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Emergence delirium prevention in American veterans diagnosed with post-traumatic stress disorder: a critical literature review with practice recommendations

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Emergence delirium prevention in American veterans diagnosed with post-traumatic stress disorder: a critical literature review with practice recommendations

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Content Running head: EMERGENCE DELIRIUM IN AMERICAN VETERANS i

EMERGENCE DELIRIUM PREVENTION IN AMERICAN VETERANS DIAGNOSED WITH POST-
TRAUMATIC STRESS DISORDER: A CRITICAL LITERATURE REVIEW WITH PRACTICE
RECOMMENDATIONS

by

Kristen Roman

A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2021

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The following manuscript was contributed in equal parts by
Jena Borgonia, Ignacio Diaz and Kristen Roman

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Dedication
We dedicate this capstone project to all American veterans.

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Acknowledgements
The authors sincerely thank Dr. Elizabeth Bamgbose for serving as our Capstone Chair as
well as Dr. Charles Griffis and Dr. Jeffrey Darna for serving as our Capstone Advisors. Their
guidance and support during the development of this capstone project was invaluable. We also
thank the faculty and administration of the USC Keck School of Medicine Program of Nurse
Anesthesia for their ongoing support of the advancement of the practice of nurse anesthesia.
The authors acknowledge the use of two figures developed by and with the expressed
permission of the original author, Kristina Hintzsche, CRNA. We thank her for granting
permission to incorporate the illustrations into this capstone project and her pursuit of
contributing pharmacologic knowledge to the field of anesthesia.

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Table of Contents

Dedication ...................................................................................................................................... iii
Acknowledgements ........................................................................................................................ iv
List of Tables ................................................................................................................................ vii
List of Figures .............................................................................................................................. viii
Abstract .......................................................................................................................................... ix
Chapter 1 ......................................................................................................................................... 1
Introduction ................................................................................................................................. 1
Clinical Problem ...................................................................................................................... 1
Research Question and Specific Aims..................................................................................... 5
Background and Significance .................................................................................................. 5
Chapter 2 ......................................................................................................................................... 7
Proposed Methods ....................................................................................................................... 7
Search Strategy ........................................................................................................................ 7
Chapter 3 ....................................................................................................................................... 11
Literature Review ...................................................................................................................... 11
Preoperative assessment and evaluation ................................................................................ 11
Intraoperative Interventions ................................................................................................... 14
Postoperative Interventions ................................................................................................... 16
Chapter 4 ....................................................................................................................................... 20
Results ....................................................................................................................................... 20
Recommendations for Practice .............................................................................................. 20
Chapter 5 ....................................................................................................................................... 25
Discussion and Conclusion ....................................................................................................... 25
References ..................................................................................................................................... 26

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Appendices .................................................................................................................................... 31
Appendix A: Literature Matrix of Contemporary ED Publications .......................................... 31
Appendix B: Appraisal of Literature ......................................................................................... 52
Appendix C: Emergence Delirium Prevention Practice Recommendations ............................. 54

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List of Tables
Table 1: Final sources for critical review of the topic: Emergence delirium prevention in American
veterans diagnosed with PTSD…………………………………….……………………………….8

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List of Figures
Figure 1: Amygdalocentric Neurocircuitry ………………………………………………4
Figure 2: Compromised Amygdalocentric Neurocircuitry Regulation……………...........4
Figure 3: Simple Logic Model…………………………………………………………….6
Figure 4: PRISMA Flow Diagram...…………………………………………………...….9

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Abstract
Emergence delirium (ED) is an acute neurologic impairment that can occur directly
following the discontinuation of general anesthesia (GA) characterized by altered cognition,
agitated psychomotor movements, and reactive aggression potentially leading to complications
such as: self-extubation, dislodgement of various indwelling catheters, patient and staff injury,
and increased length of stay in the post anesthesia care unit (McLott et al., 2013). Recent studies
have shown ED prevalence in the general adult population is estimated at 8.3% but rates as high
as 31% in certain populations such as combat veterans diagnosed with post-traumatic stress
disorder (PTSD) have been observed (Hintzsche, 2018). Additionally, veterans have a
disproportionate incidence of PTSD due to the active military conflicts in the middle east such as
Operation Iraqi Freedom and Operation Enduring Freedom (McGuire, 2012). The current
literature is lacking updated standardized recommendations to prevent ED and to date there does
not exist a standardized practice protocol for identifying, preventing, and treating emergence
delirium in veterans with PTSD.
This Doctoral Capstone provides knowledge concerning physiology of PTSD and
summarizes practice recommendations synthesized from the latest evidence-based data available
in an effort to guide anesthesia practice. Practice recommendations include preoperative
assessment tools, premedication, pre-intra and post-operative management and rescue
medication administration.
Running head: EMERGENCE DELIRIUM IN AMERICAN VETERANS 1

Chapter 1
Introduction
Emergence delirium is an acute neurologic impairment occurring directly following the
discontinuation of general anesthesia characterized by altered cognition, agitated psychomotor
movements, and reactive aggression potentially leading to complications such as self-extubation,
dislodgement of various indwelling catheters, patient and staff injury, longer length of stay in the
post anesthesia care unit, and increased healthcare costs (McLott et al., 2013). Recent studies have
shown the estimated emergence delirium prevalence in the general adult population to be between
8.3% and 31%. (Hintzsche, 2018). However, American veterans diagnosed with post-traumatic
stress disorder (PTSD) have ED prevalence estimated at 21% (Hintzsche, 2018). The
disproportionate prevalence in American veterans diagnosed with PTSD requires anesthesia
providers to be cognizant and effective in prevention, identification, and treatment of emergence
delirium when caring for this population.
Clinical Problem
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-V), PTSD is diagnosed following a traumatic event categorized by either actual or threat of
death, serious injury, or sexual violation (American Psychiatric Association, 2013). Per the DSM-V
diagnosis criteria, individuals must also present with specific categorical symptomology following
the traumatic event for longer than one month. The symptom requirements are as follows: at least
one intrusion symptom such as recurrent distressing dreams; at least one avoidance symptom such as
avoiding external reminders of the event; negative alterations in cognition as well as mood; and
significant alterations in reactivity to benign stimuli (Lovestrand et al., 2016). When utilizing the

