Effects of preemptive acetaminophen administration and preoperative anxiety on postoperative agitation and pain in adult septorhinoplasty patients

Effects of preemptive acetaminophen administration and preoperative anxiety on postoperative agitation and pain in adult septorhinoplasty patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of preemptive acetaminophen administration and preoperative anxiety on postoperative agitation and pain in adult septorhinoplasty patients Gamze Küçükosman, Dilay İlke Alp, Ergin Bilgin, Gökhan Mustafa Bayram, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7955803/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Preoperative anxiety and postoperative agitation are common in otolaryngologic surgeries such as septorhinoplasty and may adversely affect patient outcomes. Although preemptive acetaminophen is frequently used to reduce postoperative pain, its effects on agitation remain unclear. This study aimed to investigate the relationship between preoperative anxiety and postoperative agitation and pain, as well as the effect of preemptive intravenous acetaminophen administration in adult septorhinoplasty patients. Methods This prospective, randomized study was conducted between March and September 2020 at Zonguldak Bulent Ecevit University Hospital after ethics approval (protocol no: 2020/04). Eighty-six, ASA I–II adult patients (aged 18–65 years) undergoing elective septorhinoplasty were included. Patients were randomized into two groups: Group 1 received 1 g intravenous acetaminophen 30 minutes before induction, and Group 2 received it 15 minutes before the end of surgery. Preoperative anxiety was assessed using the Beck Anxiety Inventory (BAI), postoperative agitation with the Riker Sedation-Agitation Scale (RSAS), and postoperative pain with the Numeric Rating Scale (NRS) at 0, 5, 10, and 15 minutes postoperatively. p < 0.05 was considered statistically significant. Results The groups were comparable in demographic and intraoperative variables. Moderate-to-severe anxiety was observed in 2.3% of all patients. NRS scores were significantly lower in Group 1 at the 5th postoperative minute (p < 0.05), whereas no significant differences were found in RSAS scores at any time point. RSAS and NRS scores decreased over time in both groups. No significant correlations were detected between preoperative anxiety and postoperative agitation or pain. Conclusions Preemptive acetaminophen administration reduced early postoperative pain but had no significant effect on postoperative agitation in adult septorhinoplasty patients. Low levels of preoperative anxiety did not influence agitation or pain outcomes. Individualized analgesic strategies and multimodal approaches may provide more effective perioperative management in nasal surgeries. Trial registration: ClinicalTrials.gov Identifier: NCT07010042. Preemptive analgesia Acetaminophen Preoperative anxiety Postoperative agitation Septorhinoplasty Figures Figure 1 Background Preoperative anxiety is defined as a state of concern and unease experienced by the individual regarding the surgical process, and its prevalence ranges from 11% to 80% depending on the assessment method employed [ 1 , 2 ]. It has been reported that anxiety levels are influenced by age, sex, and type of surgery, and high levels of anxiety may even lead to the postponement of the surgical procedure [ 3 – 5 ]. The Beck Anxiety Inventory (BAI), which is frequently used for this purpose, is preferred due to its validity and ease of use [ 6 , 7 ]. Postoperative pain is an acute inflammatory process that begins with surgical trauma and concludes with tissue healing, while its inadequate management may lead to serious complications [ 8 , 9 ]. Female sex, younger age, type of surgery, preoperative pain severity, and anxiety are among the risk factors for postoperative pain [ 10 , 11 ]. Although pain management following septorhinoplasty is critically important, data about this issue in the literature remain limited [ 12 – 14 ]. Preemptive analgesia aims to reduce central sensitization through the administration of analgesics prior to incision and was reported to be effective in alleviating postoperative pain [ 15 ]. Acetaminophen is a safe and commonly used analgesic that can be administered alone or in combination with other agents for preemptive analgesia [ 16 , 17 ]. Postoperative agitation is a clinical condition characterized by disorientation, restlessness, and behavioral changes occurring in the early period following anesthesia [ 18 ]. Although more frequently observed in pediatric patients, it occurs in adults at rates ranging from 4.7% to 21.3% [ 19 , 20 ]. It is associated with factors such as age, sex, type of surgery, anesthesia method, anxiety, and postoperative pain [ 21 , 22 ]. The incidence of agitation is particularly high in otolaryngologic surgeries, with rates reaching up to 55% following septorhinoplasty. This condition may lead to serious complications [ 19 , 20 ]. Despite the known prevalence of agitation following septorhinoplasty, the effects of preoperative anxiety and preemptive acetaminophen administration on agitation and pain in adult patients have not been sufficiently investigated. This study aimed to evaluate the impact of these two factors on postoperative agitation and pain in adult septorhinoplasty patients. Methods Study Design and Ethical Approval This prospective study was conducted at Zonguldak Bulent Ecevit University Hospital between March and September 2020, in accordance with the Declaration of Helsinki, after obtaining local ethics committee approval (protocol No: 2020/04), informed written consent from the patients, and registration with ClinicalTrials.gov (Identifier: NCT07010042 Date:05/23/2025). The flow diagram according to CONSORT guidelines is provided in Fig. 1 [ 23 ]. Patient Selection and Exclusion Criteria Patients aged 18–65 years scheduled for elective septorhinoplasty and classified as American Society of Anesthesiologists (ASA) risk groups I–II were included. Patients who did not speak Turkish, had drug allergies, were at risk of difficult intubation, had neurological disorders or a history of revision surgery, or experienced serious intraoperative complications (hypoxia, hypotension, hypercarbia, hypoglycemia, thermoregulation disorders) were