Pharmacological and non-pharmacological interventions in patients undergoing nasal surgeries for prevention of emergence agitation: a systematic review and network meta-analysis
Intervenções farmacológicas e não farmacológicas em pacientes submetidos a cirurgias nasais para prevenção de agitação ao despertar: uma revisão sistemática e meta-análise em rede
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
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-1 for 10 minutes as a bolus, followed by 0.4 μg.kg-1.h-1), bilateral nasociliary and maxillary nerve block, ketamine (0.5 mg.kg-1 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.
Keywords
Resumo
Introdução
A agitação ao despertar é uma complicação comum após cirurgias nasais, marcada pelo aumento da agitação e um risco elevado de lesões. Fatores como cateter urinário, tubo endotraqueal, dor pós-operatória e idade mais jovem contribuem para sua ocorrência. Devido à variedade de abordagens preventivas relatadas na literatura, uma meta-análise em rede é essencial.
Métodos
Esta revisão sistemática emprega um desenho de meta-análise em rede, seguindo os critérios do Cochrane Handbook e PRISMA-NMA. Os critérios de inclusão envolvem estudos controlados randomizados sobre intervenções farmacológicas e não farmacológicas para prevenir agitação de emergência em cirurgias nasais. Buscas eletrônicas, incluindo PubMed, Scopus, Embase, Cochrane Library e Web of Science, sem restrições de idioma ou data, foram conduzidas. Dois revisores independentes selecionaram estudos, e a extração de dados foi realizada usando tabelas padronizadas. Bayesian NMA, MetaInsight web app e Cochrane Foundation Risk of Bias Assessment Tool foram aplicados para análise de dados e avaliação de viés.
Resultados
Após um rigoroso processo de seleção, 17 Ensaios Clínicos Randomizados (ECRs) abrangendo 2.122 pacientes e 14 intervenções foram incluídos. Os tratamentos mais bem classificados identificados foram dexmedetomidina intraoperatória (1 μg.kg-1 por 10 minutos como bolus, seguido por 0,4 μg.kg-1.h-1), bloqueio bilateral dos nervos nasociliar e maxilar, cetamina (0,5 mg.kg-1 administrado 20 minutos antes do final da cirurgia), compressão nasal por 40 minutos antes da indução da anestesia e sucção acima do balonete do tubo endotraqueal.
Conclusão
Tanto as intervenções farmacológicas quanto as não farmacológicas surgiram como estratégias eficazes para mitigar a agitação ao despertar após cirurgias nasais, oferecendo aos médicos opções valiosas para melhorar os resultados pós-operatórios nessa população de pacientes.
Palavras-chave
References
1. 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.
2. Hshieh TT, Fong TG, Marcantonio ER, Inouye SK. Cholinergic Deficiency Hypothesis in Delirium: A Synthesis of Current Evidence. J Gerontol Ser A. 2008;63:764−72.
3. The Cholinergic System and Inflammation: Common Pathways in Delirium Pathophysiology - Cerejeira - 2012 - Journal of the American Geriatrics Society - Wiley Online Library [Internet]. [cited 2023 Dec 31]. Available from: https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2011.03883.x.
4. Flukiger J, Hollinger A, Speich B, Meier V, Tontsch J, Zehnder T, € et al. Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis. Ann Intensive Care. 2018;8:92.
5. Jacob Y, Schneider B, Spies C, et al. 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 Mar 9;13 (1):3971.
6. Abitagaoglu S, Koksal C, Alag € oz S, Karip C € S, Ar ¸ { DE. Effect of ketamine on emergence agitation following septoplasty: a randomized clinical trial. Braz J Anesthesiol. 2021;71:381−6.
7. Demir CY, Yuzkat N. Prevention of Emergence Agitation with Ketamine in Rhinoplasty. Aesthetic Plast Surg. 2018;42:847−53.
8. Zhang X, Qi S, Lin Z, et al. 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.
9. Parthasarathy S, Krishnapriyanka KJ, Saravanan B. Effectiveness of pre-emptive nerve block on opioid consumption in patients undergoing nasal surgery under general anaesthesia: A doubleblinded randomised controlled study. Indian J Anaesth. 2022; 66:133−9.
10. Kacar CK, Uzundere O, Sal ¸ {k F, Akgund € uz M, B € {cak EA, Yekta ¸ s A. ¸ Effects of Adding a Combined Infraorbital and Infratrochlear Nerve Block to General Anaesthesia in Septorhinoplasty. J Pain Res. 2020;13:2599−607.
11. Choi H, Jung SH, Hong JM, Joo YH, Kim Y, Hong SH. Effects of Bilateral Infraorbital and Infratrochlear Nerve Block on Emergence Agitation after Septorhinoplasty: A Randomized Controlled Trial. J Clin Med. 2019;8:769.
12. Yuzkat N, Demir CY. 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;15:571−7.
13. Xu H, Shen Z, Gu Y, et al. Nasal splinting and mouth breathing training reduce emergence delirium after endoscopic sinus surgery: a randomized controlled trial. BMC Anesthesiol. 2023; 23:302.
