NCANA PTSD EMERGENCE DELIRIUM

PTSD,
Emergence Delirium,
and the PACU
LTC Denise Beaumont, CRNA

Objectives
Participants will be able to:
1. Verbalize the definitions of PTSD,
emergence delirium and their implications in
the perioperative setting.
2. Identify current evidence on
emergence delirium and PTSD.
3. Integrate strategies presented into
his/her own anesthesia practice.

1 How we got here
Definitions
Plan of Care
What the future holds
2
3
4
PTSD and Emergence Delirium

1 2 3 4
Army PACU
Gap in
Literature
Standard
Interventions
Ineffective
Wilson and
McGuireBy 2013 we knew
•ED is a problem
•Gap existed in Literature
Multi-Disciplinary
Approach
How we got
here…

Do no Harm
Question
Observation
and Analysis
Document
Discovery/Evidence
Process, outcome,
Evaluation
Practice Integration
Translation to guidelines
Star Model *

Preoperative PACU DischargeIntraoperative
Improved
patient
outcomes
Evidence-Based
Guidelines

– CMDR Jason
McGuire USN
– LTC Tyler Wilson
US Army
- LCDR Ken Wofford
USN, et al
• Donna Lovestrand
et al
• Jason Mc Lott, CRNA
et al
• Plus…
“How we got here” team

?
Emergence Delirium
•Emergence agitation
•Post operative delirium
•Emergence delirium
Definitions

Emergence
Agitation -
Pediatric
?
Emergence Delirium
Definitions

Emergence
Agitation -
Pediatric
Post-Op Delirium -
ICU
?
Emergence Delirium
Definitions

Emergence
Agitation -
Pediatric
Post-Op Delirium -
ICU
?
Emergence
Delirium -
PTSD
Emergence Delirium
Definitions

Delirium Scale?
Emergence
Agitation -
Pediatric
Post-Op Delirium -
ICU
?
Emergence
Delirium -
PTSD
Emergence Delirium
Definitions

Delirium Scale- Pediatric
• Eye contact
• Purposeful actions
• Awareness of
surroundings
• Restlessness
• Ability to console

Delirium Scale- Pediatric
• Eye contact
• Purposeful actions
• Awareness of
surroundings
• Restlessness
• Ability to console
Adult Delirium
• Purposeful eye contact
• Flashbacks/hallucinations

Tyler Wilson, 2014 [12]
Definition
• The scenario of a combat veteran who is emerging from
general anesthesia and is subsequently seen thrashing
around in a violent manner (to include pulling at monitoring
equipment, intravenous catheters, endotracheal tubes,
drains, Foley catheter, etc.), screaming, speaking
incoherently, hitting, biting, or attempting to leave the
OR…encompassing any time frame from the end of surgery
to discharge from the PACU”

1
PTSD
2 3
Definitions

1
Hyper-
arousal
PTSD
2 3
Definitions

1
Hyper-
arousal
PTSD
2
Avoidance
3
Definitions

1
Hyper-
arousal
PTSD
2
Avoidance
3
Intrusion
Symptoms
Definitions

Psychotherapy
(e.g. CBT)
Pharmacotherapy
Exposure/
Relaxation
Trusting
Relationship
Treatment of PTSD
as outpatient

Hypervigilant,
Sensitivity to
noises,
Preoccupied
with
surroundings
Hyperarousal
Prazosin or
clonidine
SSRI/SNRI
hydroxyzine
Medication Rec
Safety
Known triggers?
Seeing therapist?
Nightmares/
Psych hx
What type of
anesthesia?
Assurance of
care
History of
“Agitated Wake-ups”
1 2 3 4
Plan of Care
Preoperative
Interview

Identification of Patients
Preop
1 2
3
4
Management

Diff diagnosis
1
Meds
2
TIVA/Volatile
3
PTSD specific
4
Plan of Care Anesthesia

Anesthesia
Ketamine/Versed/dex/clonidine
Preop
1 2
3
4
Management

Auditory stimulation
Inappropriate retrieval of
memories (sounds)
Inhibit accurate
interpretation and
categorization of
memories
ED and AN
GA- Produces
amnesia, ?hyperarousal
Benzos-
amnesia, ?hyperarousal
Anesthesia and
AN
PTSD and AN
Free flow of fear to
amygdala
Hippocampus- cannot
accurately place fears
in context – benign vs.
dangerous
Amygdalocentric
neurocircuitry
(AN)