excluded. Demographic Datas All patients were informed about the study in the preoperative holding area. Written consent was obtained from those who voluntarily agreed to participate. Data were recorded about age, sex, height, weight, ASA classification, education level (primary, secondary, high school, university), occupation (homemaker, laborer, civil servant, student, self-employed), smoking status (≥ 10 cigarettes/day at least one week before surgery considered smoking), alcohol consumption (≥ 4 times/week, averaging 3–4 drinks/day considered drinking), and fasting duration. Patients who did not receive premedication and agreed to participate were assessed for preoperative anxiety using the Beck Anxiety Inventory (BAI) via face-to-face interviews in the preoperative holding area [ 6 , 7 ]. Groups and Interventions Following the BAI assessment, a 20-gauge cannula was inserted into the dorsum of the hand, and fluid infusion was initiated. Patients were randomly divided into two groups using sealed envelopes based on the timing of intravenous (iv) acetaminophen administration. The patients in Group 1 received 1 g iv acetaminophen 30 minutes before surgery, while the patients in Group 2 received 1 g iv acetaminophen 15 minutes before the end of surgery. The patients in Group 1 underwent both BAI assessment and acetaminophen infusion prior to entering the operating room, while those in Group 2 entered the operating room following only the BAI assessment. Perioperative drug administrators, surgeons, and anesthesiologists were blinded to group allocations. Anesthesia management and evaluation Standard monitoring was applied to all patients. Anesthesia induction and maintenance were performed by an anesthesiologist unaware of the study. Commonly preferred routine practices were observed: induction with propofol, rocuronium, and fentanyl, and maintenance with sevoflurane and remifentanil to maintain BIS between 40 and 60. At the end of surgery, all patients received 20 mg iv metoclopramide as an antiemetic and 1 mg/kg tramadol. The neuromuscular blockade was reversed with neostigmine and atropine, and patients were extubated upon the return of spontaneous respiration and protective reflexes. All intraoperative and postoperative medications, intraoperative fluid volumes, and operating room temperatures were recorded. All the surgical procedures were performed by the same surgical team using a similar technique. The duration from the induction to the cessation of anesthetic gases was recorded as the “anesthesia time”, the interval from the cessation of anesthetic gases to extubation was recorded as the “extubation time”, the BIS values at extubation were recorded, and the time from the cessation of anesthetic gases to achieving an Aldrete score of 9 was recorded as the “recovery time.” Recovery time (from admission to the recovery room until discharge) and complications observed in the recovery room (nausea, vomiting, coughing, head-neck pain, increased secretions) were recorded. Patients who continued to experience postoperative nausea and vomiting were planned to receive 50 µg/kg iv ondansetron. Scales used in the study Preoperative anxiety was assessed using the Beck Anxiety Inventory (BAI)[ 6 ], postoperative agitation was evaluated using the Riker Sedation-Agitation Scale (RSAS)[ 24 ], and postoperative pain was measured using the Numeric Rating Scale (NRS)[ 25 ]. Beck Anxiety Inventory : BAI is a 21-item Likert-type scale that measures the frequency of anxiety symptoms experienced by the individual, with each item scored from 0 to 3 (0 = none, 1 = mild, 2 = moderate, 3 = severe). Based on total scores, anxiety levels are classified as follows: 0–17 = low, 18–24 = moderate, ≥ 25 = high [ 6 ]. The validity and reliability study of BAI in Turkish was conducted by Ulusoy et al. (1998)[ 7 ]. In our study, a BAI score ≥ 18 was considered to indicate moderate-to-severe anxiety. Riker Sedation-Agitation Scale : RSAS, which is used to evaluate postoperative agitation (1: unresponsive, 7: dangerously agitated), is frequently preferred due to its ease of use and validated reliability. Although originally developed for intensive care patients, it was preferred due to its validity and ease of use in the evaluation of postoperative agitation in adults [ 24 ]. In this study, RSAS ≥ 5 was defined as agitation. Agitated patients were first treated with verbal commands, and if necessary, with 0.05 mg/kg iv midazolam. Numeric Rating Scale NRS is a unidimensional scale using 11 numeric values (0 to 10) to measure the intensity of pain. Patients are asked to select the number that best represents their pain, where 0 indicates no pain, and 10 indicates the worst pain imaginable. NRS is widely used in clinical practice due to its validity, reliability, and ease of application in assessing postoperative acute pain in adults [ 25 ]. In this study, patients with NRS ≥ 4 received 1 µg/kg iv meperidine. All assessments were conducted at postoperative 0, 5, 10, and 15 mins by a trained researcher who was blinded to group allocations. Statistical Analysis The sample size needed to conduct the study was calculated based on a 95% confidence interval (1-α), 95% testing power (1-β), and an effect size of d = 0.838, and it was determined that at least 32 patients needed to be included in each group [ 26 ]. Data were analyzed using the IBM SPSS (Statistical Package for the Social Sciences) V23 program. Normality was assessed with the Shapiro-Wilk test. Categorical variables were compared between groups using chi-squared tests and Yates correction. For comparisons of non-normally distributed variables between two groups, the Mann-Whitney U test was used, while, for normally distributed variables, independent-samples t-tests were utilized. Relationships between non-normally distributed variables were examined using Spearman’s rho correlation coefficient. Results are presented as mean ± standard deviation and median (minimum–maximum) values for quantitative data and frequency (percentage) values for categorical data. A significance level of p < .050 was adopted. Results The study was completed with 86 patients. The mean age of all patients was 29.11±8.92 years. No significant differences were found between the groups in terms of demographic characteristics, ASA risk classification, fasting