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Rebound from General Anesthesia

General anesthesia can be crucial to easing a patient’s pain and anxiety during a procedure.1 However, general anesthesia often comes with an extensive recovery time and unpleasant side effects.1 Depending on the type of procedure and anesthetic agent, a patient may have postoperative sleepiness, nausea, chills, vomiting and throat soreness.1 The rebound effects of anesthesia and sedation can be strong, impacting a patient’s ability to drive, to ride public transportation alone and to make judgments.1 Usually, clinicians recommend that patients who have undergone general anesthesia refrain from driving or doing activities alone for 24 hours after a procedure.2 Anesthesiology researchers have investigated the effects of different types of anesthesia on recovery, and developed strategies that can help alleviate postoperative side effects.

Some studies have compared the quality of recovery from various types of anesthetic agents. For example, a study by Moro et al. found that for 130 patients undergoing otorhinolaryngological surgery, the quality of recovery from a remifentanil-sevoflurane combination was not significantly different from recovery from a remifentanil-propofol combination.3 That is, there were no group differences in incidence of hypothermia, nausea, vomiting, pain intensity or postoperative morphine use.3 Another study found that desflurane was associated with a decreased rate of postoperative respiratory depression when compared to isoflurane.4 Meanwhile, a study by Jung et al. compared different dosages of sevoflurane to determine optimal anesthetic depth for interventional radiology.5 Though a lower dose of sevoflurane led to faster recovery and better hemodynamic rebound after anesthesia, it was also associated with more patient movement during the procedure.5 Finally, a review by Patel et al. showed no evidence suggesting that anesthesia types influence postoperative delirium in older patients, but the literature was lacking.6 More research is needed to compare the differences between various anesthetic drugs’ postoperative side effects.

Other researchers have approached using perioperative strategies to reduce postoperative side effects. For one, Viitanen et al. found that premedication with midazolam caused children treated with sevoflurane to have fewer sleep disruptions the night after surgery.7 However, another study showed that side effects of propofol were not different for patients pretreated with midazolam versus control patients, suggesting that midazolam exhibits different effects depending on the type of anesthesia used.8 Some more conclusive studies involved the use of dexmedetomidine, a drug used frequently in anesthesiology and intensive care settings.9 One study found that dexmedetomidine administered through continuous infusion (compared to placebo) prevented postoperative nausea and vomiting (PONV), as well as reduced side effects such as bradycardia and hypotension.9 Another showed that, though efficacy of dexmedetomidine differed depending on dosage, it was effective in controlling cough, agitation, hypertension, tachycardia and shivering upon recovery from anesthesia.10 Yet another study found that compared to placebo, dexmedetomidine reduced incidence of PONV and postoperative analgesic use.11 Weingarten et al. found that introduction of a new anesthetic protocol—including triple antiemetic prophylaxis and less midazolam use—was associated with decreased postoperative respiratory depression and decreased PONV.4 In a study of a nonmedication solution to unpleasant anesthesia recovery, Grech et al. found that intraoperative electroacupuncture reduced postoperative hyperglycemia and lowered postoperative stress hormones.12 A study by Jungquist et al. identified a preventive solution to postoperative side effects with electronic monitoring devices, which used machine learning to predict patients’ postoperative opioid-induced respiratory depression (OIRD).13 Taken together, these studies show that medication, alternative treatments and monitoring can help reduce postoperative side effects.

Rebound from general anesthesia can be unpleasant, often including PONV and immune and stress responses. While more research is needed to assess how different anesthetic drug affect quality of recovery, some preventive and intraoperative solutions may make recovery easier. Future studies should further explore optimizing anesthetic drug dosing and providing nonmedication strategies to alleviate postoperative discomfort.

1.         American Society of Anesthesiologists. Preparing for surgery: Recovery. When Seconds Count… 2019; https://www.asahq.org/whensecondscount/preparing-for-surgery/recovery/.

2.         Chung F, Kayumov L, Sinclair David R, Edward R, Moller Henry J, Shapiro Colin M. What Is the Driving Performance of Ambulatory Surgical Patients after General Anesthesia? Anesthesiology: The Journal of the American Society of Anesthesiologists. 2005;103(5):951–956.

3.         Moro ET, Leme FCO, Noronha BR, Saraiva GFP, de Matos Leite NV, Navarro LHC. Quality of recovery from anesthesia of patients undergoing balanced or total intravenous general anesthesia. Prospective randomized clinical trial. Journal of Clinical Anesthesia. 2016;35:369–375.

4.         Weingarten TN, Bergan TS, Narr BJ, Schroeder DR, Sprung J. Effects of changes in intraoperative management on recovery from anesthesia: A review of practice improvement initiative. BMC Anesthesiology. 2015;15(1):54.

5.         Jung YS, Han Y-R, Choi E-S, et al. The optimal anesthetic depth for interventional neuroradiology: Comparisons between light anesthesia and deep anesthesia. Korean Journal of Anesthesiology. 2015;68(2):148–152.

6.         Patel V, Champaneria R, Dretzke J, Yeung J. Effect of regional versus general anaesthesia on postoperative delirium in elderly patients undergoing surgery for hip fracture: A systematic review. BMJ Open. 2018;8(12):e020757.

7.         Viitanen H, Annila P, Viitanen M, Tarkkila P. Premedication with Midazolam Delays Recovery After Ambulatory Sevoflurane Anesthesia in Children. Anesthesia & Analgesia. 1999;89(1):75–79.

8.         Bevan JC, Veall GRO, Macnab AJ, Ries CR, Marsland C. Midazolam Premedication Delays Recovery After Propofol Without Modifying Involuntary Movements. Anesthesia & Analgesia. 1997;85(1):50–54.

9.         Jin S, Liang DD, Chen C, Zhang M, Wang J. Dexmedetomidine prevent postoperative nausea and vomiting on patients during general anesthesia: A PRISMA-compliant meta analysis of randomized controlled trials. Medicine (Baltimore). 2017;96(1):e5770.

10.       Aouad MT, Zeeni C, Al Nawwar R, et al. Dexmedetomidine for Improved Quality of Emergence From General Anesthesia: A Dose-Finding Study. Anesthesia & Analgesia. 2019;129(6):1504–1511.

11.       Zhu M, Wang H, Zhu A, Niu K, Wang G. Meta-Analysis of Dexmedetomidine on Emergence Agitation and Recovery Profiles in Children after Sevoflurane Anesthesia: Different Administration and Different Dosage. PLoS One. 2015;10(4):e0123728.

12.       Grech D, Li Z, Morcillo P, et al. Intraoperative Low-frequency Electroacupuncture under General Anesthesia Improves Postoperative Recovery in a Randomized Trial. Journal of Acupuncture and Meridian Studies. 2016;9(5):234–241.

13.       Jungquist CR, Chandola V, Spulecki C, et al. Identifying Patients Experiencing Opioid-Induced Respiratory Depression During Recovery From Anesthesia: The Application of Electronic Monitoring Devices. Worldviews on Evidence-Based Nursing. 2019;16(3):186–194.