Bi-frontal pneumocephalus is an independent risk factor for early postoperative agitation in adult patients admitted to intensive care unit after elective craniotomy for brain tumor: A prospective cohort study

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).

Risk factors for emergence agitation in adults after general anesthesia: A systematic review and meta‐analysis

“…The basic characteristics of studies were summarized in Table 1. Six studies 5,8,9,13,18,20 used Ricker sedation agitation scale, six 1,2,4,7,16,21 used Richmond agitation sedation scale (RASS), three 14,15,19 used nursing delirium screening scale (Nu‐DESC), one 17 used confusion assessment method for the intensive care unit, one 22 used a three‐point scale, and one 10 used RASS or administration of haloperidol to screen EA. Fifteen studies 1,2,4,5,7‐10,13‐18,22 reported adjusted data.…”

“…Quality evaluated by QUIPS tool (Table 2) showed 10 studies 1,2,4,5,13‐17,22 had low risk of bias of all domains, five studies 7‐9,18,21 had high risk of bias of study participation, three studies 19‐21 had high risk of adjustment for other prognostic factors and statistical analysis and reporting, and one study 10 had high risk of bias of outcome measurement and unclear risk of bias of statistical analysis and reporting. Thus, those 10 studies 1,2,4,5,13‐17,22 with low risk of bias of all domains were regarded as of high quality.…”

Feasibility of low-dose dexmedetomidine for prevention of postoperative delirium after intracranial operations: a pilot randomized controlled trial

“…During the study, pain, agitation and delirium were managed according to the recommendations in guidelines proposed by the European Society of Anaesthesiology and the American Society of Critical Care Medicine [ 3 , 17 ], which have been employed as routine clinical strategies in our ICU [ 13 , 18 , 19 ].…”

“…Postoperative analgesia was routinely administered along with patient-controlled intravenous analgesia (PCIA), which was comprised of sufentanil 100 mg and tropisetron 10 mg in 100 ml of 0.9% NaCl solution. A basal PCIA infusion (2 ml/hour) was started after confirmation of the patient’s cardiorespiratory stability and the recovery of consciousness [ 13 , 18 , 19 ]. Pain assessment was performed every 6 h or as needed using the numeric rating scale (NRS) or the Critical-Care Pain Observation Tool [ 20 ].…”

Use of the Bispectral Index to Predict Recovery of Consciousness in Patients with Spontaneous Intracerebral Hemorrhage After Surgical Hematoma Evacuation: A Prospective Cohort Study

“…Fresh frozen plasma and vitamin K were administered to those patients taking warfarin and to those whose INR was above 1.4. Continuous intravenous infusion of propofol and fentanyl was used to treat agitation [12]. We conducted a conventional glucose control scheme in our ICU.…”