Anesthesia
Ketamine/Versed/dex/clonidine
PACU
Low stim/rescue
Preop
1 2
3
4
Management

Plan of Care
PACU
Risk?
Consistency
Low Stim
Validate/talk
D
C
B
A
Begin the healing
Amydalocentric
Staffing/Security
Know your patient

Document,
document,
document
refines definitions, aids in research

Disch
RESPECT-Mil
Anesthesia
Ketamine/versed/dex/clonidine
PACU
Low stim/rescue
Preop
1 2
3
4
Management

Volatile vs TIVA
α2-adrenergic
agonists
Ketamine
vocal local
Intraop
Consistency
Medications
Validate
Psychotherapy
Delirium scale
Dex study
Research
Guidelines
Disseminate
info
Future
Identify Patient
Med Rec
History
Prepare for
discharge
Preop
Low stim
Pain control
Avoid touch
Document
PACU/Discharge

• What the future holds
– Delirium Scale for adults
– Research on dexmedetomidine - begun
in January, 2015; Other medications?
– Dissemination of data
– Cognitive Behavioral training for staff?
– Evidence-based guidelines

References
1. J. Wilson, "Army anesthesia providers' perceptions of emergence delirium after general
anesthesia in service members," AANA Journal, vol. 81, no. 6, pp. 443-440, 2013.
2. J. McGuire, "The incidence of and risk factors for emergence delirium in US military combat
veterans," Journal of Perianesthesia Nursing, vol. 27, no. 4, pp. 236-245, 2012.
3. J. Thomas, J. Wilk, L. Riviere, D. McGurk, C. Castro and C. Hoge, "Prevalence of mental health
problems and functional impairment among active component and national guard soldiers 3 and
12 months following combat in Iraq," Archives of General Psychiatry, vol. 67, no. 6, pp. 614-623,
2010.
4. K. Wofford, M. Hertzberg and C. Vacchiano, "The perioperative implications of posttraumatic
stress disorder," AANA Journal, vol. 80, no. 6, pp. 463-470, 2012.
5. J. McLott, J. Jurecic, L. Hemphill and K. Dunn, "Development of an amygdalocentric
neurocircuitry-reactive aggression theoretical model of emergence delirium in posttraumatic
stress disorder: An integrative literature review," AANA Journal, vol. 81, no. 5, pp. 379-384, 2013.
6. T. Olszewski and J. Varrasse, "The neurobiology of PTSD: implications for nurses," Journal of
Psychosocial Nursing, vol. 43, no. 6, pp. 41-47, 2005.
7. K. Wofford, M. Hertzberg, S. Silva and C. Vacchiano, "Effect of elective surgery on subjective
health in veterans with chronic posttraumatic stress disorder," AANA Journal, vol. 82, no. 4, pp.
285-292, 2014.
8. D. Lovestrand, S. Phipps and S. Lovestrand, "Posttraumatic stress disorder and anesthesia
emergence," AANA Journal, vol. 81, no. 3, pp. 199-203, 2013.
9. S. Shoum, "Posttraumatic stress disorder: a special case of emergence delirium and anesthetic
alternatives," A&A Case Reports, vol. 3, no. 5, pp. 58-60, 2014.
10.T. Wilson and S. Graves, "Pediatric considerations in a postanesthesia care unit," Journal of
Post Anesthesia Nursing, vol. 5, no. 1, pp. 16-24, 1990.
11.American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Washington, DC: Author, 1994.

