Comparative Study of Intravenous vs Inhalational Maintenance Anaesthesia on Postoperative Emergence Agitation and Recovery Parameters After General Anaesthesia

ABSTRACT

Background:

Emergence agitation (EA) is a common phenomenon observed in patients recovering from general anaesthesia, potentially leading to self-injury and compromised recovery quality.

Objectives:

This research aims to evaluate the outcome of intravenous and inhalational maintenance anaesthesia on postoperative EA and other recovery parameters.

Materials and Methods:

This research was conducted with 100 patients undergoing elective surgeries under general anaesthesia. Patients were divided into two groups: Group I received intravenous maintenance with propofol, while Group II received inhalational maintenance with sevoflurane. EA was evaluated using the Riker Sedation-Agitation Scale at predetermined intervals postoperatively. Recovery parameters such as time to extubating, orientation, and postoperative nausea and vomiting (PONV) were also recorded.

Results:

Group I demonstrated a considerably lower incidence of EA in comparison to Group II (10% vs. 30%, P < 0.05). The time to extubating and orientation was shorter in Group II, but the variation was not statistically considerable. The incidence of PONV was greater in Group II (25% vs. 10%, P < 0.05).

Conclusion:

Intravenous maintenance anaesthesia with propofol is connected with a lower incidence of emergence agitation and PONV compared to inhalational maintenance with sevoflurane. These findings suggest that propofol may be a preferable agent for maintenance anaesthesia in terms of postoperative recovery quality.

INTRODUCTION

Emergence agitation (EA) is a post-anaesthetic phenomenon characterized by confusion, disorientation, and aggressive behaviour during recovery from general anaesthesia. It poses risks such as self-injury, removal of medical devices, and increased stress on healthcare providers. The incidence of EA varies widely, with reports ranging from 10% to 80%, depending on patient population and anaesthetic techniques used.[1]

The choice of anaesthetic agents plays a crucial role in the incidence of EA and overall recovery quality. Intravenous agents like propofol are known for their rapid onset and smooth recovery profiles. In contrast, inhalational agents such as sevoflurane are favoured for their ease of administration and controllability but have been associated with higher rates of EA.[2]

Earlier researches showed contradictory findings related to the impact of anaesthetic maintenance techniques on EA. While some research suggests that propofol reduces the incidence of EA, other studies have found no significant difference between intravenous and inhalational agents. Additionally, factors such as age, type of surgery, and preoperative anxiety contribute to the development of EA.[3]

Understanding the effects of different maintenance anaesthesia techniques on EA and recovery parameters is essential for optimizing patient outcomes. This research was conducted to evaluate the incidence of EA and other recovery parameters in patients receiving intravenous versus inhalational maintenance anaesthesia during general anaesthesia.

MATERIALS AND METHODS

Study design and participants

A prospective, randomized controlled trial was conducted in department of Anaesthesiology, Chhindwara Institute of Medical Sciences, Chhindwara, MP, India, after obtaining institutional ethics committee approval [Ref. No. CIMS/EC/2024/8502] and written informed consent from all participants. One hundred patients aged 18–60 years, divided as American Society of Anaesthesiologists (ASA) physical status I or II, planned for elective surgeries under general anaesthesia were enrolled. Study was after considering the inclusion and exclusion criteria.

Randomization and group allocation

Participants were arbitrarily divided into two groups using a computer-generated randomization table as; Group I (n = 50): Received intravenous maintenance anaesthesia with propofol and Group II (n = 50): Received inhalational maintenance anaesthesia with sevoflurane.

Anaesthesia protocol

All patients were premedicated with midazolam 0.05 mg/kg and fentanyl 2 μg/kg intravenously. Induction was achieved with propofol 2 mg/kg and rocuronium 0.6 mg/kg to facilitate endotracheal intubation.

• Group I: Anaesthesia was maintained with propofol infusion at 100 μg/kg/min–150 μg/kg/min.

