Introduction
Methods
Study design
Participants
Anesthesia and perioperative care
Data collection and postoperative follow-ups
Statistical analysis
Estimation of sample size
Data analysis
Results
Patient population
Occurrence of emergence delirium
Total (n = 915) | Emergence delirium (n = 339) | No emergence delirium (n = 576) | P value | |
---|---|---|---|---|
Age (year) | 71.6 ± 5.2 | 72.9 ± 5.7 | 70.9 ± 4.8 | <0.001 |
Male sex | 548 (59.9%) | 192 (56.6%) | 356 (61.8%) | 0.123 |
Body mass index (kg/m2) | 24.2 ± 3.5 | 24.0 ± 3.7 | 24.2 ± 3.3 | 0.473 |
Education (year) | 10.2 ± 4.6 | 9.4 ± 4.4 | 10.6 ± 4.7 | <0.001 |
Preoperative comorbidity | ||||
Strokea | 52 (5.7%) | 16 (4.7%) | 36 (6.3%) | 0.336 |
Hypertension | 475 (51.9%) | 173 (51%) | 302 (52.4%) | 0.683 |
Coronary heart disease | 129 (14.1%) | 58 (17.1%) | 71 (12.3%) | 0.046 |
Arrhythmia | 57 (6.2%) | 24 (7.1%) | 33 (5.7%) | 0.415 |
Pulmonary diseaseb | 66 (7.2%) | 30 (8.8%) | 36 (6.3%) | 0.144 |
Diabetes | 219 (23.9%) | 84 (24.8%) | 135 (23.4%) | 0.646 |
Abnormal liver functionc | 45 (4.9%) | 19 (5.6%) | 26 (4.5%) | 0.462 |
Malignant tumor | 105 (11.5%) | 39 (11.5%) | 66 (11.5%) | 0.983 |
Chronic smokingd | 223 (24.4%) | 71 (20.9%) | 152 (26.4%) | 0.064 |
Alcoholisme | 144 (15.7%) | 45 (13.3%) | 99 (17.2%) | 0.116 |
Charlson Comorbidity Indexf | 2 (2, 3) | 2 (2, 3) | 2 (2, 3) | 0.580 |
History of surgery | 491 (53.7%) | 199 (58.7%) | 292 (50.7%) | 0.019 |
ASA classification | 0.018 | |||
Class II | 678 (74.0%) | 236 (69.6%) | 442 (76.7%) | |
Class III | 237 (26.0%) | 103 (31.4%) | 134 (23.3%) | |
Preoperative lab tests | ||||
Hematocrit (%) | 39.4 ± 5.3 | 38.5 ± 5.8 | 39.9 ± 4.9 | <0.001 |
Albumin (g/L) | 40.6 ± 4.7 | 39.9 ± 4.7 | 40.9 ± 4.7 | 0.002 |
Creatinine (μmol/L) | 80.2 ± 20.9 | 81.0 ± 21.9 | 79.7 ± 20.2 | 0.354 |
Glucose < 4.0 or > 10.0 mmol/L | 47 (5.1%) | 20 (5.9%) | 27 (4.7%) | 0.423 |
Na+<135.0 or > 145.0 mmol/L | 37 (4.0%) | 13 (3.8%) | 24 (4.2%) | 0.802 |
K+ < 3.5 or > 5.5 mmol/L | 117 (12.8%) | 48 (14.2%) | 69 (12%) | 0.346 |
Preoperative MMSE (score) | 26.3 ± 2.3 | 25.5 ± 2.5 | 26.7 ± 2.1 | <0.001 |
Duration of anesthesia (min) | 279 ± 77 | 285 ± 74 | 276 ± 79 | 0.075 |
Type of anesthesia | 0.616 | |||
General | 420 (45.9%) | 161 (47.5%) | 259 (45.0%) | |
Peripheral-general | 469 (51.3%) | 167 (49.3%) | 302 (52.4%) | |
Epidural-general | 26 (2.8%) | 11 (3.2%) | 15 (2.6%) | |
Intraoperative medication | ||||
Use of nitrous oxide | 553 (60.4%) | 212 (62.5%) | 341 (59.2%) | 0.319 |
Use of sevoflurane | 287 (31.4%) | 115 (33.9%) | 172 (29.9%) | 0.201 |
