NCANA PTSD EMERGENCE DELIRIUM

PTSD,Emergence Delirium, and the PACU

LTC Denise Beaumont, CRNA

ObjectivesParticipants 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 InterventionsIneffective

Wilson and McGuireBy 2013 we knew

• ED is a problem• Gap existed in

LiteratureMulti-Disciplinary

Approach


How we got here…

Do no Harm

Question

Observation

and Analysis

Document

Discovery/Evidence1

2

3

4 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 WilsonUS 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 deliriumDefinitions


Emergence

Agitation - Pediatric

?




Emergence


Post-Op Delirium -

ICU

?




Emergence


Post-Op Delirium -

ICU

?

Emergence

Delirium - PTSD




Delirium Scale?

Emergence


Post-Op Delirium -

ICU

?

Emergence

Delirium - PTSD




PTSD and Emergence DeliriumDelirium Scale- Pediatric• Eye contact• Purposeful actions• Awareness of

surroundings• Restlessness• Ability to console

PTSD and Emergence DeliriumDelirium 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)

PharmacotherapyExposure/

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 23

4

Management


Diff diagnosis

1

Meds

2

TIVA/Volatile

3PTSD specific

4

Plan of Care Anesthesia

Anesthesia

Ketamine/Versed/dex/clonidine


Preop

1 23

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 23

4

Management


Plan of Care

PACU

Risk?

Consistency

Low Stim

Validate/talkD

C

B

A

A

B

C

D Begin the healing

Amydalocentric

Staffing/Security

Know your patient


Document, document, document

refines definitions, aids in research

DischRESPECT-Mil

Anesthesia

Ketamine/versed/dex/clonidine PACU

Low stim/rescue


Preop

1 23

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

References1. 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.

References12.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.

References21.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.

http://app44webinservice.com.nursingskills/Legal/AboutNursingSkills.aspx


Questions


Name: LTC Denise Beaumont

Email: [email protected]

Phone: (210) 295-4356

mailto:[email protected]

NCANA PTSD EMERGENCE DELIRIUM

Education

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