Perioperative Butorphanol as a Multimodal Analgesic Strategy to Reduces Emergence Agitation and Attenuates Systemic Inflammation in Elderly Patients Undergoing Transurethral Resection of the Prostate: A Pragmatic Randomized Controlled Trial

When an older adult undergoes surgery to remove an enlarged prostate, the procedure itself is often routine, but the recovery can be a turbulent time for the mind. As the anesthesia wears off, some patients wake up confused, restless, or even combative, a state known as emergence agitation. This is not merely a matter of being grumpy; in a fragile patient, this sudden surge of confusion and movement can lead to dangerous complications, such as pulling out vital tubes or causing a spike in blood pressure that stresses the heart. The challenge for doctors is to manage the pain of the surgery and the irritation of the urinary catheter without using heavy sedatives that might cloud the mind further or cause nausea. For decades, the standard approach has relied on strong painkillers that target specific brain receptors, but these drugs sometimes fail to calm the specific type of deep, internal pain caused by bladder surgery, and they can sometimes make the confusion worse.

A team of researchers at the First Affiliated Hospital of Dalian Medical University in China set out to test a different strategy for elderly patients facing this specific operation. They focused on a drug called butorphanol, which works differently than the standard painkillers. While common pain medications lock onto one type of receptor in the brain to block pain, butorphanol acts on a different set of receptors that are particularly good at calming the sensation of internal organ pain, while also having a mild sedative effect. The researchers wanted to see if using this drug during and after surgery could keep older patients calmer as they woke up, reduce their pain, and perhaps even lower the body's natural inflammatory response to the stress of surgery. They conducted a carefully controlled study where patients were randomly assigned to receive either the new drug or the standard treatment, ensuring that neither the doctors nor the patients knew which one they were getting until the results were analyzed.

The study involved seventy elderly men, all between the ages of sixty-five and eighty, who were scheduled for the prostate surgery. Half of the men received butorphanol, while the other half received the standard drug, sufentanil. Both groups received the same anesthetic gases and other medications to keep them asleep during the operation. The difference lay in how their pain was managed as they woke up. The researchers watched closely to see if the patients became agitated the moment the breathing tube was removed, a critical moment when confusion often strikes. They also measured how much pain the patients felt, how well they slept in the days following the surgery, and levels of specific proteins in the blood that indicate inflammation.

The results showed a clear difference between the two groups. In the group receiving butorphanol, only two men, or about six percent, experienced agitation when they woke up. In contrast, in the group receiving the standard drug, eleven men, or about thirty-one percent, became agitated. This means the drug used in the first group was significantly more effective at keeping patients calm during the transition from sleep to wakefulness. The men who received butorphanol also reported feeling less pain immediately after the surgery. Beyond just the immediate recovery, these patients slept better on the second and third nights after the operation. Their sleep quality scores were lower, which indicates a more restful night, compared to the men in the other group.

The study also looked at the body's chemical response to the surgery. When the body is injured or stressed, it releases proteins that cause inflammation. The researchers found that the men who received butorphanol had lower levels of these inflammatory markers in their blood when they woke up compared to the men who received the standard drug. This suggests that the drug did more than just block pain; it may have helped dampen the body's overall stress response to the operation. Importantly, the men who received butorphanol did not suffer from more side effects, such as nausea or dizziness, than the others. Their heart rates and blood pressure remained stable, and they did not experience any serious safety issues.

One interesting detail emerged regarding the timing of the recovery. The men who received butorphanol took slightly longer to wake up fully and have their breathing tubes removed, with a median time of twenty-five minutes compared to fifteen minutes for the other group. However, the researchers noted that this was not a sign of a problem. Instead, it appeared to be a smoother, more gradual awakening. Rather than jolting awake in a state of confusion, these patients seemed to transition more gently, which likely contributed to their lower agitation scores and better sleep. The study also calculated the total amount of pain medication each patient effectively received, converting different drugs into a common unit of measurement. The group receiving butorphanol required less total pain medication to achieve the same level of comfort, suggesting a more efficient way to manage pain in this vulnerable population.

While the study did not find a statistically significant difference in the rates of postoperative delirium—a more severe form of confusion that can last longer—the numbers did trend in a positive direction for the butorphanol group. The researchers noted that their study was not large enough to definitively prove a difference in this specific area, but the reduction in agitation and the improvement in sleep quality are strong indicators that the drug supports a healthier recovery. The findings suggest that for elderly men undergoing this type of surgery, swapping the standard painkiller for butorphanol offers a safer, more comfortable path through the immediate postoperative hours. It provides a way to manage the unique pain of bladder surgery while keeping the mind clear and the body calm, offering a practical alternative to the heavy sedation that often complicates recovery in older adults.