• Group II: Anaesthesia was maintained with sevoflurane at an end-tidal concentration of 1.5%–2%.

Both groups received 50% nitrous oxide in oxygen. Neuromuscular blockade was maintained with intermittent doses of rocuronium.

Monitoring and data collection

Standard intraoperative monitoring included ECG, non-invasive blood pressure, pulse oximetry, end-tidal CO2, and bispectrality index (BIS). BIS values were maintained between 40 and 60.

EA was assessed using the Riker Sedation-Agitation Scale at 0, 5, 10, 15, and 30 min post-extubating. Recovery parameters recorded included:

• Time to extubating

• Time to spontaneous eye opening

• Time to orientation (ability to state name, location, and date)

• Incidence of PONV

• Postoperative pain assessed using the Visual Analog Scale (VAS)

Statistical analysis

Data were analysed using SPSS version 21 with Student’s t-test and Chi-square test at P value < 0.05.

RESULTS

Demographic data

There were no considerable variations between the groups regarding age, gender, weight, duration of surgery, or ASA physical status [Table 1].

Table 1.

Demographic data

Parameter	Group I (n=50)	Group II (n=50)	P
Age (years)	35.4±10.2	36.1±9.8	0.72
Gender (M/F)	28/22	26/24	0.68
Weight (kg)	70.5±12.3	71.2±11.7	0.81
Duration of Surgery (min)	90.2±20.5	88.7±22.1	0.65

Emergence agitation

The incidence of EA was appreciably lower in Group I compared to Group II at all measured intervals [Figure 1]. At 5 min post-extubating, EA was observed in 10% of patients in Group I versus 30% in Group II (P = 0.014).

Figure 1.

Incidence of emergence agitation at different time intervals

Recovery parameters

• Time to Extubating: Group I had a mean time of 8.2 ± 2.5 min, while Group II had 7.8 ± 2.7 min (P = 0.42) [Table 2].

• Time to Orientation: Group I recorded 12.5 ± 3.1 min, and Group II recorded 11.8 ± 2.9 min (P = 0.27).

• Incidence of PONV: Higher in Group II (25%) compared to Group I (10%) (P = 0.039).

• Postoperative Pain Scores: No considerable variation was observed between the groups at any time point.

Table 2.

Recovery parameters

Parameter	Group I	Group II	P
Time to Extubation (min)	8.2±2.5	7.8±2.7	0.42
Time to Orientation (min)	12.5±3.1	11.8±2.9	0.27
Incidence of PONV (%)	10	25	0.039

DISCUSSION

This study demonstrates that intravenous maintenance anaesthesia with propofol significantly reduces the incidence of emergence agitation compared to inhalational maintenance with sevoflurane. The findings align with previous research indicating propofol’s beneficial effects on reducing EA.[4]

The higher incidence of EA with sevoflurane may be attributed to its rapid elimination and low blood-gas partition coefficient, leading to abrupt awakening and potential disorientation.[5] Propofol’s smoother recovery profile may facilitate a more gradual return to consciousness, reducing EA risk.[6]

The incidence of PONV was also lower in the propofol group, consistent with its antiemetic properties. Sevoflurane is known to have a higher emetogenic potential, which may explain the increased PONV observed.[5]

Recovery parameters such as time to extubating and orientation were comparable between the groups, suggesting that both agents provide efficient recovery times. This contrasts with some studies indicating faster recovery with inhalational agents,[7] possibly due to the differences in anaesthetic protocols and patient populations.

The study’s drawbacks include a relatively small sample size and the exclusion of paediatric and elderly patients, who may exhibit different EA patterns. Further research with larger, more diverse populations is recommended to validate these findings.

CONCLUSION

Intravenous maintenance anaesthesia with propofol reduces the incidence of emergence agitation and postoperative nausea and vomiting compared to inhalational maintenance with sevoflurane. Both agents offer similar recovery times, but propofol may enhance overall recovery quality. Clinicians should consider these factors when selecting maintenance anaesthetic agents to optimize patient outcomes.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.