duration, intraoperative fluid volume, surgical/extubation/anesthesia/recovery durations, or BIS values at extubation. Median BAI scores were low and similar in both groups (p > .050, Table 1). Moderate-to-severe anxiety was observed in 2.3% (n=1 Group 1, n=1 Group 2) of all patients. The groups were similar to each other in terms of education levels, smoking/alcohol consumption status, intraoperative drug administration status, and postoperative complications (p > .050, Table 2). A significant difference was observed only in terms of occupational distributions, with a higher proportion of self-employed individuals in Group 2 (p = .033). No patients required additional medication for agitation, nausea-vomiting, or pain during postoperative recovery (Table 2). In both groups, RSAS and NRS scores decreased over time in the postoperative period. No significant differences were found between the groups in terms of RSAS scores at any time point (p > .050, Table 3). NRS scores were significantly lower in Group 1 only at the 5th postoperative minute (p = .044). RSAS ≥5 was observed in 37 patients during the monitoring period. No patients required pharmacological intervention for agitation. No significant correlation was observed between the preoperative BAI scores and postoperative RSAS or NRS scores of the patients. Discussion In this study, the effects of preemptive intravenous acetaminophen administration on postoperative agitation and pain, as well as the relationship between preoperative anxiety levels and these outcomes, were investigated in adult patients undergoing septorhinoplasty. According to our results, preemptive acetaminophen administration reduced pain only in the early postoperative period (at the 5th minute), but it had no significant effect on agitation scores. Additionally, the preoperative anxiety levels observed in the patients were low and showed no significant association with postoperative agitation or pain. The incidence of postoperative agitation following nasal surgeries is reported in the literature to range from 22% to 55%, often triggered by sensations of suffocation and oral- nasal obstruction. Moreover, different types of surgeries and anesthesia methods (total intravenous vs. inhalational anesthesia) are well-known risk factors for postoperative agitation. [ 19 – 22 , 27 ]. Although pain is not the sole cause of agitation, it is recognized as one of the primary factors that intensifies its severity and frequency [ 22 ]. In our study, the incidence of agitation was found to be quite low. This may reflect the strengths of our design, including standardized anesthesia management, consistent surgical teams, and routine preoperative patient education. However, the use of tramadol in postoperative analgesia may have masked the effect of acetaminophen on agitation, and RSAS may not fully capture all dimensions of postoperative agitation. Differences in evaluation criteria may also have influenced these results. The observed decline in RSAS and NRS scores over time supported the natural trajectory of recovery following surgery. No patients exhibited severe agitation requiring sedatives or physical restraint. Awake extubation is preferred after nasal surgery due to aspiration risk. However, deep extubation under anesthesia may also be used to prevent postoperative agitation and ensure better airway management [ 27 ]. In our study, the patients were extubated at similar BIS values, which may explain their comparable levels of postoperative agitation. Previous studies have reported a significant relationship between preoperative anxiety and postoperative pain in septoplasty procedures [ 11 , 19 , 28 ]. Similar results have suggested that anxiety may heighten pain perception by increasing the patient’s attention to pain [ 29 , 30 ]. Preoperative education has been shown to reduce anxiety levels, although the extent of this effect may vary depending on the psychosocial and educational background of the patient, as well as the knowledge and experience of the educator [ 31 – 33 ]. In a study by Kevser Peker, the mean preoperative anxiety score measured using BAI in septorhinoplasty patients was 12.77 ± 7.09, corresponding to a moderate level of anxiety [ 34 ]. In our study, the median BAI scores in both groups were low, and no significant association of BAI scores with postoperative pain was demonstrated. These low anxiety levels may be related to patient characteristics, cultural factors, the elective nature of the procedure, and preoperative education regarding surgery and anesthesia. Severe postoperative pain may occur following nasal surgery involving hard tissue manipulation, especially within the first three days [ 35 , 36 ]. In recent years, alternative and combination analgesic strategies have been employed to reduce opioid dependence while ensuring adequate analgesia [ 16 , 17 , 37 ]. Acetaminophen is a frequently used and safe agent in preemptive analgesia, with pharmacokinetic properties that make it more effective in the early postoperative period [ 16 , 17 ]. In our study, the analgesic effect was observed only at the 5th minute, consistent with these pharmacological characteristics. The use of tramadol in postoperative analgesia may have masked the effect of acetaminophen on agitation. Furthermore, information in the relevant literature indicates that agitation is influenced not only by pain but also by multiple other factors such as age, sex, smoking status, anesthesia method, and airway management [ 19 , 20 ]. Therefore, it is expected that acetaminophen alone may be insufficient to prevent agitation. This study had some limitations. First, its relatively small sample size may have reduced the statistical power of the study. Second, there was no placebo group in the study. Third, the study was conducted at a single center, which may restrict the generalizability of its results. Fourth, the use of tramadol in postoperative analgesia may have masked the true effect of acetaminophen. Lastly, RSAS was originally developed for intensive care settings and may not fully reflect early postoperative agitation. Additionally, factors such as individual psychological variables and pain thresholds were not considered in this study. Conclusions and suggestions Preemptive acetaminophen administration reduced early postoperative pain in