Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 4  |  Page : 593-597

Preoperative external nasal compression: does it decrease emergence agitation after nasal surgery?


Department of Anesthesia, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission08-Oct-2015
Date of Acceptance17-Jul-2016
Date of Web Publication12-Jan-2017
Date of Print Publicaton12-Jan-2017

Correspondence Address:
Ayman Kasem
Department of Anesthesia, Faculty of Medicine, Ain Shams University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.198250

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  Abstract 

Background
Emergence agitation after nasal surgeries in adults is common. Acute postoperative nasal obstruction with nasal packing is an important factor in developing agitation after nasal surgeries.
Aim The aim of this study was to evaluate the effectiveness of preoperative nasal obstruction by means of external nasal compression on the incidence of emergence agitation after nasal surgeries.
Methods
Sixty patients of American Society of Anesthesiologists I or II between 20 and 45 years of age who were scheduled for nasal surgery were randomly assigned into three equal groups: the control (C) group, the T10 group, in which nasal compression was carried out for 10 min, and the T30 group, in which nasal compression was carried out for 30 min preoperatively. All patients received the same anesthetic technique. The incidence of agitation, and recovery characteristics were evaluated during emergence. Patient satisfaction was evaluated 24 h after surgery.
Results
There was a significantly lower incidence of emergence agitation and fentanyl consumption during the emergence period in the T30 group. Moreover, patient satisfaction with recovery was significantly higher in the T30 group.
Conclusion
Elective preoperative external nasal obstruction may decrease the incidence of emergence agitation and improve patient satisfaction with recovery after nasal surgery.

Keywords: agitation, emergence, nasal surgery


How to cite this article:
Kasem A, Abdelkader A. Preoperative external nasal compression: does it decrease emergence agitation after nasal surgery?. Ain-Shams J Anaesthesiol 2016;9:593-7

How to cite this URL:
Kasem A, Abdelkader A. Preoperative external nasal compression: does it decrease emergence agitation after nasal surgery?. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2017 Dec 13];9:593-7. Available from: http://www.asja.eg.net/text.asp?2016/9/4/593/198250


  Introduction Top


Agitation on emergence from general anesthesia after nasal surgeries in which intranasal packing is used is common. The occurrence of emergence agitation increases the risk for bleeding, falling from operating room (OR) table or stretcher in the recovery room, removal of catheters, and self-extubation. This may lead to further complications such as desaturation and aspiration of blood. Thus, continuous monitoring, additional medications, and physical restraint may be required [1],[2].

Usually, awake extubation after nasal surgeries is preferred because the airway is contaminated by blood. However, awake extubation may intensify emergence agitation. Many patients complain of difficulty in breathing due to acute nasal obstruction (caused by intranasal packing), and is considered as an important factor in the occurrence of emergence agitation [3],[4],[5].

Several studies have been conducted in adults to decrease the incidence of emergence agitation after nasal surgeries using different medications [3],[5],[6],[7].

As acute nasal obstruction is a major factor in developing postoperative agitation in nasal surgeries [1],[5], we tested, in this study, the hypothesis that preoperative acute nasal obstruction (performed by means of external nasal compression) for certain period of time would decrease the incidence of postoperative agitation.

This study was conducted to evaluate the effectiveness of preoperative external nasal compression on the incidence of postoperative agitation in nasal surgeries.


  Methods Top


This study was conducted in Prince Sultan Hospital, Al-Madinah, KSA, from August 2014 to July 2015. The study protocol was approved by the Ethics Committee of the hospital. Sixty adult patients of American Society of Anesthesiologists physical status I or II between 20 and 45 years of age of both sexes, nonsmokers, with BMI less than or equal to 30, who were scheduled to undergo nasal surgery under general anesthesia, in which unilateral or bilateral nasal packing was planned to be used until 24 h after surgery, were included in the study. The objective and methods of the study were explained to them before the operation, and all patients provided written informed consent.