Use of dexmedetomidine | 430 (47.0%) | 164 (48.4%) | 266 (46.2%) | 0.520 |
Use of midazolam | 189 (20.7%) | 65 (19.2%) | 124 (21.5%) | 0.396 |
Use of etomidate | 699 (76.4%) | 273 (80.5%) | 426 (74.0%) | 0.024 |
Propofol (mg) | 840 (642, 1075) | 866 (678, 1132) | 824 (622, 1050) | 0.048 |
Remifentanil (μg) | 726 (0, 1260) | 700 (0, 1230) | 760 (0, 1299) | 0.819 |
Sufentanil (μg) | 40 (25, 69) | 40 (25, 70) | 40 (25, 68) | 0.391 |
Sufentanil equivalent (μg) | 110 (77, 160) | 110 (79, 156) | 110 (75, 165) | 0.853 |
Rocuronium (mg) | 42.1 ± 19.0 | 42.2 ± 17.8 | 42.0 ± 19.7 | 0.914 |
NSAIDsg | 726 (79.3%) | 272 (80.2%) | 454 (78.8%) | 0.609 |
Duration of surgery (min) | 203 ± 71 | 208 ± 67 | 199 ± 72 | 0.078 |
Type of surgery | 0.001 | |||
Thoraco-/laparoscopic | 549 (59.9%) | 179 (52.8%) | 369 (64.1%) | |
Non thoraco-/laparoscopic | 367 (40.1%) | 160 (47.2%) | 207 (35.9%) | |
Location of surgery | 0.063 | |||
Intra-thoracic | 198 (21.6%) | 61 (18.0%) | 137 (23.8%) | |
Intra-abdominal | 530 (57.9%) | 199 (58.7%) | 331 (57.5%) | |
Spinal/extremities/others | 187 (20.4%) | 79 (23.3%) | 108 (18.7%) | |
Estimated blood loss (ml) | 100 (10, 250) | 100 (10, 300) | 60 (10, 200) | 0.002 |
Lowest hemoglobin < 10 (g/dL) | 77 (8.4%) | 44 (13.0%) | 33 (5.7%) | <0.001 |
Total fluid infusion (ml) | 2200 (1600, 2850) | 2350 (1800, 3100) | 2100 (1600, 2600) | <0.001 |
Crystalloid (ml) | 1800 (1500, 2300) | 2000 (1600, 2500) | 1700 (1300, 2300) | <0.001 |
Artificial colloid | 530 (57.9%) | 217 (64.0%) | 313 (54.3%) | 0.004 |
Artificial colloid (ml) | 500 (0, 500) | 500 (0, 500) | 500 (0, 500) | <0.001 |
Autologous blood transfusion | 104 (11.4%) | 48 (13.2%) | 56 (9.7%) | 0.042 |
Allogeneic blood transfusion | 79 (8.6%) | 43 (12.7%) | 36 (6.3%) | 0.001 |
Urine output (ml) | 400 (250, 600) | 400 (250, 700) | 400 (250, 600) | 0.072 |
Emergence agitation | 99 (10.8%) | 73 (21.5%) | 26 (4.5%) | <0.001 |
Temperature in PACU (°C) | ||||
At PACU admission | 36.1 ± 0.4 | 36.0 ± 0.4 | 36.1 ± 0.4 | <0.001 |
Temperature < 36 °C | 301 (32.9%) | 154 (45.4%) | 147 (25.5%) | <0.001 |
NRS pain score in PACU | ||||
First pain score | 2.0 (2.0, 3.0) | 2.0 (2.0, 4.0) | 2.0 (1.0, 3.0) | 0.003 |
Average pain score | 2.0 (1.3, 3.0) | 2.3 (1.7, 3.7) | 2.0 (1.0, 3.0) | <0.001 |
Patient-controlled analgesia | 0.611 | |||
None | 42 (4.6%) | 13 (3.8%) | 29 (5.0%) | |
Intravenous | 847 (92.6%) | 315 (92.9%) | 532 (92.4%) | |
Epidural | 26 (2.8%) | 11 (3.2%) | 15 (2.6%) | |
Supplemental analgesia in 5 days | ||||
Opioidsh | 133 (14.5%) | 55 (16.2%) | 78 (13.5%) | 0.267 |
NSAIDsi | 668 (73.0%) | 245 (72.3%) | 423 (73.4%) | 0.701 |
