Transcranial direct current stimulation reduces risk of emergence agitation in patients undergoing transurethral resection of the prostate under general anesthesia
A safe, easy-to-administer neuromodulation technique targets and reduces post-anesthesia agitation, offering a novel drug-free perioperative option
image: This randomized controlled trial of 154 patients shows that a single 10-minute session of active transcranial direct current stimulation (tDCS), compared to sham stimulation, significantly reduces the incidence of emergence agitation, prevents dangerous agitation events, shortens agitation duration, and promotes faster extubation. These findings highlight tDCS as a promising, non-invasive neuromodulation technique for enhancing safety and recovery quality in the post-anesthesia care unit.
Credit: Professor Yingwei Wang from Huashan hospital Fudan University
Background and Significance
Emergence agitation is a common and potentially dangerous complication during recovery from general anesthesia, with reported incidence ranging from 4.7% to 63.5% depending on surgical type, anesthetic agents, and patient characteristics. Clinically, EA manifests as confusion, disorientation, restlessness, and in severe cases dangerous behaviors such as self-extubation, pulling out lines, falls, or self-harm. Conventional preventive measures rely on sedatives, hypnotics, and analgesics; while sometimes effective, these drugs can cause respiratory depression, hypotension, prolonged recovery, and their preventive efficacy against EA remains inconsistent. tDCS applies a low-intensity direct current across the scalp to modulate cortical excitability and network activity. Prior studies have suggested that stimulating the left dorsolateral prefrontal cortex (DLPFC) enhances cognitive control and facilitate consciousness recovery. Building on this rationale, the present study assessed whether targeted, brief anodal tDCS over the left DLPFC could lower EA risk in TURP patients.
Methods and Design
This single-center, randomized, double-blind, sham-controlled trial was conducted from October 2023 to May 2024. A total of 154 male patients undergoing TURP were enrolled and randomly assigned to either the active tDCS group (n=77) or the sham stimulation group (n=77). Patients in the active tDCS group received a 10-minute, 2 mA stimulation immediately after surgery, with the anode positioned over the left DLPFC (F3 region) and the cathode placed over the right orbitofrontal cortex (Fp2 region). The sham group only mimicked the tingling sensation without delivering sustained current, ensuring a rigorous placebo-controlled design. The primary outcome was the incidence of emergence agitation, assessed using the Riker Sedation-Agitation Scale (RSAS), with a score ≥5 defining EA. Secondary outcomes included the incidence of dangerous agitation (RSAS=7), duration of agitation, emergence time, recovery quality, and adverse events.
Key Findings
The incidence of EA was significantly lower in the active-tDCS group than in the sham-tDCS group (6.5% [5/77] vs. 22.1% [17/77]; relative risk (RR) 0.29, 95% CI, 0.12 to 0.72; P = 0.010). No cases of dangerous EA were observed in the active-tDCS group (0%) compared to 6 cases (7.8%) in the sham group (RR, 0.08, 95% CI, 0.00 to 1.34; P = 0.028). Active-tDCS significantly reduced agitation duration (6.2 ± 1.6 vs. 11.8 ± 3.2 min; mean difference -5.6 min, 95% CI, -8.7 to -2.5; P = 0.001) and accelerated extubation time (11.0 [10.0-12.0] vs. 14.0 [13.6-15.8] min; HR 3.77, 95% CI, 2.66 to 5.34; P < 0.001). No significant differences were observed between the two groups in postoperative pain scores, incidence of nausea and vomiting, recovery quality, or 24-hour delirium rates. No tDCS-related adverse events were reported.
Conclusion and Clinical Implications
The findings of this study indicate that a single, short session of anodal tDCS applied to the left dorsolateral prefrontal cortex can safely and effectively reduce the risk of emergence agitation in TURP patients under general anesthesia. tDCS offers notable advantages such as being non-invasive, free from drug-related side effects, and easy to administer using standardized positioning (International 10-20 System). It holds strong potential for clinical application and provides a new direction for improving perioperative safety and recovery quality in patients. Future studies will involve multicenter trials and expand to include patients undergoing various surgical procedures, as well as female participants, to further validate its efficacy and generalize these findings.
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Reference
DOI: https://doi.org/10.1097/cm9.0000000000003578
About Yingwei Wang from Fudan University
Prof. Yingwei Wang, M.D., Ph.D., serves as Director of the Department of Anesthesiology at Huashan Hospital, Fudan University. A leading expert in critical, pediatric, transplant, and neurosurgical anesthesia, he holds key roles in national anesthesiology societies and has received prestigious awards including the Shanghai Silver Snake Award. He has published over 30 SCI papers and leads multiple national-level research projects, including NSFC key grants.
About Daojie Xu from Fudan University
Dr. Daojie Xu, Associate Professor of Anesthesiology, serves on expert panels including the Organ Transplant Group of the Chinese Society of Anesthesiology. He has published over 10 SCI papers in journals like Anesthesiology and holds multiple National Natural Science Foundation grants. His research focuses on perioperative neural modulation and mechanisms of general anesthetics.
Funding information
This work was supported by grants from the National Natural Science Foundation of China (No. 82371285); the Foundation of Shanghai Municipal Science and Technology Commission (No. 22ZR1409600), and the Foundation of Shanghai Municipal Science and Technology Medical Innovation Research Project (No. 23Y21900600).