A total of 340 elderly patients undergoing thoracoscopic radical lung cancer surgery at Sun Yat-sen University Cancer Center from July 1 to December 31, 2024, were selected [18][19].

Inclusion criteria:

a) Age ≥ 65 years;

b) Diagnosed with primary lung cancer and scheduled for thoracoscopic radical lung cancer surgery;

c) General anesthesia with orotracheal intubation, ASA classification I - III;

d) Informed consent from patients and their families.

Exclusion criteria:

a) Severe cardiac, pulmonary, cerebral, hepatic, or renal dysfunction;

b) Contraindications to anesthesia or abnormal coagulation function;

c) Conversion to open thoracotomy during surgery or postoperative transfer to ICU;

d) Disturbance of consciousness, dementia, or hearing disorder.

Grouping: Patients were randomly divided into a control group (170 cases) and an intervention group (170 cases) using a random number table. There were no statistically significant differences in baseline characteristics between the two groups (P > 0.05), indicating comparability.

2.2.1. Control Group: Conventional Anesthesia Recovery Nursing

a) Preoperative visit and health education;

b) Intraoperative monitoring of vital signs, warmed intravenous fluids, and warming blankets;

c) Post-PACU monitoring of heart rate, blood pressure, blood oxygen, body temperature, and consciousness;

d) Airway management, oxygen therapy, suctioning, and assistance with extubation;

e) Pain observation, restraint nursing, and routine management.

2.2.2. Intervention Group: Feedforward Control Combined with Family Awakening Nursing

1) Establishment of a Feedforward Control Team

Comprising anesthesia nurses, head nurses, senior nurses, and anesthesiologists, the team systematically identified high-risk factors such as agitation, hypothermia, hypoxemia, pain, delirium, and delayed recovery, and developed stratified prevention measures and standardized protocols [20][21].

2) Preoperative Risk Assessment and Standardized Family Awakening

a) Comprehensive assessment: Age, comorbidities, pulmonary function, nutritional status, thrombosis risk, hypothermia/hypoxemia risk factors [22][23], and language type (Mandarin, Cantonese, Hakka, Teochew).

b) Standardized family awakening procedure:

Preoperative voice recording: One day before surgery, the responsible nurse guided family members to record a personalized awakening message (60 - 90 seconds) in a gentle tone and slow pace, including the patient’s name, family identity, notification of successful surgery, explanation of the PACU setting, encouragement for slow awakening, cooperation with breathing, and avoidance of agitation, while conveying family support and care. Multilingual recordings (Cantonese, Mandarin, Hakka, Teochew) were saved on PACU playback devices.

Awakening timing: Initiated immediately upon PACU admission and stable vital signs, covering the unresponsive phase, eye-opening phase, coughing phase, pre-extubation phase, and post-extubation observation phase.

Multisensory awakening:

Auditory: Low-volume looping of family recordings at the bedside;

Tactile: Nurses gently holding the patient’s hand or stroking the arm;

Verbal: Nurses softly calling the patient’s name and providing orientation cues;

Environmental: Dimmed lighting and noise reduction (≤55 dB).

Stratified awakening strategy:

Deep sedation: Continuous voice + tactile stimulation;

Moderate sedation: Intermittent playback + timed verbal cues;

Agitation tendency: Focus on soothing, reducing strong stimuli.

Post-extubation reinforcement: Continued playback for 3 - 5 minutes to prevent re-agitation and delirium.

3) Core Feedforward Control Interventions

a) Temperature control: Preoperative pre-warming for 30 minutes; intraoperative warming blankets and fluid warming; postoperative continuous rewarming [24].

b) Airway and respiratory control: Pre-extubation thorough suctioning and lung recruitment; post-extubation moderate-flow oxygen to prevent hypoxemia [25].

c) Agitation and pain control: Multimodal analgesia, dynamic NRS/FLACC assessment, and optimized sedation depth.

d) Circulatory stability: Blood pressure and heart rate monitoring to prevent severe fluctuations.

e) Delirium prevention: Timed awakening, voice stimulation, temperature maintenance, and optimized anesthesia metabolism.

Agitation incidence, Riker SAS scores;

NRS and FLACC pain scores;

Body temperature, hypothermia incidence;

Blood oxygen saturation, hypoxemia incidence;

Spontaneous breathing recovery, eye-opening, extubation, and PACU stay times;

Nausea/vomiting, delirium, arrhythmia, pulmonary complications;

Hemodynamic stability.

SPSS 26.0 was used. Measurement data were expressed as ( x ¯ ± s ) and analyzed by t-tests; count data were expressed as rates (%) and analyzed by χ² tests; repeated measures were analyzed by ANOVA. P < 0.05 indicated statistical significance.

A total of 340 elderly patients were enrolled and randomized into the control group (n = 170) and intervention group (n = 170). No patients were excluded after randomization, and no missing outcome data were observed in this study. Baseline characteristics, including age, gender, BMI, ASA classification, and operation time, were comparable between the two groups (all P > 0.05), as presented in Table 1.

Table 1. Comparison of baseline characteristics between the two groups.

Compared with the control group, the intervention group showed a significantly lower incidence of emergence agitation (7.65% vs 22.94%, χ² = 15.72, P < 0.001). The relative risk (RR) was 0.334, with a 95% confidence interval (CI) of 0.184 to 0.606. Meanwhile, Riker Sedation-Agitation Scale (SAS) scores at all time points (T1, T2, T3) were significantly lower in the intervention group (all P < 0.05). Details are shown in Table 2.

Table 2. Comparison of agitation incidence and SAS scores.

SAS = Riker Sedation-Agitation Scale.

