Effect of Total Intravenous Anesthesia vs Volatile Induction With Maintenance Anesthesia on Emergence Agitation After Nasal Surgery: A Randomized Clinical Trial

Abstract

Importance: Emergence agitation is common after nasal surgery under general anesthesia and may lead to serious consequences for the patient, including an increased risk of injury, pain, hemorrhage, and self-extubation. Despite decades of research, studies on the incidence, risk factors, and prevention of emergence agitation in adult patients are ongoing, and opinions differ on the different effects of inhalation and intravenous anesthesia.

Objective: To investigate the effect of anesthetic method on the occurrence of emergence agitation after nasal surgery.

Design, setting, and participants: This prospective, randomized, single-blind, clinical trial included 80 patients undergoing open rhinoplasty, septoplasty, turbinoplasty, endoscopic sinus surgery, and functional endoscopic sinus surgery under general anesthesia who were randomized to receive total intravenous anesthesia (TIVA) with remifentanil hydrochloride and propofol (n = 40) or volatile induction and maintenance of anesthesia (VIMA) with sevoflurane and nitrous oxide (n = 40) in Asan Medical Center, a tertiary referral center in Seoul, Republic of Korea. Data were collected from August 24 through October 14, 2016, and analyzed from October 26, 2016, through September 14, 2017.

Main outcomes and measures: The occurrence of emergence agitation defined by the following 2 individual criteria: a Richmond Agitation-Sedation Scale score of at least 1 and a Riker Sedation-Agitation Scale score of at least 5 immediately after extubation.

Results: Among the 80 patients included in the analysis (68.8% men [n = 55]; mean [SD] age, 41.6 [17.9] years), emergence agitation measured by the Richmond Agitation Sedation Scale occurred in 8 of 40 patients (20.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 17.5 (95% CI, 3.6-31.4). Emergence agitation measured by the Riker Sedation-Agitation Scale score occurred in 10 of 40 patients (25.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 22.5 (95% CI, 7.3-37.7).

Conclusions and relevance: The occurrence of emergence agitation after nasal surgery under general anesthesia can be significantly reduced by using TIVA rather than VIMA.

Trial registration: CRIS identifier: KCT0002145.

Figure 1.. CONSORT Flow Diagram

TIVA indicates total intravenous anesthesia; VIMA, volatile induction and maintenance of anesthesia.

Figure 2.. Occurrence Rate of Emergence Agitation

Findings are based on the Richmond Agitation–Sedation Scale (RASS) and the Riker Sedation–Agitation Scale (RSAS). TIVA indicates total intravenous anesthesia; VIMA, volatile induction and maintenance of anesthesia. Each group included 40 patients.