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DSM-V criteria, PTSD is estimated to have an 8.3% lifetime prevalence in the American general
population (Kilpatrick et al., 2013). In comparison, according to the United States Department of
Veterans Affairs (VA), American veterans and active military personnel have significantly higher
rates of PTSD than the general American population ranging between 13.8% and 30.9% depending
on a myriad of factors such as age, gender, history of sexual assault during military service, combat
or non-combat experience, and specific military campaigns (Gradus, n.d.). The US Army Office of
the Surgeon General reported 138,197 diagnoses of PTSD per year between 2000 and 2014 in
American veterans (Umholtz et al., 2016). The substantial number of new diagnoses are principally
due to the active military conflicts - Operation Iraqi Freedom and Operation Enduring Freedom - in
the Middle East. The increased exposure to distressing events and traumatic injuries predisposes
veterans to developing PTSD, thus joining the thousands of other veterans from the Vietnam and
Gulf Wars diagnosed with PTSD in prior decades (Gradus, n.d.). The Centers for Disease Control
and Prevention (CDC) define an epidemic as an “increase in the number of cases of a disease above
what is normally expected in a population in that area” (CDC, 2012). As indicated by starkly higher
PTSD rates in veterans compared to the general American population, PTSD has become an
American veteran mental health epidemic with significant potential downstream effects making it
imperative anesthesia providers become educated on how to prevent emergence (ED) in this high-
risk population.
The proposed pathophysiology for PTSD and ED originates from the impairment of the
amygdalocentric neurocircuitry (AN), consisting of the amygdala, medial prefrontal cortex (mPFC),
and the hippocampus (Hintzsche, 2018). Functional magnetic resonance imaging in PTSD patients
has revealed reduced mPFC and hippocampus cross sectional areas due to remodeling processes

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associated with massive releases of glutamate - the primary excitatory neurotransmitter during
uncontrolled severe stress (McLott et al., 2013; Hintzsche, 2018).
The mPFC and the hippocampus are responsible for executive function and information
retrieval for situational awareness, respectively, while also containing gamma-aminobutyric acid
(GABA) mediated inhibitory mechanisms to regulate the autonomic responses to stress by the
amygdala (Figure 1). As a result of experiencing severe stressful stimuli, PTSD patients have altered
responses in each AN structure. Ineffective inhibitory regulation of the amygdala hinders one’s
ability to accurately identify stimuli as benign or dangerous secondary to the impaired capacity to
retrieve memories and accurately apply contextual information to categorize the sensory input
(Figure 2). Compromised regulation, coupled with hyperactive glutamate release during stress
responses, perpetuates an exaggerated state of fear and reactive aggression to benign situations
(McLott et al., 2013). Medications given during general anesthesia further impair the AN, reducing
the efficiency and accuracy in which PTSD patients assess sensory input, noxious stimuli, and the
unfamiliar environment following surgical procedures, thereby increasing the chances of developing
the hallmark symptoms of ED (McLott et al., 2013).
Emergence from general anesthesia is typically a safe, unremarkable process; however,
numerous studies have identified PTSD as a significant risk factor for increasing the probability of
making the emergence process precarious for patients and healthcare providers (McGuire,
2012). Wilson (2014) revealed through a qualitative study, 88% of military anesthesia providers
believed PTSD was directly linked to not only the prevalence but the severity of ED symptoms
ranging from moaning and reactive excitement to assaulting healthcare providers (Wilson, 2014).

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Figure 1
Amygdalocentric Neurocircuitry (Hintzsche, 2018)

Note. Reprinted figure was included with the explicit permission from Hintzsche (2018).

Figure 2
Compromised Regulation of the Amygdalocentric Neurocircuitry (Hintzsche, 2018).

Note. Reprinted figure was included with the explicit permission from Hintzsche (2018).

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Additionally, in a separate qualitative study, Wilson (2013) revealed 30% of military anesthesia
providers believed ED cases were increasing over time and 97% perceived ED as an injury risk not
only to service members exhibiting delirium, but also the operating room and post-anesthesia care
unit (PACU) staff (Wilson, 2013). As this vulnerable population continues to acquire age-related
physiologic and chronic illness, an increasing number will require surgical procedures involving
general anesthesia. The probability of American veterans with PTSD developing ED poses a serious
safety risk. Currently, there is no standardized practice protocol regarding prevention, identification,
and treatment of ED in American veterans with PTSD.
Research Question and Specific Aims
The PIO question guiding this evidence-based search was: “What interventions are most
efficacious at preventing ED for American veterans diagnosed with PTSD undergoing surgical
procedures requiring general anesthesia?”
The specific aims were to:
1. Perform a critical literature review.
2. Synthesize current data on preventing ED in American veterans diagnosed with PTSD.
3. Develop comprehensive evidence-based practice recommendations.
Background and Significance
Investigation of ED did not emerge in the literature until Eckenhoff, Kneale and Dripps
(1961) conducted a retrospective chart review of 14,436 patients in 1961. Historically, ED was
attributed to the type of inhaled anesthetic administered; at the time this included primarily ether,