adult patients undergoing septorhinoplasty but was not sufficient on its own to prevent agitation. Preoperative anxiety levels were low and showed no significant effect on postoperative agitation or pain. Given the multifactorial nature of agitation, multimodal analgesic strategies and individualized pain management approaches may be more effective. Therefore, future studies with larger sample sizes, multicenter designs, and placebo-controlled protocols are needed. Declarations Acknowledgements None. Disclosure statement No potential conflict of interest was reported by the author(s). Data availability statement The data that support the findings of this study are available from the corresponding author, G.K., upon reasonable request. Ethical approval This study was approved by Zonguldak Bulent Ecevit University Ethics Committee (Meeting decision No: 2020/04) and registration with ClinicalTrials.gov (Identifier: NCT07010042 Date: 05/23/2025). Funding Sources: No funding was received Author Contributions Concept-design: Küçükosman G, Bollucuoğlu K, Köksal BG, Ayoğlu; Data collection: Alp Dİ, Bayram GM, Bilgin E;Data analysis and interpretation: Küçükosman G, Köksal BG, Ayoğlu H;Manuscript draft: Küçükosman G, Bollucuoğlu K;Critical revision of content:Küçükosman G, Bollucuoğlu K, Köksal BG, Ayoğlu H;Final approval and responsibility:Küçükosman G,Bilgin , Köksal BG, Ayoğlu H. All authors (Küçükosman G, Alp Dİ, Bilgin E, Bayram GM, Bollucuoğlu K, Köksal BG, Ayoğlu H) reviewed the results and approved the final version of the manuscript. References Oh J, Lee W, Ki S, Suh J, Hwang S, Lee J. Assessment of preoperative anxiety and influencing factors in patients undergoing elective surgery: an observational cross- sectional study. Med (Kaunas). 2024;60(3):403. Kumar A, Dubey PK, Ranjan A. Assessment of anxiety in surgical patients: an observational study. Anesth Essays Res. 2019;13(3):503–8. 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15:39:12","extension":"html","order_by":71,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":148667,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7955803/v1/e1d0080a59814bc0ef2daa06.html"},{"id":97722121,"identity":"01cb0b2f-b4b7-4031-8f33-cb28d6d60d42","added_by":"auto","created_at":"2025-12-08 15:39:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":281547,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConsolidated Standards of Reporting Trials (CONSORT) flow diagram.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7955803/v1/903bc3e80827a261e13f1b3e.png"},{"id":100547977,"identity":"701c26a2-a109-4cbe-9e81-c8a891dd051c","added_by":"auto","created_at":"2026-01-19 08:17:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":842664,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7955803/v1/5e4a12b3-032a-42c8-a351-743349a97c3c.pdf"},{"id":97722118,"identity":"01a229c2-f9fc-46ee-b003-9229aaa23a86","added_by":"auto","created_at":"2025-12-08 15:39:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":61352,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7955803/v1/0765814993c5882064ffb26d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of preemptive acetaminophen administration and preoperative anxiety on postoperative agitation and pain in adult septorhinoplasty patients","fulltext":[{"header":"Background","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePreoperative anxiety is defined as a state of concern and unease experienced by the individual regarding the surgical process, and its prevalence ranges from 11% to 80% depending on the assessment method employed [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It has been reported that anxiety levels are influenced by age, sex, and type of surgery, and high levels of anxiety may even lead to the postponement of the surgical procedure [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The Beck Anxiety Inventory (BAI), which is frequently used for this purpose, is preferred due to its validity and ease of use [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePostoperative pain is an acute inflammatory process that begins with surgical trauma and concludes with tissue healing, while its inadequate management may lead to serious complications [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Female sex, younger age, type of surgery, preoperative pain severity, and anxiety are among the risk factors for postoperative pain [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Although pain management following septorhinoplasty is critically important, data about this issue in the literature remain limited [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Preemptive analgesia aims to reduce central sensitization through the administration of analgesics prior to incision and was reported to be effective in alleviating postoperative pain [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Acetaminophen is a safe and commonly used analgesic that can be administered alone or in combination with other agents for preemptive analgesia [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePostoperative agitation is a clinical condition characterized by disorientation, restlessness, and behavioral changes occurring in the early period following anesthesia [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although more frequently observed in pediatric patients, it occurs in adults at rates ranging from 4.7% to 21.3% [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. It is associated with factors such as age, sex, type of surgery, anesthesia method, anxiety, and postoperative pain [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The incidence of agitation is particularly high in otolaryngologic surgeries, with rates reaching up to 55% following septorhinoplasty. This condition may lead to serious complications [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the known prevalence of agitation following septorhinoplasty, the effects of preoperative anxiety and preemptive acetaminophen administration on agitation and pain in adult patients have not been sufficiently investigated. This study aimed to evaluate the impact of these two factors on postoperative agitation and pain in adult septorhinoplasty patients.