NRS pain score in wards | ||||
First pain score | 2.0 (1.0, 3.0) | 2.0 (1.0, 3.0) | 2.0 (1.0, 3.0) | 0.785 |
Average pain score | 1.3 (0.3, 2.5) | 1.2 (0.2, 2.5) | 1.5 (0.3, 2.5) | 0.562 |
Effects of emergence delirium on postoperative outcomes
Total (n = 915) | Emergence delirium (n = 339) | No emergence delirium (n = 576) | OR, mean difference or HR (95% CI)a | P value | |
---|---|---|---|---|---|
Delirium within 5 days | 104 (11.4%) | 57 (16.8%) | 47 (8.2%) | OR = 2.275 (1.506, 3.436) | <0.001 |
Length of stay in PACU (min) | 43 ± 15 | 45 ± 16 | 41 ± 14 | Mean D = 4.1 (2.0, 6.1) | <0.001 |
Length of stay in PACU ≥ 60 min | 105 (11.5%) | 51 (15.0%) | 54 (9.4%) | OR = 1.712 (1.137, 2.576) | 0.010 |
Non-delirium complications within 5 days | 75 (8.2%) | 35 (10.3%) | 40 (6.9%) | OR = 1.543 (0.959, 2.481) | 0.074 |
Non-delirium complications within 30 days | 89 (9.7%) | 43 (12.7%) | 46 (8.0%) | OR = 3.486 (1.296, 9.376) | 0.013 |
Length of stay in hospital (day) | 8.0 (7.7, 8.3) | 8.0 (7.5, 8.5) | 7.0 (6.6, 7.3) | HR = 1.022 (1.003, 1.041) | 0.008 |
Length of stay in hospital ≤ 5 (day) | 209 (22.8%) | 63 −(18.6%) | 146 (25.3%) | OR = 0.672 (0.482, 0.937) | 0.019 |
Length of stay in hospital ≥ 11 (day) | 248 (27.1%) | 105 (31.0%) | 143 (24.8%) | OR = 1.359 (1.009, 1.830) | 0.044 |
Cognitive function at 30 days (score)b | 34.4 ± 2.4 [16] | 34.3 ± 2.4 [7] | 34.4 ± 2.4 [9] | Mean D = 0.06 (−0.27, 0.39) | 0.736 |
Quality of life at 30 days (score)c | |||||
Social relationships | 82.9 ± 6.0 [16] | 82.7 ± 5.8 [7] | 83.1 ± 6.1 [9] | Mean D = 0.43 (−0.39, 1.25) | 0.304 |
Environmental | 78.4 ± 5.9 [16] | 78.2 ± 5.6 [7] | 78.5 ± 6.1 [9] | Mean D = 0.35 (−0.45, 1.16) | 0.391 |
Physical | 74.7 ± 6.1 [16] | 74.6 ± 6.3 [7] | 74.7 ± 5.9 [9] | Mean D = 0.12 (−0.71, 0.95) | 0.780 |
Psychological | 82.1 ± 5.6 [16] | 81.9 ± 5.7 [7] | 82.2 ± 5.5 [9] | Mean D = 0.22 (−0.54, 0.98) | 0.565 |
Association between emergence delirium and postoperative delirium
Postoperative delirium | Emergence delirium | |||
---|---|---|---|---|
Odds ratio (95% CI) | P value | Odds ratio (95% CI) | P value | |
Age (years) | 1.071 (1.032–1.110) | <0.001 | 1.077 (1.049–1.105) | < 0.001 |
Male sex | 0.903 (0.597–1.365) | 0.627 | 0.807 (0.614–1.060) | 0.124 |
Body mass index (kg/m2) | 0.944 (0.889–1.002) | 0.058 | 0.986 (0.948–1.025) | 0.473 |
Education (year) | 0.984 (0.942–1.028) | 0.474 | 0.945 (0.917–0.973) | < 0.001 |
Preoperative comorbidity | ||||
Stroke | 2.514 (1.273–4.964) | 0.008 | 0.743 (0.406–1.360) | 0.336 |
Hypertension | 0.841 (0.559–1.265) | 0.406 | 0.946 (0.723–1.237) | 0.683 |