Patients were randomly assigned into three groups using the sealed envelope technique: the 10 min (T10) group, in which patient’s nose was closed with a plastic clip (same one being used for swimming) for 10 min before induction of anesthesia, the 30 min (T30) group, in which patient’s nose was closed for 30 min before induction of anesthesia, and the control group (the C group), in which no nasal closure was carried out before surgery. All patients were instructed to breath from mouth and were observed by a recovery room nurse who did not participate in data collection.

Patients were premedicated with intravenous midazolam 0.025 mg/kg, 15 min before induction of anesthesia. All patients received the same general anesthetic technique by an anesthetist who did not participate in data collection. General anesthesia was induced with intravenous fentanyl (2 µg/kg) and propofol (2.0–2.5 mg/kg). Tracheal intubation was facilitated with cisatracurium (0.15 mg/kg). Oropharyngeal packing was performed and positioning of the patients was carried out. Anesthesia was maintained with oxygen in N2O and sevoflurane. Pressure-controlled mode was used to keep ETCO2 in the range of 30–35 mmHg. All patients received 4 mg ondansetron and 1 g paracetamol intravenously nearly 15 min before the end of surgery. Standard monitoring was maintained throughout the procedure (ECG, noninvasive arterial pressure, oxygen saturation, capnometry, temperature, and neuro - muscular transmission [NMT]).

Once the surgery was complete, the oropharyngeal pack was removed, and oral suction was carried out. After confirming the return of neuromuscular function using train-of-four peripheral nerve stimulation, reversal agents (neostigmine 0.02 mg/kg and glycopyrrolate 0.2 mg) were given. Following these steps, sevoflurane was turned off (which was defined as ‘time 0’ in the emergence process) in the three groups, and mechanical ventilation was then converted to manual ventilation with 100% oxygen. The patients were not disturbed, except by continual verbal orders to open their eyes. All other types of stimulation were prevented. Extubation was performed when patients began spontaneous breathing and were able to respond to verbal orders. Emergence is defined as the time interval from ‘time 0’ until discharge of the patient from the OR to the postanesthesia care unit (PACU). Agitation level during emergence was evaluated using the Riker sedation-agitation scale ([Table 1] ), and each patient’s maximum agitation score was recorded. If the score was 5 and more, incremental doses of 20 µg fentanyl were given until the patient was calm (score of 4 or less), and the total dose of fentanyl was recorded.
Table 1: Riker sedation-agitation scale [8]

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The ability to cough during emergence was assessed using a four-point numerical scale (0=no cough; 1=single cough; 2=persistent cough lasting less than 5 s; and 3=persistent cough lasting ≥5 s or bucking). The length of the period from ‘time zero’ to first verbal response and extubation was recorded. Respiratory rate at the time of extubation was measured. Desaturation (SpO2 ≤90%), laryngospasm, and other complications during emergence were also recorded.

In the PACU, all patients were routinely managed using the following standardized postoperative protocol: (a) serial assessments of pain with a 11-point numerical rating scale (0=no pain and 10=worst pain) and emergence agitation using the Riker sedation-agitation scale (at admission, every 5 min for the first 15 min, and then every 15 min thereafter, until discharge from the PACU); (b) rescue analgesic administration of meperidine in patients with a pain score up to 5, and physical restraint or intermittent midazolam administration in severe cases of emergence agitation based on the decision of attending anesthesiologists; (c) antiemetic treatment with metocloperamide 10 mg intravenously in patients with intolerable postoperative nausea and vomiting; and (d) discharge from the PACU based on a modified Aldrete score (scores of ≥9 were considered appropriate for discharge).

After surgery of 24 h, patient’s satisfaction with recovery was assessed using the four-point numerical rating scale (3=very satisfied, 2=satisfied, 1=neutral, and 0=unsatisfied).

Statistics

PASS 13 was used for sample size calculation. On the basis of a pilot study in our department, it was calculated that 17 patients per group would detect 40% decrease in the incidence of emergency delirium with 0.05 significance level and 80% power. To compensate for possible dropouts, 20 patients per group were included.