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chloroform or iodoform. There is only a smattering of publications referencing “postoperative
psychosis,” “post-surgical agitation,” or “wild wake-ups” following Eckenhoff et al. (1961).
However, interest and published research regarding ED resurged at the turn of the 21st century as the
incidence of ED in military combat veterans intensified. This was related to continued conflicts in
the Middle East, returning home a growing number of military veterans suffering from PTSD
(McGuire, 2012). A comprehensive list of the contemporary literature on the topic of ED can be
found in Appendix A: Literature Matrix of Contemporary ED Publications.
The current literature lacks consensus on standardized recommendations to prevent ED in
veterans diagnosed with PTSD. Therefore, the authors followed a simple logic model (Figure 3)
centered on employing an extensive literature review of the most efficacious preventative
interventions of ED for combat veterans diagnosed with PTSD.
Figure 3
Simple Logic Model

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Chapter 2
Proposed Methods
Search Strategy
The following databases were examined for potential evidence: Google Scholar, PubMed, the
Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Database
of Systematic Reviews and Proquest. The “Similar Articles” feature in PubMed was used to search for
additional evidence and searches were further supplemented through snowballing techniques -
searching for records by reviewing citations of articles pertinent to the research question and
population of interest. Only full-text, English-language sources from scholarly journals between 2003
and 2018 were considered for review. The following levels of evidence were included: systematic
reviews of randomized controlled trials (RCTs), cohort studies, correlational studies, literature
reviews, case studies and expert opinions. The following search terms were used alone and in
combination: post-traumatic stress disorder, emergence, delirium, veterans, military personnel,
prevention, and dexmedetomidine. Sources were included into practice recommendations only when
study sample populations were comprised of American military veterans with PTSD undergoing
surgical intervention requiring general anesthesia who were alert and oriented to self, time, place and
purpose of surgical intervention prior to induction of anesthesia. Sources were excluded if the sample
population reported a history of psychosis, dementia, Alzheimer’s disease, or exhibited any other
cognitive impairment at the time of surgery. The titles of the sources were examined first for inclusion,
then abstracts, followed by full texts. Appraisal of the relevant literature was carried out for all articles
meeting inclusion criteria in the final critical literature review. Independent appraisal by each author
was carried out on ten of the sources to establish inter-rater agreement across all appraisal categories.

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Then additional sources were appraised by one author following these established criteria. CARE
Guidelines for Case Reports (Gagnier et al., 2013), Rapid Critical Appraisal Checklists (Slutsky,
2005), Critical Appraisal of Literature Review, and CEBM Survey Appraisal were used on all relevant
articles (Appendix B) and all articles were graded according to the generalizability of the evidence and
appraised according to the level of evidence (Slutsky, 2005).
Table 1
Final sources for critical review: ED prevention in American veterans diagnosed with PTSD
Source Title Level of
Evidence
1 McGuire (2012) The incidence of and risk factors for emergence delirium in U.S. military combat
veterans
III
2 Umholtz et al.
(2016)
Postanesthesia emergence in patients with post-traumatic stress disorder III
3 Wheat et al.
(2018)
Military service members and emergence delirium screening: An evidence-based
practice project
III
5 Wilson (2013) Army anesthesia providers’ perceptions of emergence delirium after general
anesthesia in service members
III
6 Wilson (2014) Pharmacologic, physiologic, and psychological characteristics associated with
emergence delirium in combat veterans
III
7 Wilson (2012) Experiences of military CRNAs with service personnel who are emerging from
general anesthesia
III
8 Crosby et al.
(2007)
Emergence flashback in a patient with posttraumatic stress disorder V
9 Gentili et al.
(2017)
Postoperative agitation on emergence of general anesthesia revealing former post-
traumatic stress disorder
V
10 Nguyen, et al.
(2016)
Emergence delirium with post-traumatic stress disorder among military veterans IV
11 Hintzsche (2018) Subanesthetic-dose ketamine to decrease emergence delirium in the surgical patient
with posttraumatic stress disorder
IV
12 Lovestrand et al.
(2016)
Management of emergence delirium in adult PTSD patients: Recommendations for
practice
IV

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13 McGuire et al.
(2010)
Risk factors for emergence delirium in U.S. military members IV
14 McLott et al.
(2013)
Development of an amygdalocentric neurocircuitry-reactive aggression theoretical
model of emergence delirium in posttraumatic stress disorder: An integrative literature
review
IV
15 McGuire &
Wilson (2013)
Reply: possible confounding by mefloquine in the association of emergence delirium
with PTSD and TBI among combat veterans
V

A total of 118 potential sources of evidence were located using the stated search terms, with
an additional 32 located through snowballing. One article was excluded after appraisal, leaving 15
articles meeting criteria for the research statement: emergence delirium prevention in American
veterans diagnosed with PTSD (Table 1). An additional eight articles do not meet the inclusion
criteria of “sample population comprised of American military veterans with PTSD,” yet they offer
interventions for ED in the non-military population, some specifically related to individuals with
PTSD. Future research on this topic should include a broadening of the scope of the research
question to include non-military patients. The complete process of article culling can be seen in
Figure 4.

