Abstract
Postoperative agitation frequently occurs after general anesthesia and may be associated with serious consequences. However, studies in neurosurgical patients have been inadequate. We aimed to investigate the incidence and risk factors for early postoperative agitation in patients after craniotomy, specifically focusing on the association between postoperative pneumocephalus and agitation. Adult intensive care unit admitted patients after elective craniotomy under general anesthesia were consecutively enrolled. Patients were assessed using the Sedation-Agitation Scale during the first 24 hours after operation. The patients were divided into two groups based on their maximal Sedation-Agitation Scale: the agitation (Sedation-Agitation Scale ≥ 5) and non-agitation groups (Sedation-Agitation Scale ≤ 4). Preoperative baseline data, intraoperative and intensive care unit admission data were recorded and analyzed. Each patient’s computed tomography scan obtained within six hours after operation was retrospectively reviewed. Modified Rankin Scale and hospital length of stay after the surgery were also collected. Of the 400 enrolled patients, agitation occurred in 13.0% (95% confidential interval: 9.7–16.3%). Body mass index, total intravenous anesthesia, intraoperative fluid intake, intraoperative bleeding and transfusion, consciousness after operation, endotracheal intubation kept at intensive care unit admission and mechanical ventilation, hyperglycemia without a history of diabetes, self-reported pain and postoperative bi-frontal pneumocephalus were used to build a multivariable model. Bi-frontal pneumocephalus and delayed extubation after the operation were identified as independent risk factors for postoperative agitation. After adjustment for confounding, postoperative agitation was independently associated with worse neurologic outcome (odd ratio: 5.4, 95% confidential interval: 1.1–28.9, P = 0.048). Our results showed that early postoperative agitation was prevalent among post-craniotomy patients and was associated with adverse outcomes. Improvements in clinical strategies relevant to bi-frontal pneumocephalus should be considered.Trial registration: ClinicalTrials.gov (NCT02318199).
Highlights
Postoperative agitation after general anesthesia has been reported to occur in 3.7 to 29% of patients and may be associated with serious consequences, such as unplanned extubation, injuries and longer post-anesthesia care unit stay [1,2,3,4,5,6,7]
All patients were enrolled within six Agitation after craniotomy for brain tumor hours of intensive care unit (ICU) admission, with 258/400 (64.5%) patients enrolled just after admission, 131/400 (32.8%) patients enrolled between one and three hours after admission and 11/400 (2.7%) patients enrolled between four and six hours after admission
Our main findings were: 1) early postoperative agitation was prevalent in adult patients who had undergone elective craniotomy for brain tumors and was associated with adverse neurological outcomes; and 2) independent risk factors for agitation included bi-frontal pneumocephalus and delayed extubation, especially with the need for mechanical ventilation
Summary
Postoperative agitation after general anesthesia has been reported to occur in 3.7 to 29% of patients and may be associated with serious consequences, such as unplanned extubation, injuries and longer post-anesthesia care unit stay [1,2,3,4,5,6,7]. In our previous pilot study, which included 123 patients who underwent elective intracranial operations, we found the incidence of agitation within 12 hours postoperatively to be 29%, which was higher than that previously observed in other surgical populations [4]. Investigations of this phenomenon in neurosurgical populations have been inadequate [1, 3, 5,6,7]. Due to the preventable nature of pneumocephalus, further investigation is needed to clarify its relationship with agitation We conducted this prospective cohort study of adult patients who had undergone elective craniotomy for brain tumors. The association of agitation with long-term outcomes was analyzed
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