Data were analyzed using SPSS 18.0 for Windows (SPSS Inc., Chicago, Illinois, USA). Analysis of variance was used to compare the three groups for quantitative parametric data, and if there was a significant difference among the groups, a post-hoc Tukey’s test was performed. The Kruskal–Wallis test was used for analysis of quantitative nonparametric data. The χ2-test was used for comparison of qualitative data. Continuous parametric data were presented as mean±SD, nonparametric data as median (interquartile range), and categorical data were presented as number of patients. P-values less than 0.05 were considered significant and less than 0.001 as highly significant.


  Results Top


All patients completed the study. There were no significant differences between the three groups as regards age, BMI, sex, type of surgery, and duration of surgery ([Table 2]).
Table 2: Patient characteristics

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There were no differences between the three groups as regards the time of extubation, respiratory rate at the time of extubation, or the grades of cough during emergence. In the PACU, we found that there were no differences between the three groups as regards numerical pain scores and requirement of meperidine or antiemetic administration. Discharge time from the PACU was similar in all groups. Among all patients in the study, only one patient in the control group developed laryngospasm and desaturation and was managed safely in the OR ([Table 3]).
Table 3: Criteria on recovery

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We found that there was a significantly lower incidence of emergence agitation in the T30 group compared with the other two groups, although the incidence of dangerous emergence agitation (Riker sedation-agitation score=7) was similar in the three groups of our study. Moreover, the patient satisfaction was significantly higher in the T30 group compared with the other two groups ([Table 4]).
Table 4: Emergence agitation and patient satisfaction

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  Discussions Top


Emergence agitation following nasal surgeries is a postanesthetic state that develops in the early phase of recovery from general anesthesia, and is characterized by agitation, disorientation, confusion, and possible violent behavior including self-extubation, removal of catheters, removal of nasal packs, hemorrhage, and even severe injuries from falling from the OR table or stretcher in the recovery room. Moreover, it may cause the medical staff injuries and increases the demand on human resources [9].

It has been reported that the overall incidence of emergence agitation in adults was around 21%, and it was more common in men than in women and after inhalational than after total intravenous anesthesia [1].

Previous studies [1],[9],[10] had reported that oral cavity, nasal, and otolaryngeal surgical procedures have a higher incidence of emergence agitation in both adults and children. Although, its pathogenesis remains unclear, its higher incidence after nasal surgical procedures has been explained by the sense of suffocation during emergence from anesthesia [9].

The occurrence of emergence agitation in adults carries a higher risk for injury to both the patient and the medical staff, as medical staff may not be able to restrain the agitation like in pediatric emergence agitation. Thus, more medical staff should be available beside adults during recovery from anesthesia [7].

Few studies have been conducted on the occurrence of emergence agitation in adults after nasal surgery [3],[5],[6],[7].

Kim et al. [7] compared emergence agitation in adults after closed reduction of nasal bone fracture using either sevoflurane or propofol anesthesia and concluded that propofol may decrease the incidence of emergence agitation compared with sevoflurane.

In another study, intraoperative dexmedetomidine infusion (0.4 mg/kg/h) until extubation was found to provide smooth and hemodynamically stable emergence without complications after nasal surgery and improved the quality of recovery 24 h after surgery. The incidence of emergence agitation was lower in the dexmedetomidine group than in the control group (28 vs 52%, P=0.041) [3].

In agreement with these results, Khurshid and colleagues reported that the use of dexmedetomidine as intraoperative infusion from induction until extubation resulted in smooth emergence from general anesthesia after nasal surgery, with a lower incidence of emergence agitation. The incidence of emergence agitation was lower in the dexmedetomidine group (26%) than in the control group (50%) [5].

In a recent study, Polat and colleagues compared dexmedetomidine and remifentanil infusion in emergence agitation during recovery after nasal surgery and concluded that using either of the two drugs as an anesthetic maintenance until extubation provided a smoother and hemodynamically stable emergence, without complications. Although remifentanil was superior to dexmedetomidine in decreasing the incidence of emergence agitation, dexmedetomidine was more effective compared with remifentanil with regard to pain scores and vomiting after surgery [6].