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Figure 4
PRISMA flow literature search diagram examining ED prevention in American veterans with PTSD

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Chapter 3
Literature Review
Preoperative Assessment and Evaluation
Anesthesia preoperative patient evaluations are intended to reduce perioperative morbidity
and mortality with the end goal of ensuring patients return to their optimal functioning capacity
postoperatively (Zambouri, 2007). Comprehensive and accurate preoperative assessments are
imperative to identify at risk patient populations, multifactorial risk factors, ascertain comorbidities,
anticipate potential complications, and are indicated to tailor anesthesia care to improve patient
outcomes.
Recognizing at-risk veteran population characteristics is crucial to identify necessary
preoperative evaluations and develop anesthetic ED prevention interventions. Umholtz et al. (2016)
implemented a retrospective cohort study amongst 1763 US military combat veterans and
documented ED was more prevalent in older males with higher ASA classifications undergoing
emergent surgery. The presence of PTSD symptoms, such as anxiety, before surgery was an
independent predictor of ED after correcting for confounding variables (Umholtz et al., 2016).
Moreover, Umholtz et al. (2016) also established a strong association between PTSD and ED in
combat veterans. PTSD patients were typically younger, had higher body mass indexes, histories of
depression, increased preoperative anxiety, and recreational drug use (Umholtz et al., 2016). In a
prospective, descriptive, correlational study, McGuire (2012) claims combat exposure and prior
episodes of ED are each significant risk factors subsequent ED occurrence. Several studies have also
established varying positive correlations between non-PTSD psychiatric histories and mental health
conditions such as anxiety, depression, and sleep disturbances with ED (Lepouse et al., 2006;

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Lovestrand, 2016; McGuire, 2012; McGuire & Burkard, 2010; Shoum, 2014; Wheat, 2018; Crosby
et al., 2007).
Increased ED prevalence is also associated with certain scheduled procedures. Lepouse et al.
(2006) performed a prospective cohort study on 1359 civilian adults diagnosed with PTSD
undergoing general anesthesia and revealed statistically significant increased ED incidence in
patients undergoing breast procedures and abdominal surgeries. Additionally, longer surgical
procedures, traumatic brain injuries, and high postoperative pain are strongly correlated with the
postoperative development of ED (Lepouse et al., 2006; McGuire & Burkard, 2010; Shoum, 2014;
Umholtz et al., 2016).
Thoroughly assessing home medication prescriptions yields valuable information regarding
patient comorbidities, while also aiding in the selection of preoperative medications. Shoum (2014)
posits in a case series PTSD is often under- and mis- diagnosed; thus, psychiatric medications may
be prescribed for non-PTSD diagnoses, such as major depression or bipolar disorder, but may in fact
be given to treat the symptomology of undiagnosed PTSD. Shoum (2014) cautions anesthesia
providers to be cognizant of potential elevated ED risk in patients prescribed psychiatric home
medications. Burns (2003) published a case study about a civilian woman undergoing plastic
surgery in which home use of benzodiazepines was associated with ED occurrence. Similarly,
Radtke et al. (2010) performed a prospective observational study and identified benzodiazepine
premedication in the perioperative setting as a preventable risk factor for developing ED. Lepouse et
al. (2006) established a statistically significant positive correlation between benzodiazepine
premedication and ED incidence after univariate analysis. However, conflicting data exists between
benzodiazepine premedication and the association with ED prevalence. Umholtz et al. (2006)
discovered combat veterans with PTSD who received midazolam preoperatively experienced ED at

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rates three times lower than patients who did not receive anxiolytic premedication. Lepouse et al.
(2006) further disclosed long-term treatment with antidepressants such as selective serotonin
reuptake inhibitors (SSRIs) decrease ED rates. Due to SSRIs having long elimination half-lives, the
authors postulate the medication remains at therapeutic levels postoperatively, thus reducing the
probability of patients emerging in a hyper-excitable state (Lepouse et al., 2006).
Specific screening instruments have been devised to assess the possibility of increased ED
risk during preoperative assessments. The three validated tools for ED prediction are: State-Trait
Anxiety Inventory (STAI), Patient Health Questionnaire-9 (PHQ-9), and the PTSD Military
Checklist (PCL-M) (McGuire, 2012). The STAI evaluates levels of preoperative anxiety. After
regression modeling, STAI has been identified as the most sensitive identifier in predicting ED in
surgical patients with PTSD (McGuire, 2012; Wheat et al., 2018). Higher STAI scores are positively
correlated with a higher prevalence of ED in American combat veterans (McGuire,
2012). Furthermore, depression is identified as another strong predictor of ED development in
American veterans with PTSD undergoing surgical procedures requiring general anesthesia. The
PHQ-9 tool is a 9-item questionnaire with weighted answers aimed to identify patients with
depression (Kroenke et al., 2001). In a landmark study evaluating the PHQ-9, researchers concluded
a score equal to or greater than 10 had a specificity and sensitivity of 88% for major depression
(Kroenke et al., 2001). The tool can be self-administered by patients or proctored by anesthesia
providers. Lastly, 60 percent of veterans with PTSD never seek treatment, are not diagnosed, and do
not receive the necessary mental health care they require because of stigma surrounding mental
health (Roscoe, 2020). To assist in identifying undiagnosed PTSD veterans, the PCL-M was
developed by the U.S. military. The PCL-M is a 17-item checklist instrument and can be completed
by the patient in five to ten minutes independently or with clinician assistance (U.S. Department of