Coronary heart disease | 1.030 (0.576–1.844) | 0.919 | 1.468 (1.008–2.139) | 0.046 |
Arrhythmia | 1.729 (0.846–3.536) | 0.133 | 1.254 (0.728–2.160) | 0.415 |
Pulmonary disease | 2.043 (1.073–3.892) | 0.030 | 1.456 (0.880–2.411) | 0.144 |
Diabetes | 1.264 (0.799–1.999) | 0.317 | 1.076 (0.787–1.472) | 0.646 |
Abnormal liver function | 2.703 (1.325–5.515) | 0.006 | 1.256 (0.684–2.306) | 0.462 |
Malignant tumor | 1.742 (1.000–3.033) | 0.050 | 1.005 (0.660–1.530) | 0.983 |
Charlson Comorbidity Index (point) | 1.104 (1.024–1.190) | 0.010 | 1.016 (0.961–1.073) | 0.580 |
ASA classification III (vs. II) | 2.065 (1.363–3.128) | 0.001 | 1.434 (1.065–1.930) | 0.018 |
Chronic smoking | 1.164 (0.733–1.848) | 0.520 | 0.739 (0.536–1.018) | 0.064 |
Alcoholism | 0.815 (0.450–1.475) | 0.499 | 0.737 (0.504–1.080) | 0.117 |
History of surgery | 1.439 (0.947–2.186) | 0.088 | 1.382 (1.054–1.813) | 0.019 |
Preoperative lab tests | ||||
Hematocrit (%) | 0.932 (0.898–0.967) | < 0.001 | 0.951 (0.927–0.975) | <0.001 |
Albumin (g/L) | 0.957 (0.919–0.996) | 0.030 | 0.956 (0.929–0.984) | 0.002 |
Creatinine (μmol/L) | 1.005 (0.996–1.014) | 0.288 | 1.003 (0.997–1.009) | 0.354 |
Na+<135.0 or > 145.0 mmol/L | 0.686 (0.207–2.273) | 0.537 | 0.916 (0.460–1.823) | 0.802 |
K+ < 3.5 or > 5.5 mmol/L | 0.887 (0.469–1.675) | 0.711 | 1.210 (0.814–1.797) | 0.346 |
Preoperative MMSE (score) | 0.858 (0.792-0.930) | < 0.001 | 0.791 (0.743-0.841) | <0.001 |
Duration of anesthesia (min) | 1.004 (1.002–1.006) | 0.001 | 1.002 (1.000–1.003) | 0.075 |
General anesthesia (vs. combined) | 1.519 (1.051–2.197) | 0.026 | 0.939 (0.736–1.200) | 0.616 |
Intraoperative medication | ||||
Use of nitrous oxide | 1.054 (0.693–1.602) | 0.807 | 1.150 (0.873–1.516) | 0.319 |
Use of sevoflurane | 1.071 (0.693–1.656) | 0.757 | 1.206 (0.902–1.607) | 0.201 |
Use of dexmedetomidine | 0.645 (0.423–0.981) | 0.040 | 1.092 (0.835–1.429) | 0.520 |
Use of midazolam | 1.325 (0.823–2.133) | 0.246 | 0.865 (0.618–1.210) | 0.396 |
Use of etomidate | 1.435 (0.851–2.421) | 0.175 | 1.456 (1.050–2.020) | 0.024 |
Propofol (mg) | 1.001 (1.000–1.001) | 0.039 | 1.000 (1.000–1.001) | 0.048 |
Remifentanil (μg) | 1.000 (1.000–1.000) | 0.578 | 1.000 (1.000–1.000) | 0.819 |
Sufentanil (μg) | 1.007 (1.002–1.012) | 0.012 | 1.002 (0.998–1.006) | 0.391 |
Sufentanil equivalent (μg) | 1.001 (0.998–1.004) | 0.488 | 1.000 (0.998–1.002) | 0.853 |
Rocuronium (mg) | 1.011 (1.000–1.023) | 0.052 | 1.000 (0.993–1.007) | 0.914 |
NSAIDs | 1.186 (0.702–2.006) | 0.524 | 1.091 (0.781–1.523) | 0.609 |
Total fluid infusion (ml) | 1.000 (1.000–1.000) | 0.002 | 1.000 (1.000–1.000) | <0.001 |