14. Kumari A, Agrawal A. Effect of Preoperative Preconditioning of Patients with External Nasal Compression for Different Time Intervals on Emergence Agitation After Nasal Surgeries: A Randomised Controlled Trial. J Clin Diagn Res [Internet]. 2023. [cited 2024 Jun 15]; Available from https://www.jcdr.net//article_- fulltext.asp?issn=0973-709x&year=2023&volume=17&issue=8&- page=UC57&issn=0973-709x&id=18371.
15. Watt J, Del Giovane C. Network Meta-Analysis. In: Evangelou E, Veroniki AA, editors. Meta-Research: Methods and Protocols [Internet]. New York, NY: Springer US; 2022 [cited 2024 Jan 1]. p. 187−201. (Methods in Molecular Biology). Available from: https://doi.org/10.1007/978-1-0716-1566-9_12.
16. Cochrane Handbook for Systematic Reviews of Interventions [Internet]. [cited 2023 Aug 29]. Available from: https://training.cochrane.org/handbook/current.
17. Hutton B, Salanti G, Caldwell DM, et al. The PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions: Checklist and Explanations. Ann Intern Med. 2015;162:777−84. 18. RoB 2: a revised tool for assessing risk of bias in randomised trials | The BMJ [Internet]. [cited 2023 Aug 29]. Available from: https://www.bmj.com/content/366/bmj.l4898.
19. Nevill CR, Cooper NJ, Sutton AJ. A multifaceted graphical display, including treatment ranking, was developed to aid interpretation of network meta-analysis. J Clin Epidemiol. 2023;157:83−91.
20. Owen RK, 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;10:569−81.
21. Balduzzi S, Rucker G, Nikolakopoulou A, Papakonstantinou T, € Salanti G, Efthimiou O, et al. netmeta: An R Package for Network Meta-Analysis Using Frequentist Methods. J Stat Softw. 2023;106:1−40.
22. gemtc: Network Meta-Analysis Using Bayesian Methods version 1.0-2 from CRAN [Internet]. [cited 2024 Jan 1]. Available from: https://rdrr.io/cran/gemtc/.
23. Beliveau A, Boyne DJ, 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;19:196.
24. rjags-package: Bayesian graphical models using MCMC in rjags: Bayesian Graphical Models using MCMC [Internet]. [cited 2024 Jan 1]. Available from: https://rdrr.io/cran/rjags/man/rjagspackage.html.
25. Plummer M, Best N, Cowles K, Vines K. CODA: convergence diagnosis and output analysis for MCMC. R News. 2006;6:7−11.
26. Brooks SP, Gelman A. General Methods for Monitoring Convergence of Iterative Simulations. J Comput Graph Stat. 1998; 7:434−55.
27. 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 J Clin Otorhinolaryngol Head Neck Surg. 2015;29:1881−5.
28. 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. 2023;35:177−86.
29. Deepak BK, Kulkarni M, Sumanth MM, Kulkarni MM. Effect of intraoperative infusion of dexmedetomidine on emergence agitation among adults undergoing nasal surgeries-a prospective randomised double-blind study. Middle East J Anesthesiol. 2018;25:95−101.
30. Garg A, Kamal M, Mohammed S, Singariya G, Chouhan DS, 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;62:524−30.
31. 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; 111:222−8.
32. RK N. Dexmedetomidine Infusion for Prevention of Emergence Agitation after Nasal Surgery. J Evol Med Dent Sci. 2020;9:844 −50.
33. Jalja R, Lopa H, Sameer H. Role of dexmedetomidine infusion on post operative emergence agitation and quality of recovery after nasal surgery: A prospective randomized double blind controlled trial. Indian J Clin Anaesth. 2020;7:533−7.
34. Abbas Naqvi SA, Ahmad MS, Khan Z. Prevention of emergence agitation with dexmedetomidine in the patients undergoing nasal surgery under anesthesia with Desflurane. Med Forum Mon. 2021;32:24−8.
35. Paudel B, Gautam S, Bhandari D, Paudel S. To Evaluate the Effect of Intraoperative Dexmedetomidine on Emergence Agitation in Patient Undergoing Nasal and Pharyngeal Surgery. SSR Inst Int J Life Sci. 2024;10:3682−8.
36. Xu K, Pan Y, Zhu M. Effects of dexmedetomidine on the recovery profiles from general anesthesia in patients undergoing endoscopic sinus surgery. Int J Clin Exp Med. 2016;9:8405−10.
37. Lee SJ, Sung TY. Emergence agitation: current knowledge and unresolved questions. Korean J Anesthesiol. 2020;73 (6):471−85.
38. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166:1338 −44.
39. Ely EW, Truman B, Shintani A, et al. Monitoring Sedation Status Over Time in ICU Patients: Reliability and Validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289:2983.
40. Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999;27:1325−9.
41. 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;27:853−8.
42. Khan BA, Guzman O, Campbell NL, et al. 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;142:48−54.
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