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Ethical Approval\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e This prospective study was conducted at Zonguldak Bulent Ecevit University Hospital between March and September 2020, in accordance with the Declaration of Helsinki, after obtaining local ethics committee approval (protocol No: 2020/04), informed written consent from the patients, and registration with ClinicalTrials.gov (Identifier: NCT07010042 Date:05/23/2025). The flow diagram according to CONSORT guidelines is provided in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePatient Selection and Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatients aged 18\u0026ndash;65 years scheduled for elective septorhinoplasty and classified as American Society of Anesthesiologists (ASA) risk groups I\u0026ndash;II were included. Patients who did not speak Turkish, had drug allergies, were at risk of difficult intubation, had neurological disorders or a history of revision surgery, or experienced serious intraoperative complications (hypoxia, hypotension, hypercarbia, hypoglycemia, thermoregulation disorders) were excluded.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eDemographic Datas\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAll patients were informed about the study in the preoperative holding area. Written consent was obtained from those who voluntarily agreed to participate. Data were recorded about age, sex, height, weight, ASA classification, education level (primary, secondary, high school, university), occupation (homemaker, laborer, civil servant, student, self-employed), smoking status (\u0026ge;\u0026thinsp;10 cigarettes/day at least one week before surgery considered smoking), alcohol consumption (\u0026ge;\u0026thinsp;4 times/week, averaging 3\u0026ndash;4 drinks/day considered drinking), and fasting duration.\u003c/p\u003e\u003cp\u003ePatients who did not receive premedication and agreed to participate were assessed for preoperative anxiety using the Beck Anxiety Inventory (BAI) via face-to-face interviews in the preoperative holding area [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eGroups and Interventions\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFollowing the BAI assessment, a 20-gauge cannula was inserted into the dorsum of the hand, and fluid infusion was initiated. Patients were randomly divided into two groups using sealed envelopes based on the timing of intravenous (iv) acetaminophen administration. The patients in \u003cb\u003eGroup 1\u003c/b\u003e received 1 g iv acetaminophen 30 minutes before surgery, while the patients in \u003cb\u003eGroup 2\u003c/b\u003e received 1 g iv acetaminophen 15 minutes before the end of surgery. The patients in\u003c/p\u003e\u003cp\u003eGroup 1 underwent both BAI assessment and acetaminophen infusion prior to entering the operating room, while those in Group 2 entered the operating room following only the BAI assessment. Perioperative drug administrators, surgeons, and anesthesiologists were blinded to group allocations.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eAnesthesia management and evaluation\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eStandard monitoring was applied to all patients. Anesthesia induction and maintenance were performed by an anesthesiologist unaware of the study. Commonly preferred routine practices were observed: induction with propofol, rocuronium, and fentanyl, and maintenance with sevoflurane and remifentanil to maintain BIS between 40 and 60. At the end of surgery, all patients received 20 mg iv metoclopramide as an antiemetic and 1 mg/kg tramadol. The neuromuscular blockade was reversed with neostigmine and atropine, and patients were extubated upon the return of spontaneous respiration and protective reflexes.\u003c/p\u003e\u003cp\u003eAll intraoperative and postoperative medications, intraoperative fluid volumes, and operating room temperatures were recorded. All the surgical procedures were performed by the same surgical team using a similar technique.\u003c/p\u003e\u003cp\u003eThe duration from the induction to the cessation of anesthetic gases was recorded as the \u0026ldquo;anesthesia time\u0026rdquo;, the interval from the cessation of anesthetic gases to extubation was recorded as the \u0026ldquo;extubation time\u0026rdquo;, the BIS values at extubation were recorded, and the time from the cessation of anesthetic gases to achieving an Aldrete score of 9 was recorded as the \u0026ldquo;recovery time.\u0026rdquo; Recovery time (from admission to the recovery room until discharge) and complications observed in the recovery room (nausea, vomiting, coughing, head-neck pain, increased secretions) were recorded. Patients who continued to experience postoperative nausea and vomiting were planned to receive 50 \u0026micro;g/kg iv ondansetron.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eScales used in the study\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePreoperative anxiety was assessed using the Beck Anxiety Inventory (BAI)[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], postoperative agitation was evaluated using the Riker Sedation-Agitation Scale (RSAS)[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and postoperative pain was measured using the Numeric Rating Scale (NRS)[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eBeck Anxiety Inventory\u003c/b\u003e: BAI is a 21-item Likert-type scale that measures the frequency of anxiety symptoms experienced by the individual, with each item scored from 0 to 3 (0\u0026thinsp;=\u0026thinsp;none, 1\u0026thinsp;=\u0026thinsp;mild, 2\u0026thinsp;=\u0026thinsp;moderate, 3\u0026thinsp;=\u0026thinsp;severe). Based on total scores, anxiety levels are classified as follows: 0\u0026ndash;17\u0026thinsp;=\u0026thinsp;low, 18\u0026ndash;24\u0026thinsp;=\u0026thinsp;moderate, \u0026ge;\u0026thinsp;25\u0026thinsp;=\u0026thinsp;high [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The validity and reliability study of BAI in\u003c/p\u003e\u003cp\u003eTurkish was conducted by Ulusoy et al. (1998)[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In our study, a BAI score\u0026thinsp;\u0026ge;\u0026thinsp;18 was considered to indicate moderate-to-severe anxiety.