Influencing factors and risk prediction model for emergence agitation after general anesthesia for primary liver cancer

INTRODUCTION

General anesthesia involves the administration of narcotic drugs to temporarily suppress the central nervous system, leading to reversible loss of consciousness, sensation, and reflexes[1]. Emergence agitation (EA) refers to a transient state of consciousness and behavior separation during the transition from anesthesia to full consciousness. It is a common postoperative complication in patients undergoing general anesthesia[2], with an incidence of 17.09%-24.80%[3]. The symptoms of EA mainly manifest as emotional agitation, restlessness, and disorientation[4]. Prolonged agitation may result in hazardous behaviors, such as self-removal of masks and catheters, resulting in hypoxia, falls, bleeding from surgical incisions, and limb injuries, which compromises surgical outcomes and patient safety. Primary liver cancer ranks fifth globally and third in Asia-Pacific cancer-related deaths[5], with surgery being the foremost treatment option[6]. Hepatocellular carcinoma resection, characterized by prolonged operation time, extensive drug use, and large wound area, predisposes patients to higher EA risk. Thus, early identification of EA risk factors in patients with primary liver cancer after surgery is crucial for timely intervention. Currently, clinical factors influencing EA remain unclear and may be related to factors such as catheter irritation, pain, or drugs[7]. In view of this, our study aimed to analyze factors influencing the occurrence of EA in patients with primary liver cancer after surgery and construct a risk prediction model to aid the prevention of EA in this population.

MATERIALS AND METHODS

RESULTS

DISCUSSION

Patients undergoing general anesthesia pass through three stages: Light anesthesia, non-anesthesia, and awakening during the recovery of normal physiological functions after surgery. During this process, protective physiological reflexes gradually return. However, some abnormal changes may occur, with the most significant neurological manifestation being EA[11]. Patients with EA often exhibit ambiguous consciousness, drowsiness, failure to follow instructions, involuntary movements, extreme disorientation, restlessness, and other agitations. If left untreated, EA can lead to complications such as increased internal bleeding, cerebrovascular disease, myocardial infarction, endangerment of suture lines, and in severe cases, surgical failure, pipeline dislodgement, falls, and other accidental injuries[12]. These consequences not only pose a serious threat to medical safety but also endanger patients’ lives and health, leading to potential disputes between doctors and patients. Currently, the clinical factors contributing to EA are not fully understood. General anesthetic drugs are believed to exert varying degrees of inhibition on the central nervous system, leading to the emergence of reflex confrontation and an abnormal state of consciousness[13,14]. The results of this study indicate a postoperative EA incidence of 25.5%. A study by Kang et al[15] reported a postoperative EA incidence of 14.1% among 1950 adult patients operated under general anesthesia, while Abitağaoğlu et al[16] observed a 15.4% incidence among 102 postoperative patients. The relatively high incidence observed in our study suggests that EA remains a significant concern in postoperative patients recovering from general anesthesia. Discrepancies with other studies may stem from differences in population inclusion criteria, age demographics, and geographical variations. This study identified potential influencing factors, revealing postoperative analgesia as a protective factor against EA, while old age, indurating catheter use, ASA grade III, and postoperative pain emerged as risk factors. The incidence of EA increased with age, possibly due to abnormal melatonin secretion. Melatonin, an amine hormone secreted by the pineal glands of both mammals and humans, decreases with age, leading to dysfunctions that hinder postoperative recovery and increase EA incidence[17]. Some scholars also believe[18] that older people may have poorer physical fitness and lower pain tolerance than younger people. Similarly, due to reduced physical function, these patient populations often lack confidence in treatment and are prone to anxiety, thereby contributing to an increased occurrence of EA. Indwelling catheter use was associated with an elevated EA risk, potentially due to unconscious urethral mucosal injury during surgery and subsequent pain and discomfort during recovery[19]. The ASA grade is also a risk factor for EA. Patients with higher ASA grades are more susceptible to fluctuations in respiration, circulation, and the internal environment during anesthesia and surgery[20]. In addition, patients with higher ASA grades often require larger doses of anesthesia, which can lead to excessive anesthetic drug levels in the body. This can inhibit the cardiovascular system, resulting in an increased risk of EA for various reasons[21]. The incidence of EA notably rises in patients experiencing intense postoperative pain. This is primarily because pain, discomfort, and other stimuli can trigger defensive reflexes, resulting in an increased incidence of EA[22-24]. Healthcare professionals can alleviate patients’ fear of pain through psychological support, effective communication, and other methods. Additionally, they can provide personalized analgesic intervention based on patients’ individual conditions. The results of this study showed that postoperative analgesia serves as a protective factor against EA. A study by Yang et al[25] further supports this, indicating that postoperative analgesia significantly reduces the incidence of postoperative EA among patients undergoing general anesthesia. This underscores the importance of postoperative analgesia as a protective measure against EA occurrence. The study has some limitations worth noting. Firstly, its focus solely on patients undergoing general anesthesia may overlook factors relevant to other anesthesia types. Secondly, as a retrospective analysis conducted in a single center, the findings may not be fully generalizable to broader patient populations. Additionally, although the sample size was adequate, larger multicenter studies could offer more robust insights. The complexity of risk factors and reliance on retrospective data pose further limitations, alongside the study’s primary reliance on EA as the outcome measure, potentially neglecting other clinical endpoints. Furthermore, limited follow-up post-discharge restricts understanding of long-term complications. Addressing these limitations in future research could advance our understanding and improve preventive strategies for EA.

CONCLUSION

In conclusion, age, indwelling catheter use, ASA grade, and postoperative pain significantly affect the occurrence of EA. Therefore, clinical attention should be directed towards these factors, and appropriate prevention and control measures should be implemented. In addition, postoperative analgesia serves as a protective factor against EA. Hence, tailored analgesia programs can be offered based on the individual clinical circumstances of the patients. Future studies should explore the comprehensive understanding of EA in patients undergoing general anesthesia, focusing on refining preventive strategies and improving patient outcomes. Investigations into additional influencing factors, long-term complications, and the efficacy of personalized analgesic interventions could further enhance EA management and patient care.

Data sharing statement

Anonymous datasets can be obtained from the corresponding author upon request.