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Veterans Affairs, 2012). Higher PCL-M scores are shown to have a strong correlation with
increased ED prevalence in American veterans (McGuire, 2012).
Intraoperative Interventions
Reported intraoperative measures to prevent ED focus on the judicious selection of anesthetic
modalities and pharmacological agents. Shoum (2014) concluded general anesthesia, as well as any
medications inducing loss of consciousness, should be avoided when possible to minimize the risk of
disorientation upon awakening. A prospective observational cohort study of 1970 non-military adult
patients revealed total intravenous anesthesia (TIVA) to be associated with decreased rates of ED
compared to volatile anesthetic gases (Munk et al., 2016). Lepouse et al. (2006) found statistically
significant lower rates of ED in patients receiving propofol TIVA compared to those receiving
volatile anesthetics. There were no statistically significant differences in ED rates between the
different volatile anesthetics (Lepouse et al., 2006). Gentili et al. (2017) performed a case series of
non-military patients diagnosed with PTSD who presented with ED and claim volatile anesthetics
contribute to ED development. In a descriptive correlational study, Wilson (2013) surveyed 87
military anesthesia providers and revealed 88% felt potent inhalational agents contributed to ED
while TIVA significantly reduced rates. Utilizing local anesthetics and regional blocks are
encouraged as the veteran patient with PTSD is more likely to remain oriented and grounded to
reality if the awake state appropriately meets surgical needs; however, there is a dearth of literature
examining these alternative modalities (Shoum, 2014).
Ketamine, an N-methyl-D-aspartate (NMDA) antagonist, is the subject of much debate in the
available literature regarding its effects on ED prevalence. In a qualitative study, surveyed military
certified registered nurse anesthetists (CRNAs) associated the use of ketamine with a smoother

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emergence from general anesthesia among veterans with PTSD (Wilson & Pokorny,
2012). Lovestrand et al. (2016) promote in an ED literature synthesis the incorporation of ketamine
early intraoperatively and to continue administering small doses for longer duration surgeries.
Specific doses were not included in the recommendations. However, a double blind randomized
controlled trial involving non-military surgical patients aged 60 years or older showed no difference
in the rates of ED between the control group and the treatment groups who received subanesthetic
doses of ketamine in the intraoperative period (Avidan et al., 2016). Avidan et al. (2016) had limited
study generalizability to military veterans with PTSD, due to the sample examined being elderly
non-veterans. Hintzsche (2018) proposed a theoretical model for the effectiveness of subanesthetic
doses of ketamine in preventing ED in general population patients diagnosed with PTSD. Hintzsche
(2018) posit both ED and PTSD are exacerbated by noxious stimuli and stress which are partly
mediated by glutamate, an excitatory neurotransmitter. By administering subanesthetic doses of
ketamine, glutamate is blocked at its NMDA receptor site preventing ED while also avoiding the
negative side effects of anesthetic doses of ketamine such as hallucinations and confusion.
Nevertheless, ketamine use to prevent ED remains greatly debated. McGuire & Burkard (2010) warn
in their literature review the potential for increased prevalence of ED and hallucinations in American
veterans by administering ketamine but did not address or differentiate risk according to dosages.
The conflicting research warrants further investigation on the efficacy of ketamine in preventing ED.
ED is a multifactorial phenomenon partially attributed to patients emerging from anesthesia
while experiencing physiologic stress such as hypothermia, hypoxia, hypercarbia, postoperative
nausea and vomiting, residual neuromuscular blockade and uncontrolled postoperative pain
(Lepouse et al., 2006; Lovestrand et al., 2016; McGuire & Burkard, 2010). Lovestrand et al. (2016)
and McGuire & Burkard (2010) recommend in their literature synthesis any physiologic causes of

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ED must be treated first prior to administering rescue medications. Lepouse et al. (2006) posit in a
prospective study postoperative pain and noxious stimuli are likely etiologies of ED, while noting
elimination of the physiologic stress - such as removing an endotracheal tube (ETT) or
administration of analgesics - were at times sufficient interventions to reduce the severity or
completely resolve the ED episode. Pre-emptive analgesic protocols and vigilant monitoring of
physiologic stressors such as bladder distention, fecal impaction, ETT discomfort, residual
neuromuscular blockade, and loud environmental stimuli can mitigate ED occurrence (Lepouse et
al., 2006). McGuire & Burkard (2010) postulate hypothermia caused by impaired thermoregulation
secondary to general anesthesia leads to sympathetic nervous system stimulation upon emergence
potentially causing ED. By maintain normothermia, the potential risk of triggering ED is reduced.
Postoperative Interventions
Postoperative evaluation and interventions reviewed for military veteran patients at risk
centered on early detection of behaviors associated with ED, environmental control, reorientation
and rescue medications. Tools with potential efficacy for ED risk detection are discussed in previous
sections, yet it is essential that anesthesia providers have tools to assess ED once it has occurred;
specifically, tools to identify occurrence, intensity and resolution following intervention. Although
no postoperative instrument currently exists to identify ED in the adult population, McGuire (2012)
conducted a prospective cohort study and established both the validity and inter-rater reliability of
the Pediatric Anesthesia Emergence Delirium (PAED) scale as a tool to assess ED within a sample
population of 130 veterans. The PAED is a five-item scale used to measure the patient’s behavioral
response after emergence from general anesthesia, with an aggregate score from five-point scaled
responses. The study concluded the PAED Scale measured the same behaviors of ED regardless of

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17
age (McGuire, 2012). Both the Richmond Agitation and Sedation Scale (RAAS) (Read et al., 2017;
Munk et al., 2016) and the Aldrete Score (Read et al., 2017) have also been implemented to assess
for agitation and readiness for discharge respectively, though neither have been established as
reliable or validated tools for the measurement of ED.
The literature has established environmental control and the presence of comforting stimuli
play a role in minimizing noxious stimuli upon emergence. Nguyen et al. (2016) found arousing
patients with verbal coaching and controlled noise level in the OR was successful in preventing ED
in non-veteran patients with known recurrent ED. Although Nguyen et al. (2016) discussed case
studies of only two patients, these findings are further supported by Lovestrand et al. (2016) who
recommend a quiet environment and calm disposition of PACU staff to reduce the risk of triggering
the alterations of amygdala and hippocampus functioning seen in PTSD. In a case study, Crosby et
al. (2007) posit having a supportive family member, friend, or other person known to the patient
present upon emergence, may help ground a patient at risk for flashbacks, a finding that was also
supported by case studies conducted by Read et al. and Shoum (2014) and is reflected in
recommendations by Lovestrand at al. (2013). Crosby et al. (2007) further suggest grounding
interventions and reorientation should be utilized in lieu of medications to prevent ED
symptomatology, as pharmacological intervention may exacerbate symptoms.
Review of current literature reveals use of rescue medication as the current standard of care
in the treatment of ED, though no standard recommendation for the type or dose of medication
exists. Benzodiazepine medications have been found unhelpful in the amelioration of ED symptoms,
and, in fact, may exacerbate confusion driving the delirious reaction (Lepouse et al., 2006). The
exact role of benzodiazepines to ameliorate symptoms of PTSD in the veteran population is unclear
in the literature as no randomized studies have been conducted and the use of benzodiazepines in