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRiker Sedation-Agitation Scale\u003c/b\u003e: RSAS, which is used to evaluate postoperative agitation (1: unresponsive, 7: dangerously agitated), is frequently preferred due to its ease of use and validated reliability. Although originally developed for intensive care patients, it was preferred due to its validity and ease of use in the evaluation of postoperative agitation in adults [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In this study, RSAS\u0026thinsp;\u0026ge;\u0026thinsp;5 was defined as agitation. Agitated patients were first treated with verbal commands, and if necessary, with 0.05 mg/kg iv midazolam.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eNumeric Rating Scale\u003c/strong\u003e\u003cp\u003eNRS is a unidimensional scale using 11 numeric values (0 to 10) to measure the intensity of pain. Patients are asked to select the number that best represents their pain, where 0 indicates no pain, and 10 indicates the worst pain imaginable. NRS is widely used in clinical practice due to its validity, reliability, and ease of application in assessing postoperative acute pain in adults [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In this study, patients with NRS\u0026thinsp;\u0026ge;\u0026thinsp;4 received 1 \u0026micro;g/kg iv meperidine.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAll assessments were conducted at postoperative 0, 5, 10, and 15 mins by a trained researcher who was blinded to group allocations.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe sample size needed to conduct the study was calculated based on a 95% confidence interval (1-α), 95% testing power (1-β), and an effect size of d\u0026thinsp;=\u0026thinsp;0.838, and it was determined that at least 32 patients needed to be included in each group [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eData were analyzed using the IBM SPSS (Statistical Package for the Social Sciences) V23 program. Normality was assessed with the Shapiro-Wilk test. Categorical variables were compared between groups using chi-squared tests and Yates correction. For comparisons of non-normally distributed variables between two groups, the Mann-Whitney U test was used, while, for normally distributed variables, independent-samples t-tests were utilized. Relationships between non-normally distributed variables were examined using Spearman\u0026rsquo;s rho correlation coefficient. Results are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and median (minimum\u0026ndash;maximum) values for quantitative data and frequency (percentage) values for categorical data. A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;.050 was adopted.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study was completed with 86\u0026nbsp;patients. The mean age of all patients was 29.11\u0026plusmn;8.92 years. No significant differences were found between the groups in terms of demographic characteristics, ASA risk classification, fasting duration, intraoperative fluid volume, surgical/extubation/anesthesia/recovery durations, or BIS values at extubation. Median BAI scores were low and similar in both groups (p \u0026gt; .050, Table 1). Moderate-to-severe anxiety was observed in 2.3% (n=1 Group 1, n=1 Group 2) of all patients.\u003c/p\u003e\n\u003cp\u003eThe groups were similar to each other in terms of education levels, smoking/alcohol consumption status, intraoperative drug administration status, and postoperative\u0026nbsp;complications (p \u0026gt; .050, Table 2). A significant difference was observed only in terms of occupational distributions, with a higher proportion of self-employed individuals in Group 2 (p = .033). No patients required additional medication for agitation, nausea-vomiting, or pain during postoperative recovery (Table 2).\u003c/p\u003e\n\u003cp\u003eIn both groups, RSAS and NRS scores decreased over time in the postoperative period.\u0026nbsp;No significant differences were found between the groups in terms of RSAS scores at any\u0026nbsp;time point (p \u0026gt; .050, Table 3). NRS scores were significantly lower in Group 1 only at the 5th postoperative minute (p = .044). RSAS \u0026ge;5 was observed in 37 patients during the monitoring period. No patients required pharmacological intervention for agitation.\u003c/p\u003e\n\u003cp\u003eNo significant correlation was observed between the preoperative BAI scores and postoperative RSAS or NRS scores of the patients.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIn this study, the effects of preemptive intravenous acetaminophen administration on postoperative agitation and pain, as well as the relationship between preoperative anxiety levels and these outcomes, were investigated in adult patients undergoing septorhinoplasty. According to our results, preemptive acetaminophen administration reduced pain only in the early postoperative period (at the 5th minute), but it had no significant effect on agitation scores. Additionally, the preoperative anxiety levels observed in the patients were low and showed no significant association with postoperative agitation or pain.\u003c/p\u003e\u003cp\u003e The incidence of postoperative agitation following nasal surgeries is reported in the literature to range from 22% to 55%, often triggered by sensations of suffocation and oral- nasal obstruction. Moreover, different types of surgeries and anesthesia methods (total intravenous vs. inhalational anesthesia) are well-known risk factors for postoperative agitation. [\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e–\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Although pain is not the sole cause of agitation, it is recognized as one of the\u003c/p\u003e\u003cp\u003eprimary factors that intensifies its severity and frequency [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our study, the incidence of agitation was found to be quite low. This may reflect the strengths of our design, including standardized anesthesia management, consistent surgical teams, and routine preoperative patient education. However, the use of tramadol in postoperative analgesia may have masked the effect of acetaminophen on agitation, and RSAS may not fully capture all dimensions of postoperative agitation. Differences in evaluation criteria may also have influenced these results. The observed decline in RSAS and NRS scores over time supported the natural trajectory of recovery following surgery. No patients exhibited severe agitation requiring sedatives or physical restraint.