Insufficient emergence is a common issue in elderly surgical patients following general anesthesia in the post anesthesia care unit (PACU). To determine inadequate emergence a variety of agitation-sedation scales are available, including the New Sheffield sedation scale, the Richmond sedation agitation scale, the motor activity evaluation scale, and the Riker agitation-sedation scale and evidence shows that both Richmond and Riker measures has good inter-rater reliability (17–19).
Few researchers have evaluated the prevalence of inadequate emergence, which ranges from 3 to 6%, in older adults (5, 16, 20–23). There hasn't been any research done on the frequency of hypoactive emergence in the same patient population, however, it occurs 3.2% of the time in adult surgical patients (5, 23), It is less than what we discovered. This discrepancy may be explained by the fact that the current study involved elderly patients who had undergone thoracoabdominal operations. In the current study inadequate emergence was shown in 9.60% (emergence delirium 5.70%( 3.6–8.2) and hypoactive emergence 3.90%( 2.1–5.9) of elderly patients. Compared to earlier reports, the current study's prevalence of emergence delirium was lower than previously published articles (5, 6, 10, 15, 16). The difference could be explained by the fact that most previous studies included patients of all ages having surgery of any kind, and those studies may have overlooked hypoactive emergence, which exaggerated the incidence (5, 6, 10, 16). Furthermore, the existing literature uses a variety of periods and inadequate emergence evaluation techniques to gather data (5, 6, 24). To be noted, emergence delirium often occurs early after anesthesia. According to our findings, the incidence of postoperative emergence fell comfortably within the predicted comparable range (5, 6, 11, 25).
Only a few studies have assessed the frequency of inadequate emergence (5, 6) The described incidences varied between 8.2% and 15% values which is comparable to our finding(9.6%).
Thus far, only a few studies have assessed the incidence of emergence delirium in an adult population(5, 6, 11). The described incidences varied between 3–6%. This is comparable to our finding of emergence delirium with an occurrence of 5%. To date, there are no studies that also investigated the incidence of hypoactive emergence in the same patient population.
Although there are written guidelines produced by anesthesiologists’ associations(26) regarding preoperative fasting, they are still scarcely respected. Fasting times remain unduly long(27). Patient stress caused by long preoperative fasting times may be regarded as a precipitating factor leading to the emergence of delirium and postoperative delirium. We think that fasting was the cause of the higher frequency of emergence delirium in our study.
In line with other research, pain was found to be a possible risk factor for the development of delirium (5, 6, 11). We propose to implement a more proactive approach to pain management in order to decrease the use of insufficient analgesic regimens and decrease the occurrence of postoperative emerging delirium.
Final thoughts: inadequate emergence following thoracoabdominal procedure is a frequent consequence. Avoidable factors that contribute to the emergence of delirium include anxiety, past smoking history, substance abuse, preoperative anemia, surgical history, hypertension, metochloropromide, and thiopentone were found to be independently linked to a higher risk of emergence of delirium. This finding is supported with previously published articles (11, 20, 24, 28).
Patients with hypoactive emergence had a significantly lower temperature on PACU admission and received a greater quantity of crystalloids during surgery (5, 6).
In our study, hypoactive emergence occurred more frequently in ASAIII, Exercise tolerance test (MET < 4), anesthesia maintenance with halothane, and patients with hypothermia on PACU admission, were independently associated were factors for elective geriatric thoracoabdominal surgeries under GA but preoperative fluid fasting(> 6hr), pethidine, Estimated blood loss(> 500ml), surgical duration > 2hrs, and PONV requiring antiemetic’s, were high risk for both inadequate emergence delirium and hypoactive emergence. Whereas male sex and ketofol administration were associated with a lower risk of inadequate emergence as shown in Table 3.
Factors without influence
In the current study Ketamine, Propofol, Diabetes mellitus, Exercise tolerance test (MET < 4), Alcoholism, BMI (> 30 kg/m2), ASA III(vs II ), education, Halothane Isoflorane, Pethidine with Diclofenac, Morphine, PACU hypotension Blood transfusion, Hypothermia on PACU admission, Presence of catheter did not have any influence on the development of inadequate emergence(5, 6, 15, 19, 25, 29).
Among the study's merits include a fairly representative sample size, a particular study population, and surgical procedures. Since the independent variables are identified it helps to lessen the likelihood of inaccurate emergence, it is essential to precisely identify high-risk patients
Limitation of the study: first since this study is cross-sectional, we are unable to establish a causal relationship between inadequate emergences. Second, as our study was limited to one center, there may be limitations to the generalizability of our findings. Thirdly, Whether inadequate emergence is associated with worse long-term outcomes is still up for debate and requires further investigation.