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18
non-veteran populations show contradicting results in efficacy to treat the symptoms of emergence
delirium (Lepouse et al., 2006). Current recommendations to utilize modalities other than
benzodiazepines as a rescue medication reflect findings of case studies, non-randomized studies or
clinical observations (Lepouse et al., 2006; Shoum, 2014; Read et al., 2017).
The use of dexmedetomidine as a rescue medication for ED is not a standard of care, yet
utilization of this drug in the military medical center setting is increasing due to its favorable
pharmacokinetic and pharmacodynamic profile including its ability to provide sympatholytic,
anxiolytic, sedative, anti-delirious, and analgesic effects without respiratory depression (Nguyen et
al., 2016; Read et al., 2017). Read et al. (2017) showed the utility and efficacy of dexmedetomidine
as a rescue therapy for adults with ED in the PACU in a case study of three patients. After
administering a bolus dose of 0.5 -1 mcg/kg in conjunction with a continuous infusion of 0.5-1
mcg/kg/h. Read et al. (2017) found patients experienced a resolution of ED symptoms within two
hours. Lovestrand et al. (2016) recommend considering an intraoperative dexmedetomidine infusion
of 0.5 – 1 mcg/kg, followed by a bolus of 10 - 40 mcg given prior to emergence, with an additional
bolus utilized as a rescue medication for ED symptoms refractory to verbal and environmental
techniques. In a case series involving military veterans diagnosed with PTSD and reported prior ED
history, Nguyen et al. (2016) incorporated dexmedetomidine infusions and boluses resulting in a
smooth, uneventful emergence. In January of 2015, McGuire et al. began a funded, institutional
board reviewed data collection to investigate the efficacy of dexmedetomidine in adults with ED and
results of this investigation are still pending (Lovestrand et al., 2016).
A reported clinical consequence of ED is the need of additional staff in order to restrain the
agitated patient. Munk et al. (2016) found additional staff were required in 31% of ED cases;
adequate staffing and preparation is tantamount to ensuring a safe environment for both patient and

EMERGENCE DELIRIUM IN AMERICAN VETERANS

19
staff. Upon resolution of ED, patients often have no memory of the event and discussion with the
anesthesia provider and post-anesthesia care unit staff can empower patients to advocate for
preventative care in the future (Umholtz et al., 2016). Similarly, Lovestrand et al. (2016) posit
accurate and comprehensive documentation of ED is essential to future interventions for patients
with a known history and enables providers to effectively anticipate, prevent and treat ED episodes.

EMERGENCE DELIRIUM IN AMERICAN VETERANS

20
Chapter 4
Results
Recommendations for Practice
Preoperative Recommendations. Preoperative recommendations to prevent ED in
American veterans diagnosed with PTSD emphasize early identification of high-risk patients via
comprehensive medical record examination, preoperative interview utilizing screening tools, and
interdisciplinary communication and collaboration.
Medical Record Evaluation.
• Identify scheduled surgical procedures associated with higher ED prevalence. Patients
undergoing breast surgery, abdominal surgery, prolonged procedures, emergent cases,
traumatic brain injuries, and procedures with expected severe postoperative pain are at
increased risk for ED incidence (Lepouse et al., 2006; McGuire & Burkard, 2010; Shoum,
2014; Umholtz et al., 2016).
• Appraise available psychiatric consultation notes for diagnoses of PTSD, anxiety, major
depression, and screening tool scores for STAI, PHQ-9, and PCL-M ED (Lepouse et al.,
2006; Lovestrand, 2016; McGuire, 2012; McGuire & Burkard, 2010; Shoum, 2014; Wheat,
2018; Crosby et al., 2007).
• Evaluate home medication lists noting prescriptions for psychiatric diagnoses including, but
not limited to, benzodiazepines and SSRIs (Burns, 2003; Lepouse et al., 2006; Lovestrand et
al., 2016). Home use benzodiazepines have been shown to contribute to ED development
(Burns, 2003). However, long-term SSRI treatment have been associated with decreased ED
rates (Lepouse et al., 2006).

EMERGENCE DELIRIUM IN AMERICAN VETERANS

21
• Review prior surgical and anesthesia notes for indications of difficult emergence or
emergence agitation (McGuire & Burkard, 2010; Lovestrand et al., 2016).
• Review social history for military combat experience (McGuire, 2012; McGuire & Burkard).
Preoperative Patient Interview.
• Perform a complete psychiatric history focusing on diagnoses that increase risk of ED
development such as PTSD, anxiety, depression, and sleep disturbances (Lovestrand et al.,
2016; McGuire, 2012; McGuire and Burkard, 2010; Shoum, 2014).
• Ask veterans with known history of PTSD regarding symptoms, severity, and flashback
triggers (Crosby et al., 2007; Lovestrand et al., 2016; McGuire, 2012).
• Utilize validated assessment tools to identify high-risk veterans, specifically the STAI for
preoperative anxiety, PHQ-9 for depression, and PCL-M for military personnel with PTSD
(McGuire, 2012).
• STAI has been identified as the most sensitive identifier in predicting ED (McGuire, 2012).
Higher STAI scores are directly correlated with higher ED prevalence (McGuire, 2012).
• PHQ-9 scores greater than or equal to 10 have a specificity and sensitivity of 88% for major
depression (Kroenke et al., 2001). PHQ-9 can be self-administered by the patient or
proctored and is a strong predictor of ED development in American veterans with PTSD
(McGuire, 2012).
• PCL-M is used by the US military to identify veterans suspected of having PTSD (US
Department of Veterans Affairs, 2012). Higher PCL-M scores are associated with increased
ED prevalence (McGuire, 2012).