\u003c/p\u003e\u003cp\u003eAwake extubation is preferred after nasal surgery due to aspiration risk. However, deep extubation under anesthesia may also be used to prevent postoperative agitation and ensure better airway management [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In our study, the patients were extubated at similar BIS values, which may explain their comparable levels of postoperative agitation.\u003c/p\u003e\u003cp\u003ePrevious studies have reported a significant relationship between preoperative anxiety and postoperative pain in septoplasty procedures [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Similar results have suggested that anxiety may heighten pain perception by increasing the patient’s attention to pain [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Preoperative education has been shown to reduce anxiety levels, although the extent of this effect may vary depending on the psychosocial and educational background of the patient, as well as the knowledge and experience of the educator [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e–\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In a study by Kevser Peker, the mean preoperative anxiety score measured using BAI in septorhinoplasty patients was 12.77 ± 7.09, corresponding to a moderate level of anxiety [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In our study, the median BAI scores in both groups were low, and no significant association of BAI scores with postoperative pain was demonstrated. These low anxiety levels may be related to patient characteristics, cultural factors, the elective nature of the procedure, and preoperative education regarding surgery and anesthesia.\u003c/p\u003e\u003cp\u003eSevere postoperative pain may occur following nasal surgery involving hard tissue manipulation, especially within the first three days [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In recent years, alternative and combination analgesic strategies have been employed to reduce opioid dependence while ensuring adequate analgesia [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Acetaminophen is a frequently used and safe agent in preemptive analgesia, with pharmacokinetic properties that make it more effective in the early postoperative period [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In our study, the analgesic effect was observed only at the 5th minute, consistent with these pharmacological characteristics. The use of tramadol in postoperative analgesia may have masked the effect of acetaminophen on agitation. Furthermore, information in the relevant literature indicates that agitation is influenced not\u003c/p\u003e\u003cp\u003eonly by pain but also by multiple other factors such as age, sex, smoking status, anesthesia method, and airway management [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore, it is expected that acetaminophen alone may be insufficient to prevent agitation.\u003c/p\u003e\u003cp\u003eThis study had some limitations. First, its relatively small sample size may have reduced the statistical power of the study. Second, there was no placebo group in the study. Third, the study was conducted at a single center, which may restrict the generalizability of its results. Fourth, the use of tramadol in postoperative analgesia may have masked the true effect of acetaminophen. Lastly, RSAS was originally developed for intensive care settings and may not fully reflect early postoperative agitation. Additionally, factors such as individual psychological variables and pain thresholds were not considered in this study.\u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions and suggestions","content":"\u003cp\u003ePreemptive acetaminophen administration reduced early postoperative pain in adult patients undergoing septorhinoplasty but was not sufficient on its own to prevent agitation. Preoperative anxiety levels were low and showed no significant effect on postoperative agitation or pain. Given the multifactorial nature of agitation, multimodal analgesic strategies and individualized pain management approaches may be more effective. Therefore, future studies with larger sample sizes, multicenter designs, and placebo-controlled protocols are needed.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Disclosure statement\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNo\u0026nbsp;potential\u0026nbsp;conflict of\u0026nbsp;interest\u0026nbsp;was\u0026nbsp;reported by\u0026nbsp;the\u0026nbsp;author(s).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Data availability statement\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe data that support the findings of this study are available from the corresponding author, G.K., upon reasonable request.\u003c/p\u003e\n\u003cp\u003eEthical\u0026nbsp;approval\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThis study was approved by Zonguldak Bulent Ecevit University Ethics Committee (Meeting decision\u0026nbsp;No: 2020/04) and registration with ClinicalTrials.gov (Identifier: NCT07010042 Date: 05/23/2025).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources:\u0026nbsp;\u003c/strong\u003eNo funding was received\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eConcept-design: K\u0026uuml;\u0026ccedil;\u0026uuml;kosman G,\u0026nbsp;Bollucuoğlu K, K\u0026ouml;ksal BG, Ayoğlu; Data collection: Alp Dİ, Bayram GM, Bilgin E;Data analysis and interpretation: K\u0026uuml;\u0026ccedil;\u0026uuml;kosman G, K\u0026ouml;ksal BG, Ayoğlu H;Manuscript draft: K\u0026uuml;\u0026ccedil;\u0026uuml;kosman G, Bollucuoğlu K;Critical revision of content:K\u0026uuml;\u0026ccedil;\u0026uuml;kosman G, Bollucuoğlu K, K\u0026ouml;ksal BG, Ayoğlu H;Final approval and responsibility:K\u0026uuml;\u0026ccedil;\u0026uuml;kosman G,Bilgin ,\u0026nbsp;K\u0026ouml;ksal BG, Ayoğlu H.\u003c/p\u003e\n\u003cp\u003eAll authors (K\u0026uuml;\u0026ccedil;\u0026uuml;kosman G, Alp Dİ, Bilgin E, Bayram GM, Bollucuoğlu K, K\u0026ouml;ksal BG, Ayoğlu H) reviewed the results and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOh J, Lee W, Ki S, Suh J, Hwang S, Lee J. 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Braz J Anesthesiol. 2025;75(1):844565.