Pain scores including Numerical Rating Scale (NRS) and Face, Legs, Activity, Cry, Consolability (FLACC) scores were both significantly lower in the intervention group than those in the control group (both P < 0.05), indicating better analgesic effects. Detailed comparisons are listed in Table 3.

Table 3. Comparison of NRS and FLACC pain scores ( x ¯ ± s ).

NRS = Numerical Rating ScaleFLACC = Face, Legs, Activity, Cry, Consolability Scale.

The incidence of hypothermia was 8.24% in the intervention group versus 24.71% in the control group (χ² = 18.56, P < 0.001, RR = 0.334, 95%CI: 0.186 - 0.598). The incidence of hypoxemia in the PACU was 5.29% vs 17.06% (χ² = 12.44, P < 0.001, RR = 0.310, 95%CI: 0.152 - 0.631). Hypoxemia at 2 hours after ward transfer was also significantly lower (2.35% vs 10.59%, P < 0.05). Data are presented in Table 4.

Table 4. Comparison of the incidence of hypothermia and hypoxemia between the two groups [n (%)].

All recovery indicators including spontaneous breathing recovery time, eye-opening time, extubation time, and PACU stay time were significantly shorter in the intervention group (all P < 0.05). Table 5 shows the detailed comparison.

Table 5. Comparison of recovery time between the two groups ( x ¯ ± s , min).

Individual complications were separately analyzed and compared. The incidences of agitation, hypothermia, hypoxemia, delirium, nausea/vomiting, and pulmonary complications were all significantly lower in the intervention group (all P < 0.05). The total complication rate was 17.06% in the intervention group and 40.00% in the control group (χ² = 22.81, P < 0.001, RR = 0.426, 95%CI: 0.294 - 0.618). Detailed data are listed in Table 6.

Table 6. Comparison of individual complications and total complication rate [n (%)].

Elderly patients are often confused, unfamiliar with the environment, and prone to fear, agitation, and delirium during the recovery period of general anesthesia. Family voice has four major functions: high familiarity, emotional attachment, sense of security, and orientation recovery, which can quickly reduce stress responses and reduce the risks of struggling, extubation, and falling from the bed.

Feedforward control prevents hypothermia, hypoxia, and pain in advance; family affection awakening accelerates consciousness recovery and shortens delayed awakening. The two work together to make recovery more stable, faster, and safer.

This study supports recording in Mandarin, Cantonese, Hakka, and Chaozhou dialects, which is more in line with the language habits of elderly patients and leads to more stable awakening effects.

Family affection awakening is cost-free, non-invasive, easy to operate, and highly compliant; feedforward control is standardized, reproducible, and quality-controllable. The combined model is suitable for widespread promotion in thoracic surgery, PACU, elderly surgery, and oncological surgery.

The results of this study confirm that combining feedforward control, which focuses on risk prediction and early intervention, with family affection awakening characterized by emotional comfort and multi-sensory stimulation, can simultaneously reduce the incidence of multiple adverse events such as agitation, pain, hypothermia, hypoxemia, delirium, nausea and vomiting, and pulmonary complications. The total complication rate in the intervention group was only 17.06%, much lower than 40.00% in the control group, indicating that this model can reduce risks during anesthesia recovery from the source and provide a reliable guarantee for the early postoperative safety of elderly patients with lung cancer.

Through familiar family voice, multi-sensory stimulation, and orientation awakening, family affection awakening significantly reduces fear, anxiety, and agitation during the recovery period, and significantly lowers SAS agitation scores, NRS and FLACC pain scores. This model not only embodies the patient-centered care concept but also introduces the family support system into perioperative care, making up for the lack of humanistic care in traditional recovery nursing, especially suitable for the elderly with decreased cognitive function and sensitive stress responses.

Studies have shown that the spontaneous breathing recovery time, eye opening time, extubation time, and PACU stay time in the intervention group are significantly shorter than those in the control group, suggesting that feedforward control lays a physiological foundation for rapid recovery through temperature management, airway protection, and circulatory stability, while family affection awakening accelerates consciousness recovery and shortens delayed awakening. The synergistic effect of the two can effectively shorten the patient’s stay in the anesthesia care unit, improve the bed turnover efficiency of the department, and conform to the core goal of Enhanced Recovery After Surgery (ERAS).

Aiming at the linguistic characteristics of South China, Hong Kong SAR, and Macao SAR, this study supports voice recording in Mandarin, Cantonese, Hakka, and Chaozhou dialects, making awakening intervention closer to the patients’daily language environment and improving intervention compliance and effectiveness. This method is easy to operate, non-invasive, cost-free, and easy to standardize, and can be widely used in thoracic surgery, PACU, elderly surgery, and perioperative oncological nursing in hospitals at all levels.

This study deeply integrates prospective risk management with humanistic care, and constructs a closed-loop nursing model of “prediction-prevention-awakening-comfort-stabilization”, breaking through the passive nursing mode of traditional “monitoring-response”. This model not only improves nursing quality and safety but also enhances nurses’ risk prediction ability, promotes the development of anesthesia recovery nursing towards refinement, predictability, and humanization, and provides practical and theoretical support for the improvement of the perioperative nursing system for elderly thoracic surgery patients.

This model does not require a large amount of medical resources and equipment investment, and can significantly improve recovery outcomes only by optimizing nursing processes, strengthening risk prevention and control, and integrating family emotional support. It is suitable for promotion in hospitals at all levels. Its comprehensive advantages in reducing complications, shortening recovery time, and improving comfort and safety make it an ideal nursing plan for elderly patients undergoing radical resection of lung cancer during anesthesia recovery.