Allogeneic blood transfusion | 1.613 (0.856–3.038) | 0.139 | 2.179 (1.369–3.469) | 0.001 |
Estimated blood loss (ml) | 1.000 (1.000–1.001) | 0.111 | 1.001 (1.000–1.001) | 0.002 |
Lowest intraoperative Hb < 10 g/dL | 2.446 (1.366–4.379) | 0.003 | 2.454 (1.529–3.939) | <0.001 |
Duration of surgery (min) | 1.003 (1.001–1.006) | 0.010 | 1.002 (1.000–1.004) | 0.078 |
Thoraco-/laparoscopic surgery | 0.790 (0.524–1.192) | 0.262 | 1.593 (1.213–2.093) | 0.001 |
Location of surgery | ||||
Intra-thoracic | 1.278 (0.678–2.407) | 0.448 | 1.350 (0.952–1.915) | 0.092 |
Intra-abdominal | 1.129 (0.654–1.947) | 0.663 | 1.643 (1.081–2.497) | 0.020 |
Spinal/extremities/others | Ref | Ref | ||
Emergence agitation | 1.478 (1.185-1.843) | 0.001 | 5.515 (4.515–6.737) | < 0.001 |
Temperature at PACU admission | 0.930 (0.585–1.479) | 0.760 | 0.437 (0.316–0.604) | < 0.001 |
Temperature < 36 °C | 0.990 (0.640–1.529) | 0.963 | 2.429 (1.828–3.228) | < 0.001 |
First NRS pain score in PACU | 0.911 (0.802–1.036) | 0.157 | 1.129 (1.041–1.224) | 0.003 |
Average NRS pain score in PCAU | 0.992 (0.866–1.137) | 0.912 | 1.255 (1.146–1.375) | <0.001 |
Use of patient-controlled analgesia | 3.775 (1.777–8.021) | 0.001 | 1.286 (0.780–2.118) | 0.324 |
Supplemental NSAIDs within 5 days | 1.264 (0.781–2.046) | 0.340 | – | – |
Supplemental opioids within 5 days | 1.692 (0.800–3.580) | 0.169 | – | – |
Emergence delirium | 2.275 (1.506–3.436) | < 0.001 | – | – |
First NRS pain score in wards | 1.412 (1.242–1.606) | < 0.001 | – | – |
Average NRS pain score in wards | 1.534 (1.327–1.773) | < 0.001 | – | – |
Postoperative complications in 5 days | 4.415 (2.411–7.124) | < 0.001 | – | – |
Factors | Univariable analyses | Multivariable analysisa | ||
---|---|---|---|---|
Odds ratio (95% CI) | P value | Odds ratio (95% CI) | P value | |
Emergence delirium | 2.275 (1.506–3.436) | < 0.001 | 1.717 (1.078–2.735) | 0.023 |
Age (year) | 1.071 (1.032–1.110) | < 0.001 | 1.048 (1.004–1.093) | 0.031 |
Body mass index (kg/m2) | 0.944 (0.889–1.002) | 0.058 | 0.965 (0.904–1.031) | 0.293 |
Charlson Comorbidity Index (unit) | 1.104 (1.024-–1.190) | 0.010 | 1.058 (0.968–1.155) | 0.215 |
History of surgery | 1.439 (0.947–2.186) | 0.088 | 1.268 (0.784–2.049) | 0.334 |
Preoperative hematocrit (%) | 0.932 (0.898–0.967) | < 0.001 | 0.951 (0.906–0.998) | 0.042 |
Preoperative albumin (g/L) | 0.957 (0.919–0.996) | 0.030 | 1.037 (0.981–1.096) | 0.196 |
Preoperative MMSE (score) | 0.858 (0.792–0.930) | < 0.001 | 0.885 (0.809–0.969) | 0.008 |
General anesthesia | 1.519 (1.051–2.197) | 0.026 | 1.147 (0.713–1.845) | 0.571 |