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchulz KF, Altman DG, Moher D, CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. J Clin Epidemiol. 2010;63(8):834\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRiker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999;27(7):1325\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: visual analog scale (VAS), numeric rating scale (NRS), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011;63(Suppl 11):S240\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePolat R, Peker K, Baran I, Aydin GB, Topcu Guloksuz C, Donmez A. Comparison between dexmedetomidine and remifentanil infusion in emergence agitation during recovery after nasal surgery: a randomized double-blind trial. Anaesthesiologie. 2024;73(1):64. [Retracted].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim SY, Kim JM, Lee JH, Song BM, Koo BN. Efficacy of intraoperative dexmedetomidine infusion on emergence agitation and quality of recovery after nasal surgery. Br J Anaesth. 2013;111(2):222\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoc M, Tezcan B, Ozdemir H, Arslan A, Cetin M. Evaluation of the effect of preoperative anxiety on postoperative pain in septoplasty operations. Kulak Burun Bogaz Ihtis Derg. 2011;21(2):79\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGranot M, Ferber SG. The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity: a prospective study. Clin J Pain. 2005;21(5):439\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVillemure C, Bushnell MC. Cognitive modulation of pain: how do attention and emotion influence pain processing? Pain. 2009;144(1\u0026ndash;2):1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSamadi A. Preoperative education and its impact on patients\u0026rsquo; anxiety and surgical outcomes: a review. J Heart Health Rep. 2024;5(2):144503.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAli A, Rani P, Kaur R, Kumar A, Thomas L. Effect of structured preoperative education on perioperative anxiety among women undergoing surgery: a randomized controlled trial. BMC Health Serv Res. 2024;24:11388.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJamwal A. Structured perioperative education interventions to reduce anxiety and depression: a narrative review. Glob J Qual Saf Healthc. 2023;10:23743735231151535.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeker K. Preoperative anxiety evaluation using Beck and State-Trait Anxiety scales: patients undergoing septorinoplasty. J Anesth Reanim Sci Surg (JARSS). 2020;28(2):109\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSzychta P, Antoszewski B. Assessment of early postoperative pain following septorhinoplasty. J Laryngol Otol. 2010;124(11):1194\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAydil U, Yilmaz M, Akyildiz I, Bayazit Y, Keseroglu K, Ceylan A. Pain and safety in otorhinolaryngologic procedures under local anesthesia. 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Life (Basel). 2024;14(10):1272.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Preemptive analgesia, Acetaminophen, Preoperative anxiety, Postoperative agitation, Septorhinoplasty","lastPublishedDoi":"10.21203/rs.3.rs-7955803/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7955803/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePreoperative anxiety and postoperative agitation are common in otolaryngologic surgeries such as septorhinoplasty and may adversely affect patient outcomes. Although preemptive acetaminophen is frequently used to reduce postoperative pain, its effects on agitation remain unclear. This study aimed to investigate the relationship between preoperative anxiety and postoperative agitation and pain, as well as the effect of preemptive intravenous acetaminophen administration in adult septorhinoplasty patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e This prospective, randomized study was conducted between March and September 2020 at Zonguldak Bulent Ecevit University Hospital after ethics approval (protocol no: 2020/04). Eighty-six, ASA I\u0026ndash;II adult patients (aged 18\u0026ndash;65 years) undergoing elective septorhinoplasty were included. Patients were randomized into two groups: Group 1 received 1 g intravenous acetaminophen 30 minutes before induction, and Group 2 received it 15 minutes before the end of surgery. Preoperative anxiety was assessed using the Beck Anxiety Inventory (BAI), postoperative agitation with the Riker Sedation-Agitation Scale (RSAS), and postoperative pain with the Numeric Rating Scale (NRS) at 0, 5, 10, and 15 minutes postoperatively. p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe groups were comparable in demographic and intraoperative variables. Moderate-to-severe anxiety was observed in 2.3% of all patients. NRS scores were significantly lower in Group 1 at the 5th postoperative minute (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), whereas no significant differences were found in RSAS scores at any time point. RSAS and NRS scores decreased over time in both groups. No significant correlations were detected between preoperative anxiety and postoperative agitation or pain.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003ePreemptive acetaminophen administration reduced early postoperative pain but had no significant effect on postoperative agitation in adult septorhinoplasty patients. Low levels of preoperative anxiety did not influence agitation or pain outcomes. Individualized analgesic strategies and multimodal approaches may provide more effective perioperative management in nasal surgeries.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eClinicalTrials.gov Identifier: NCT07010042.\u003c/p\u003e","manuscriptTitle":"Effects of preemptive acetaminophen administration and preoperative anxiety on postoperative agitation and pain in adult septorhinoplasty patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 15:39:01","doi":"10.21203/rs.3.rs-7955803/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6bb97ee3-bb3d-4ff2-8fd6-30c3fb110db9","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-17T17:38:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 15:39:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7955803","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7955803","identity":"rs-7955803","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}