Prevention of Emergence Agitation with Ketamine in Rhinoplasty

Overview

Emergence agitation is restlessness, disorientation or distress while waking from general anesthesia. After nose surgery it risks disturbing the operative result. This prospective randomized study measured how often it happens after rhinoplasty in adults, whether a sub-anesthetic dose of ketamine prevents it, and which patients are at risk.

Sections of note

• 140 patients scheduled for elective rhinoplasty, randomly divided into two equal groups of 70.
• Twenty minutes before the end of surgery, the control group received 1 ml saline intravenously and the treatment group 0.5 mg per kg ketamine intravenously.
• Agitation was scored with the Richmond Agitation-Sedation Scale immediately after extubation and in the recovery unit.
• Pain was scored on a 0 to 10 Numerical Rating Scale every 10 minutes until discharge from recovery.
• Agitation just after extubation: 54.3 percent in the control group versus 8.6 percent in the ketamine group, p below 0.001.
• Agitation in the recovery unit: 28.6 percent in the control group versus none in the ketamine group, p below 0.001.
• Male sex, severe pain scoring 5 or more, and smoking were significant risk factors at both time points, p below 0.001. Level of evidence IV.

What it means for a patient

• More than half of the untreated patients here were agitated on waking, which is higher than many people expect.
• A single low dose of ketamine near the end of surgery eliminated agitation in the recovery unit in this trial.
• Men, smokers, and patients with severe pain were at higher risk.
• Limits: one center, follow-up only through the recovery unit, and the abstract reports no side effect rates for ketamine such as hallucination or nausea.

Why this paper matters

Agitation on waking risks bleeding and displacement of the freshly operated nose, and is rarely quantified for this operation. A randomized comparison with clear group sizes is stronger evidence than most rhinoplasty literature. The authors call for larger studies to identify further preventive measures.

Terms

• Emergence agitation: Restlessness, disorientation or distress while waking from general anesthesia.
• Ketamine: An anesthetic drug that also has pain-relieving effects at low doses.
• Sub-anesthetic dose: A dose lower than that needed to produce anesthesia.
• Extubation: Removal of the breathing tube at the end of anesthesia.
• Richmond Agitation-Sedation Scale: A standard scale scoring how agitated or sedated a patient is.