Use of dexmedetomidine | 0.645 (0.423–0.981) | 0.040 | 0.658 (0.413–1.047) | 0.077 |
Use of midazolam | 1.325 (0.823–2.133) | 0.246 | 1.277 (0.751–2.171) | 0.367 |
Use of etomidate | 1.435 (0.851–2.421) | 0.175 | 1.524 (0.849–2.739) | 0.158 |
Allogeneic blood transfusion | 1.613 (0.856–3.038) | 0.139 | 1.038 (0.495–2.176) | 0.922 |
Duration of surgery (min) | 1.003 (1.00–1.006) | 0.010 | 1.002 (0.998–1.005) | 0.329 |
Supplemental opioids within 5 days | 1.692 (0.800–3.580) | 0.169 | 1.403 (0.774–2.542) | 0.264 |
Use of patient-controlled analgesia | 3.775 (1.777–8.021) | 0.001 | 2.984 (1.035–8.608) | 0.043 |
Average NRS pain score in wards | 1.534 (1.327–1.773) | < 0.001 | 1.579 (1.347–1.852) | <0.001 |
Postoperative complications in 5 days | 4.415 (2.411–7.124) | < 0.001 | 3.422 (1.834–6.384) | <0.001 |
Risk factors of emergence delirium
Factors | Univariate analysis | Multivariate analysisa | ||
---|---|---|---|---|
Odds ratio (95% CI) | P value | Odds ratio (95% CI) | P value | |
Age (year) | 1.077 (1.049–1.105) | < 0.001 | 1.042 (1.003–1.083) | 0.037 |
Male sex | 0.807 (0.614–1.060) | 0.124 | 0.530 (0.332–0.846) | 0.008 |
Education (year) | 0.945 (0.917–0.973) | < 0.001 | 0.996 (0.952–1.043) | 0.872 |
ASA classification III | 1.434 (1.065–1.930) | 0.018 | 1.291 (0.830–2.006) | 0.257 |
Chronic smoking | 0.739 (0.536–1.018) | 0.064 | 0.651 (0.373–1.137) | 0.131 |
Alcoholism | 0.737 (0.504–1.080) | 0.117 | 0.929 (0.485–1.780) | 0.824 |
History of surgery | 1.382 (1.054–1.813) | 0.019 | 1.054 (0.712–1.559) | 0.792 |
Preoperative hematocrit (%) | 0.951 (0.927–0.975) | < 0.001 | 0.993 (0.953–1.036) | 0.761 |
Preoperative albumin (g/L) | 0.956 (0.929–0.984) | 0.002 | 0.953 (0.912–0.997) | 0.036 |
Preoperative MMSE (score) | 0.791 (0.743–0.841) | < 0.001 | 0.799 (0.727–0.878) | < 0.001 |
Use of sevoflurane | 1.206 (0.902–1.607) | 0.201 | 1.009 (0.676–1.508) | 0.963 |
Use of etomidate | 1.456 (1.050–2.020) | 0.024 | 1.263 (0.803–1.987) | 0.313 |
Allogeneic blood transfusion | 2.179 (1.369–3.469) | 0.001 | 1.696 (0.867–3.318) | 0.123 |
Duration of surgery (min) | 1.002 (1.000–1.004) | 0.078 | 1.000 (0.997–1.003) | 0.949 |
Emergence agitation | 5.515 (4.515–6.737) | < 0.001 | 6.007 (4.752–7.595) | < 0.001 |
Thoraco-/laparoscopic surgery | 1.593 (1.213–2.093) | 0.001 | 0.807 (0.543–1.199) | 0.288 |
Hypothermia at PACU admissionb | 2.429 (1.828–3.228) | < 0.001 | 2.672 (1.790–3.988) | < 0.001 |
Average NRS pain score in PACU | 1.255 (1.146–1.375) | < 0.001 | 1.309 (1.150–1.489) | < 0.001 |
Use of patient-controlled analgesia | 1.286 (0.780–2.118) | 0.324 | 0.946 (0.455–1.969) | 0.882 |