Anesthesia Emergence: Managing Patient Discomfort
Managing a patient’s emergence from anesthesia requires being mindful of several complications that can disturb the patient’s experience. Ideally, anesthesia emergence should be a speedy and smooth process, with minimal disturbance [1]. Thanks to the advent of improved anesthetic agents, monitoring devices, and reversal antidotes, fluid emergence has become more possible in recent years [1]. However, medical professionals still face a number of difficulties, so knowledge of how best to monitor, support, and medicate patients is necessary for optimizing emergence.
Several proactive, meaningful changes that improve the emergence process can be readily introduced into treatment. Before the patient receives anesthesia, several conditions–such as obesity, diabetes mellitus, use of beta-blockers, history of drug abuse, treatment of chronic pain with opioids, or an American Society of Anesthesiologists status greater than III–should be noted [2]. Many of these conditions can result in anesthesia awareness with recall (AAWR), where patients regain awareness intraoperatively [2]. To mitigate sensory impairment and subsequent confusion upon emergence, patients who use hearing aids and glasses should be given easy access to them [3]. Lastly, speaking with the patient upon their awakening and not extubating until they reach full consciousness have also proven successful at preventing AAWR [2]. These approaches are versatile, and thus can be used to maximize patient comfort without requiring much additional expenditure on the part of medical staff.
Improving monitoring practices can also be a means of making anesthesia emergence easier for patients. Regular, attentive monitoring by nursing staff, with acute regard to a patient’s pre-existing conditions, is important in preventing disturbances such as emergence delirium [3]. Incorporating the use of electroencephalography-based monitors has also been shown to promote faster emergence for patients after surgery [1]. These monitors include the Patient State Index, Spectral EntropyTM, and bispectral index monitoring (BISTM) [1]. Medical teams can also monitor patients’ hemodynamics and ECG, even in patients without risk factors following minimal-risk surgeries, to prevent sudden myocardial infarction [4]. Although monitoring can be somewhat time-intensive, it is a significant way of ensuring that a patient recovers as best as possible.
Additionally, research has identified a set of treatment adjustments that may prevent compromised emergences from anesthesia. The three principal anesthetic inhalation agents (sevoflurane, desflurane, and isoflurane) should be used at low flow rates, whenever possible, to decrease emergence time and speed up recovery [5]. Among these agents, desflurane generally contributes to faster emergence and recovery because of its lower blood-gas solubility, but it can also produce respiratory depression and increase heart rate, depending on the dose received [5]. If using sevoflurane or isoflurane, xenon can quicken emergence time; however, its cost is a deterrent to routine use at the moment [1]. Methylphenidate has also proven effective at hastening emergence from isoflurane by reversing postoperative respiratory depression and unconsciousness [6].
Certain drugs and treatments have been shown to increase emergence time; avoiding them when possible may improve patient experience. Deliriogenic drugs, including benzodiazepines, can be substituted with α2 adrenergic agonists to reduce the chance of post-operative neurological dysfunction [3]. Even though pain can bring about postoperative delirium and other forms of emergence discomfort, excessive administrations of opioids can also contribute to discomfort [3]. Consequently, medical professionals are advised to provide patients with opioids judiciously [3]. Reception of GABAergic sedatives like propofol should also be limited [3]. Physicians are advised to continuously consider individual patients’ needs and not administer more than is required.
Evidently, there are numerous strategies that medical professionals should balance in order to ease their patients out of anesthesia and into a healthy, optimal recovery process.
References
[1] S. B. Bhaskar, “Emergence from anaesthesia: Have we got it all smoothened out?,” Indian Journal of Anaesthesia, vol. 57, no. 1, p. 1-3, Jan-Feb 2013. [Online]. Available: https://doi.org/10.2146/ajhp100092. [Accessed October 11, 2020].
[2] M. Cascella, S. Bimonte, N. J. Amruthraj, “Awareness during emergence during anesthesia: Features and future research directions,” World Journal of Clinical Cases, vol. 8, no. 2, January 2020, p. 245-254. [Online]. Available: https://doi.org/10.12998/wjcc.v8.i2.245. [Accessed October 11, 2020].
[3] R. D. Sanders et al., “Anticipating and managing postoperative delirium and cognitive decline in adults,” British Medical Journal, vol. 343, no. 7816, p. 197-200, July 2011. [Online]. Available: https://doi.org/10.4103/0019-5049.108549. [Accessed October 11, 2020].
[4] T. N. Dang et al., “Acute myocardial infarction in patient without cardiac risk factors during emergence from general anesthesia: a case report,” JA Clinical Reports, vol. 6, no. 48, June 2020. [Online]. Available: https://doi.org/10.4103/0019-5049.108549. [Accessed October 11, 2020].
[5] T. Meyer, “Managed inhaled anesthesia: Challenges from a health-system pharmacist’s perspective,” American Journal of Health-System Pharmacy, vol. 67, no. 8, p. S4-S8, Apr 2010. [Online]. Available: https://doi.org/10.4103/0019-5049.108549. [Accessed October 11, 2020].
[6] K. Solt et al., “Methylphenidate Actively Induces Emergence from General Anesthesia,” Anesthesiology, vol. 115, October 2011, p. 791-803. [Online]. Available: https://doi.org/10.1097/ALN.0b013e31822e92e5. [Accessed October 11, 2020].