EMERGENCE DELIRIUM IN AMERICAN VETERANS

22
Interdisciplinary Collaboration and Patient Education.
• Alert interdisciplinary OR team of high-risk veteran patients and collaborate to create tailored
perioperative measures to reduce ED risk focused on the following: reducing noxious stimuli;
providing a quiet, positive, and reassuring environment; optimal multi-modal analgesia; and
employ interventions with consistency (Lovestrand, 2013).
• Educate identified high-risk veterans and their support persons regarding ED risks and
planned preventative interventions (Lovestrand, 2013).
Intraoperative Recommendations. Intraoperative recommendations for the prevention of
ED focuses on the judicious use of pharmacological agents.
• Prioritize the use of anesthetic techniques; allow patient to be awake if a local anesthetic or
regional block is appropriate (Shoum, 2014). If possible, avoid general anesthesia and any
medications that induce loss of consciousness (Shoum, 2014).
• Avoid benzodiazepines in all operative phases as they are associated with a higher incidence
of ED, particularly among veterans with PTSD (Lepouse et al., 2006; Lovestrand et al., 2016;
Radtke et al., 2010).
• TIVA is associated with less incidence of ED and is preferred over the use of volatile
anesthetic gases during the intraoperative phase (Gentili et al., 2017; Lepouse et al., 2006;
Munk et al., 2016; Wilson & Pokorny, 2012).
• Administer dexmedetomidine intraoperatively to reduce the risk of ED (Lovestrand et al.,
2016; Nguyen et al., 2016; Shoum, 2014).

EMERGENCE DELIRIUM IN AMERICAN VETERANS

23
• Avoid preventable physiological noxious stimuli such as hypothermia, hypoxia, hypercarbia,
postoperative nausea and vomiting, and uncontrolled postoperative pain (Lepouse et al.,
2006; Lovestrand et al., 2016; McGuire & Burkard, 2010; Wheat et al., 2018).
Postoperative Recommendations. Postoperative recommendations include early detection
of ED, environmental control, reorientation and use of a rescue medication.
Detection of ED.
• Use the PAED scale as an early ED detection tool as it has been found to measure the same
behaviors of ED regardless of age (Lovestrand et al., 2016; McGuire, 2012).
• Utilize the RAAS tool in determining the efficacy of rescue treatment and should be used
when rescue interventions are necessary (Read et al., 2017; Munk et al., 2016).
• Use the Aldrete Score to determine readiness for discharge after the resolution of an ED
episode (Read et al., 2017).
Environmental Control & Reorientation.
• Arouse patients with verbal coaching and controlled noise level in the OR and PACU
(Lovestrand et al., 2016; McGuire & Burkard, 2010; Nguyen et al., 2016; Wilson & Pokorny,
2012).
• Allow supportive family member, friend, or other person known to the patient to be present
upon emergence to help ground patients at risk for ED (Crosby et al., 2007; Lovestrand et al.,
2016; Nguyen et al., 2016).

EMERGENCE DELIRIUM IN AMERICAN VETERANS

24
• Revert to grounding methods and reorientation in lieu of medications to prevent ED
symptomatology when possible since pharmacological interventions may exacerbate ED
symptoms (Crosby et al., 2007).
Rescue Medication.
• Prior to administering rescue medication, first assess and correct any physiologic noxious
stimuli including, but not limited to, hypoxia, hypercarbia, hypothermia, residual
neuromuscular blockade, uncontrolled pain, and postoperative nausea and vomiting (Lepouse
et al., 2006; Lovestrand et al., 2016; McGuire & Burkard, 2010; Wheat et al., 2018).
• Avoid benzodiazepine medications as they are unhelpful in the amelioration of ED symptoms
and may exacerbate the delirious state (Read et al., 2017).
• Administer dexmedetomidine as a rescue medication. (Lovestrand et al., 2016; Nguyen et al.,
2016; Read et al., 2017; Shoum, 2014).
Further Postoperative Recommendations.
• Adequate staff and preparation. PACUs should anticipate the need of additional staff to aid in
reorientation, rapid medication administration and should be trained in the use of the PAED,
RAAS and Aldrete tools (Munk, 2016; Read, 2017; Shoum, 2014).
• Patient and team debriefing after ED resolution. It is recommended that involved
perioperative staff discuss the event, the interventions taken, and educate patients to inform
future anesthesia providers regarding their ED risk (Lovestrand et al., 2016; Umholtz et al.,
2016).
• Accurate and comprehensive documentation for alerting future providers, facilitate incidence
data collection, and promote continuity of care (Lovestrand et al., 2016).

