning, and thrashing. Such incidents are seen in five to ten percent of cases with general anesthesia. The risk of such complications following anesthesia is higher after the use of benzodiazepines, following breast surgery, abdominal surgery, musculoskeletal surgery, surgical procedures with long durations, induction of anesthesia with Etomidate, a pain numeric rating scale (NRS, a scale used to evaluate pain) of six to ten in the post-anesthesia care unit. In addition, patients who are very young or too old have a higher risk of anesthesia emergence complications.
What Is Emergence Agitation?
Changes in the levels of consciousness and mental state during recovery from anesthesia can cause the emergence of agitation. Eckenhoff et al., in 1960, first described their observations of ‘neurologic excitement’ in a period when a patient emerged from anesthesia. Emergence agitation is described as ‘an unpleasant state of extreme arousal.’ It is more commonly seen in patients having pain, anxiety, fear, and more complex neurobehavioral syndromes (conditions associated with brain disorders or injuries). Pediatric patients have also been observed to show oppositional behaviors. This could probably be because of the unfamiliar experience they had undergone during a surgical procedure.
Emergence agitation is usually observed during the early stages of recovery from anesthesia, like 14 minutes after anesthesia cessation. However, the medical literature has recorded cases that showed the emergence of agitation 45 minutes after anesthesia cessation. The course of duration is self-limiting. Hence, the role of medical intervention, or the benefits it can give, is still controversial. The effects of this condition, like the untimely loss of intravenous catheters or drainage tubes, patient or staff injury, and parental and staff dissatisfaction, are always a matter of concern. Long-term outcomes after anesthesia, like post-operative cognitive dysfunction or maladaptive behaviors, are seen in some pediatric patients. However, they require more research to be dealt with.
What Are the Risk Factors for Emergence Agitation?
The risk factors for emergence agitation are divided into three categories: patient-related, anesthesia-related, and surgical factors.
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Patient-Related Factors: The factors related to the patient can include male gender, preschool age, higher pre-operative anxiety level, and baseline sleep-related breathing disorder (any respiratory conditions that interfere or worsen while sleeping). It is commonly seen that pediatric patients seem to be more impulsive, emotional, less social, or more arrogant while recovering from anesthesia in some cases. The intensity of agitation can also depend on some factors like parental anxiety, young age, exposure to similar medical experiences, and immature social skills. Studies show that those who have high levels of anxiety before surgery are also at a higher risk of developing emergency agitation.
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Anesthesia-Related Factors: The route of administration can influence the emergence following anesthesia. Studies show that intravenous administration of anesthesia is relatively linked to a lesser number of cases of emergence agitation, in contrast to the administration of gaseous anesthetics. Rapid emergence and slow emergence following anesthesia have also been shown to have a link to agitation after anesthesia. However, more research is needed on this matter.
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Surgical Factors: The recovery after anesthesia depends on the type of surgical procedure. Studies show that surgeries with a shorter duration had an increased risk of emergence agitation. The abrupt cessation of gaseous anesthesia and the duration of emergence could be linked to this. According to research by Eckenhoff et al., suffocation during the emergence periods, especially in head and neck surgeries, could be a cause of emergence agitation. Hence, the type of anesthesia should be decided after considering the type and duration of the surgical procedure, and the post-operative complications usually observed.
How Is Emergence Agitation Managed?
Non-pharmacological approaches have been taken and have been found to be effective in managing the incidence of agitation emergence. They can include pre-operative counseling, relaxation techniques like yoga and breathing exercises, and open communication between the surgeon and the patient. Pharmacological approaches like pre-operative administration of intranasal Dexmedetomidine (a sedative agent) 20 minutes before the procedure have been shown to reduce anxiety before the procedure and post-operative agitation. Other medicines that are known for reducing the risk of emergency agitation include oral Gabapentin, intraoperative Magnesium infusion, intraoperative Dexamethasone, and Midazolam.
Conclusion
Different terms like emergence, excitation, agitation, and delirium are used to describe hyperactive behavior following recovery from anesthesia. Steps taken to reduce agitation can include trying to relax the patient prior to the procedure. However, the understanding of the condition is not complete, and more research is required to discover new methods to reduce the agitation following anesthesia. In addition, the long-term outcomes of this condition also require a focus in the research. This can help to formulate potential mitigation strategies to tap emergence agitation effectively.