References
12.J. Wilson, "Pharmacologic, physiological and psychological characteristics associated with
emergence delirium in combat veterans," AANA Journal, vol. 82, no. 5, pp. 355-362, 2014.
13.K. Wofford and C. Vacchiano, "Sorting through the confusion: adverse cognitive change after
surgery in adults," AANA Journal, vol. 79, no. 4, pp. 335-342, 2011.
14.American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition, Arlington, VA: Author, 2013.
15.C. Lepouse, C. Lautner, L. Liu, P. Gomis and A. Leon, "Emergence delirium in adults in the post-
anaesthesia care unit," British Journal of Anesthesia, vol. 96, no. 6, pp. 747-753, 2006.
16.N. Sikich and J. Lerman, "Development and psychometric evaluation of the pediatric emergence
delirium scale," Anesthesiology, vol. 100, no. 5, pp. 1138-1145, 2004..
17.Z. Kain, A. Caldwell-Andrews, I. Maranets, B. McClain, D. Gaal, L. Mayes, R. Feng. and H.
Zhang, "Preoperative anxiety and emergence delirium and postoperative maladaptive
behaviors," Anesthesia and Analgesia, vol. 99, pp. 1648-1654, 2004.
18.M. Raskind, E. Peskind, D. Hoff, K. Hart, H. Holmes, D. Warren, J. Shofer and e. al., "A parallel
group placebo controlled study of prazosin for trauma nightmares and sleep disturbance in
combat veterans with post-traumatic stress disorder," Biological Psychiatry, vol. 61, pp. 928-934,
2007.
19.A. Alao, J. Selvarajah and S. Razi, "The Use of clonidine in the treatment of nightmares among
patients with co-morbid PTSD and traumatic brain injury," International Journal of Psychiatry and
Medicine, vol. 44, no. 2, pp. 165-169, 2012.
20.R. Gertler, H. Brown, D. Mitchell and E. Silvus, "Dexmedetomidine: A novel sedative-analgesic
agent," Proceedings of the Baylor University Medical Center, vol. 14, no. 1, pp. 13-21, 2001.

References
21.J. Wilson and M. Pokorny, "Experiences of military CRNAs with service personnel who are
emerging from general anesthesia," AANA Journal, vol. 80, pp. 260-265, 2012.
22.J. Sneyd, "Droperidol: past, present and future," Aanesthesia [serial online], vol. 64, pp. 1161-
1164, 2009.
23.T. Thurston, C. Williams and S. Foshee, "Reversal of a paradoxical reaction to midazolam with
flumazenil," Anesthesia and Analgesia, vol. 83, no. 1, p. 192, 1996.
24.F. Radtke, M. Frank, L. Hagemann, M. Seeling, K. Wernecke and C. Spies, "Risk factors for
inadequate emergence after anesthesia: emergence delirium and hypoactive emergence,"
Minerva Anestesiological, vol. 76, no. 6, pp. 304-403, 2010.
25.A. Magaw, "A report of 245 cases of anesthesia by nitrous oxide gas and ether," St. Paul
Medical Journal, vol. 3, pp. 231-233, 1901.
26.S. Keogh, K. Fry, E. Mbugua, M. Ayallo, H. Quinn, G. Otieno and N. T.D., "Vocal local versus
pharmacological treatments for pain management in tubal ligation procedures in rural Kenya: a
non-inferiority trial," BMC Women's Health, vol. 14, p. 21, 2014.
27.F. Nightingale, Notes on Nursing: What it is and What it is Not, New York: D. Appleton and
Company, 1860.
28.Nursing Skills Fair, Mosby's Nursing Skills, Maryland Heights, MO: Elsevier, 2012.
http://app44webinservice.com.NursingSkills/Legal/AboutNursingSkills.aspx
29.A. Prins, R. Kimerling and G. Leskin, "PTSD in Iraq war veterans: implications for primary care,"
in Iraq War Clinician Guide - 2nd Edition, Washington, DC, National Center for PTSD and
Department of Defense, 2011, Chapter 7.
30.C. Engel, T. Y. C. Oxman, D. Gould, S. Barry, P. Stewart, K. Kroenke, J. Williams and A.
Dietrich, "RESPECT-Mil: Feasibility of a systems-level collaborative care approach to depression
and post-traumatic stress disorder in military primary care," Military Medicine, vol. 173, no. 10,
pp. 935-940, 2008.

PTSD and
Emergence Delirium
Questions

Name: LTC Denise Beaumont
Email: denise.m.beaumont.mil@mail.mil
Phone: (210) 295-4356

NCANA PTSD EMERGENCE DELIRIUM

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