IJNHCR Journal

Figure 2: The greatest risk for postoperative.

Discussion

At present, the influencing factors of EA are not yet clear in clinical practice. It is generally believed that the central nervous system is inhibited to varying degrees by general anesthetic drugs, leading to reflexive resistance and abnormal consciousness [4, 6]. Among the 1998 cases included in this study, the incidence of this complication was 6.5%. The results of this study showed that a history of smoking and drinking, intubation duration>4 hours, postoperative indwelling drainage tube, urological surgery type, postoperative hypothermia, postoperative pain, and age of 60-74 years were risk factors for agitation during the recovery period after general anesthesia.

Analysis of Risk Factors for Agitation during the Recovery Period after General Anesthesia

A history of smoking and drinking is a risk factor for agitation during the postoperative recovery period. This may be related to the reduced function of the respiratory system, the impact on the circulatory system, and the decreased metabolic function. Smoking can affect the function of the respiratory tract, leading to coughing and increasing the likelihood of postoperative agitation [7]. The combustion of tobacco produces CO, and the nicotine stimulates the sympathetic and parasympathetic nerve ganglia, causing a series of physiological reactions that increase the probability of postoperative agitation [8]. Alcohol is metabolized by the liver, and alcohol dependence can reduce the patient’s liver metabolic function [9]. In this study, postoperative hypothermia was identified as a risk factor for postoperative agitation. This may be related to the slowed metabolism of anesthetic drugs and the disorder of body temperature regulation. A decrease in body temperature during surgery can affect the liver’s metabolic function of anesthetic drugs [10], leading to incomplete metabolism of anesthetic drugs within the corresponding time, increasing the risk of EA. The long-term exposure of the surgical site can affect the body’s temperature regulation function, leading to a decline in various bodily functions and increasing the risk of EA.

Intubation duration>4 hours is a risk factor for the occurrence of EA. The results showed that when the intubation time>4 hours, the OR value steadily increased, indicating that the longer the intubation time, the higher the incidence of EA. Tracheal intubation for more than 2 hours can cause edema of the tracheal mucosa, and local damage can cause discomfort, thereby increasing the risk of postoperative agitation [11].An increase in intubation time also leads to an increase in the dosage of anesthetic drugs used, thereby inhibiting the patient’s various bodily functions to varying degrees and reducing the patient’s metabolic function [12]. Urological surgery is a significant influencing factor, which may be related to hyponatremia and bladder irritation. The use of non-electrolyte fluids for irrigation during urological surgery can easily lead to hyponatremia, increasing the risk of postoperative agitation [13]. Most minimally invasive urological surgeries are performed through the urethra. When surgical instruments or urinary catheters enter the bladder through the urethra, they promote the release of inflammatory mediators, thereby causing or exacerbating bladder irritation. When patients wake up, the discomfort can cause agitation [14].

Postoperative indwelling drainage tube is also a significant risk factor for the occurrence of EA. Surgeries with postoperative indwelling drainage tubes cause greater surgical trauma. Moreover, patients are unconscious during this process. In the early stages of anesthesia recovery, patients’ reactions to sensations are in a hyper-sensitive state, and any uncomfortable stimulation can cause their agitated behaviour [15]. In addition, postoperative pain is also a significant risk factor for causing postoperative agitation, as postoperative pain can cause patients to have a reflexive resistance phenomenon, stimulating the patient’s central nervous system and causing symptoms such as moaning and agitation [16].

This study showed that age between 60-74 years was a nearly significant influencing factor (P = 0.054). Clinical experience has found that age is of great significance for postoperative agitation. The reasons are considered to be related to abnormal secretion of melatonin and the decline of various bodily system functions [17]. The older the age, the worse the physical condition, and the functions of the circulatory and respiratory systems also decline accordingly. Moreover, the pain tolerance is relatively lower than that of the younger group [18], At the same time, due to the decline of physical functions, patients are more likely to become anxious. [19], thereby increasing the occurrence of postoperative agitation. In the results of this study, patients aged 60 - 74 years were a risk factor for postoperative agitation, but the results for those aged ≥ 75 years were not significant. The reason may be that the sample size of this age group is relatively small, significantly lower than other groups, or it may be due to the stricter surgical and anesthetic management for the elderly. Some studies have shown that male patients, postoperative indwelling urinary catheters, ASA classification>II, and abdominal surgery are risk factors for postoperative EA [20], in this study; the above factors were not obvious. This may be due to the differences in the main surgical patients and surgical types conducted in different hospitals, or it may be that effective preventive measures were adopted for the above factors in this study, reducing the possibility of them becoming risk factors.

Measures to Prevent Agitation during the Recovery Period after General Anesthesia

Healthcare professionals should place emphasis on assessing patients’ age, history of smoking and alcohol use, postoperative body temperature, intubation duration, patients undergoing urological surgery, and postoperative pain. For elderly patients, it is essential to enhance intraoperative management and closely monitor various indicators. Preoperatively, pain threshold assessments can be conducted for patients, and for those with a low threshold, appropriate doses of analgesic drugs can be administered prophylactically. For patients with alcohol dependence, anesthetic drugs should be used judiciously, and drugs that are metabolized by the kidneys can be selected to alleviate the metabolic burden on the liver [9]. Patients with a history of smoking should be encouraged to quit smoking prior to surgery. For patients undergoing urological surgery, local anesthesia such as lidocaine ointment can be applied for surface anesthesia of the urethral orifice to reduce the likelihood of bladder irritation postoperatively [8], Preoperative communication and explanation should be thorough to prevent stress reactions during postoperative awakening. For patients with prolonged intubation, the surgical workflow can be optimized to minimize surgery time. The body temperature of patients should be closely monitored, and if a large volume of fluid needs to be infused during surgery, a fluid warmer should be used. After entering the recovery room, a warm air blower can be used for warming based on the patient’s body temperature, which can effectively enhance the metabolism of anesthetic drugs [21]. Stimulations to patients, such as suctioning and other irritating procedures, should be minimized.

Limitation

This study is a single-center investigation that only assessed factors related to the patient’s own condition, as well as intraoperative and postoperative factors that may influence postoperative agitation. However, preoperative factors that could potentially lead to postoperative agitation remain unknown. Future research could explore preoperative factors, patient psychological factors, intraoperative drug factors, and the qualifications of nursing staff. Additionally, while numerous factors contribute to postoperative agitation in patients under general anesthesia, the interrelationships between these factors warrant further investigation.

Conclusion

The occurrence of postoperative agitation in patients under general anesthesia is influenced by multiple factors, with age 60-74 years, history of smoking and drinking, intubation duration>4 hours, postoperative indwelling drainage tube, urological surgery type, postoperative hypothermia, and postoperative pain being the main risk factors. This suggests that nursing staff can strengthen the assessment of the above factors when receiving patients in the anesthesia recovery room, and predictively judge whether patients are at risk of EA; closely monitor patients’ postoperative vital signs, and provide effective nursing care, thereby reducing the incidence of postoperative agitation, improving the quality of awakening, and improving patient prognosis.

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