As mentioned before, acute nasal obstruction with nasal packs is one of the risk factors for emergence agitation; we thought that making patients have acute nasal obstruction and training them to be obligatory mouth breather for some time before surgery might affect the incidence of postoperative agitation, with better patient satisfaction. We used external nasal compression for that purpose. To the best of our knowledge, no such study has been conducted before.

In the current study, there were no differences between the three groups as regards the criteria on recovery and the incidence of postoperative complications such as desaturation, laryngospasm, postoperative nausea and vomiting, and the consumption of rescue analgesics in the recovery room. However, there was a significantly lower incidence of emergence agitation in the T30 group compared with the other two groups, although the incidence of dangerous emergence agitation was similar in the three study groups. Moreover, the amount of fentanyl consumption during the emergence period was significantly lower in the T30 group compared with the other two groups. Patient satisfaction with recovery was significantly higher in the T30 group.

Although emergence agitation was lower in the T30 group, the optimum time of nasal closure before surgery is yet to be determined. Moreover, the effectiveness of the preoperative nasal compression should be compared with the standard pharmacological methods and further studies are required.


  Conclusion Top


Training of patient to be obligatory mouth breathers for 30 min with elective preoperative external nasal compression may decrease the incidence of emergence agitation and improve patient satisfaction after nasal surgery with postoperative nasal packing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Yu D, Chai W, Sun X, Yao L. Emergence agitation in adults: risk factors in 2,000 patients. Can J Anaesth 2010;57:843–848.  Back to cited text no. 1
    
2.
Lepousé C, Lautner CA, Liu L, Gomis P, Leon A. Emergence delirium in adults in the post-anaesthesia care unit. Br J Anaesth 2006;96:747–753.  Back to cited text no. 2
    
3.
Kim SY, Kim JM, Lee JH, Song BM, Koo BN. Efficacy of intraoperative dexmedetomidine infusion on emergence agitation and quality of recovery after nasal surgery. Br J Anaesth 2013;111:222–228.  Back to cited text no. 3
    
4.
Feldman MA, Patel A. Anesthesia for eye, ear, nose and throat surgery. In: Miller RD, editor. Miller’s anesthesia. Vol. 2. Philadelphia, PA: Churchill Livingstone Elsevier; 2010;2368.  Back to cited text no. 4
    
5.
Khurshid H, Muneer K, Malla MS. Effect of dexmedetomidine on emergence agitation after nasal surgeries. Indian J Clin Anaesth 2015;2:126–130.  Back to cited text no. 5
    
6.
Polat R, Peker K, Baran I, Bumin AG, Gülöksüz TC, Dönmez A. Comparison between dexmedetomidine and remifentanil infusion in emergence agitation during recovery after nasal surgery. Anaesthesist 2015;64:740–746.  Back to cited text no. 6
    
7.
Kim YS, Chae YK, Choi YS, Min JH, Ahn SW, Yoon JW et al. A comparative study of emergence agitation between sevoflurane and propofol anesthesia in adults after closed reduction of nasal bone fracture. Korean J Anesthesiol 2012;63:48–53.  Back to cited text no. 7
    
8.
Riker RR, Fraser GL, Simmons LE, Wilkins ML. Validating the Sedation-Agitation Scale with the Bispectral Index and Visual Analog Scale in adult ICU patients after cardiac surgery. Intensive Care Med 2001;27:853–858.  Back to cited text no. 8
    
9.
Kim HJ, Kim DK, Kim HY, Kim JK, Choi SW. Risk factors of emergence agitation in adults undergoing general anesthesia for nasal surgery. Clin Exp Otorhinolaryngol 2015;8:46–51.  Back to cited text no. 9
    
10.
Voepel-Lewis T, Malviya S, Tait AR. A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit. Anesth Analg 2003;96:1625–1630.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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