EMERGENCE DELIRIUM IN AMERICAN VETERANS

25
• Although Ketamine has been noted in qualitative studies to be a potentially useful agent
(Wilson & Pokorny, 2012), there is not enough quantitative evidence to formulate a
recommendation regarding its intraoperative use for veterans with PTSD.
Chapter 5
Discussion and Conclusion
After conducting a gap analysis of the PIO question: “what interventions are most efficacious
at preventing and treating ED in American veterans undergoing surgical procedures requiring
general anesthesia,” the investigators have determined it is paramount for practice recommendations
be standardized and modernized. For military veterans with PTSD, the occurrence of ED results in
risk of patient, personal, and staff injury. Preventing ED in American veterans requires a multi-
faceted, comprehensive approach based on the latest scientific literature aimed at utilizing
assessment tools to identify at-risk patients, performing thorough health and medication history
assessments preoperatively, avoiding intraoperative pharmacological agents and anesthetic
techniques known to increase the probability of delirium during emergence, optimizing the PACU
environmental setting to minimize noxious stimuli, vigilant multimodal pain management, and the
development of a validated ED assessment tool to provide patients with the safest, most effective
rescue medications as soon as it is identified. Anesthesia providers and perioperative staff should
not operate in an environment where they are ill-equipped to identify, prevent, and treat ED in this
vulnerable population. The findings and evidence-based practice recommendations detailed in this
paper will advance the quality of care provided, optimize outcomes, improve patient and provider
safety, and guide forthcoming perioperative research.

EMERGENCE DELIRIUM IN AMERICAN VETERANS

26
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10.1097/MD.000000000002854
Lepouse, C., Lautner, L., Liu, P., Gomis, P., & Leon, A. (2006). Emergence delirium in adults in the
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Li, X., Yang, J., Nie, X., Zhang, Y., Li, X., Li, L., Wang, D., & Ma, D. (2017). Impact of
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Running head: EMERGENCE DELIRIUM IN AMERICAN VETERANS 31

Appendices
Appendix A: Literature Matrix of Contemporary ED Publications

APA Reference Summary of Main Concept
Quantitative
or Qualitative
Research?
Methods
(Design,
instruments,
questionnaires
)
Main Findings of the Study
Avidan, M. S., Maybrier, H. R.,
Abdallah, A. B., Jacobsohn, E.,
Vlisides, P. E., Pryor, K. O., ... &
Downey, R. J. (2017).
Intraoperative ketamine for
prevention of postoperative
delirium or pain after major
surgery in older adults: an
international, multicentre, double-
blind, randomised clinical trial.
The Lancet, 390(10091), 267-275.

Quantitative Double Blind
Randomized
Control Trial
No difference in delirium
incidence between combined
ketamine groups and placebo
groups.

More postop hallucinations and
nightmares with increasing
ketamine doses vs. placebo.

Authors conclude that a single
subanesthetic dose of ketamine
did not decrease delirium in older
adults, may cause more harm than
good by inducing hallucinations
and nightmares.
Burns, S. M. (2003). Delirium
during emergence from
anesthesia: a case study. Critical
care nurse, 23(1), 66-69.

47 y/o woman underwent
plastic surgery with IV
sedatives. No GA. Pt
intermittently withdrawn,
Qualitative Case Study Preop medication history critical
in formulating anesthetic plan but
patients may withhold
information. Repeated
questioning and validation from

EMERGENCE DELIRIUM IN AMERICAN VETERANS

32
unresponsive and combative
after emergence.

Intraoperatively pt received:
• fentanyl
• midazolam
• propofol
• droperidol

Pt denied taking medications
during preoperative phase.
Family revealed
postoperatively that pt takes
fluoxetine, citoprolam and
lorazepam, and was
undergoing family conflict.
family members may be
necessary.
Crosby, S. S., Mashour, G. A.,
Grodin, M. A., Jiang, Y., &
Osterman, J. (2007). Emergence
flashback in a patient with
posttraumatic stress disorder.
General hospital psychiatry,
29(2), 169.

Non-military female refugee
pt with PTSD had flashback
upon emergence.

Pt received preop and intraop:
• fentanyl
• midazolam
• propofol
• ondansetron

Pt received midazolam and
propofol when agitated
postop.
Qualitative Case study Outlined differences between a
flashback and true delirium.
Flashbacks lack waxing and
waning course of disorientation
typical of delirium, but flashbacks
can be concurrent with delirium.

Flashbacks in PTSD may be
treated with grounding techniques
that orient pt to time and place.

Knowledge of pt’s trauma hx and
triggers are crucial in formulating

EMERGENCE DELIRIUM IN AMERICAN VETERANS

33
interventions that help
ground/orient pt.

Per authors, use of postop
midazolam and propofol likely
made flashback worse.

Gentili M.E., Gnaho A, Musellec
H. (2017). Postoperative agitation
on emergence of general
anesthesia revealing former post-
traumatic stress disorder. Rev
Neurol, 173(3):172-173. doi:
10.1016/j.neurol.2017.02.007.
Three brief case studies of
non-military personnel
diagnosed with PTSD who
experienced ED. All cases
treated with midazolam.
Qualitative Case Series All patients had general
anesthesia with propofol,
sevoflurane, and remifentanil. ED
was treated with midazolam (3
mg max). No patient was
conscious of confusion during the
PACU stay.
Behaviors included re-
experiencing/mimicking a plane
crash, and two assaults.
Recommends avoidance of
volatile anesthetics. Promotes a
minimally stimulating
environment, and staff education
in non-medical treatments of
delirium.
Gross, A.F., & Stern, T.A. (2014).
Neuropsychiatric conditions
associated with anesthesia
exposure. Psychosomatics, 55(1),
21-8. doi:
10.1016/j.psym.2013.06.020
Eliminated- Not related to ED
specifically

EMERGENCE DELIRIUM IN AMERICAN VETERANS

34
Hipp, D. Ely, E.W. (2012).
Pharmacologcial and
nonpharmacological management
of delirium in critically ill
patients. Neuropathics. 9. 158-
175. Doi 10.1007/s13311-011-
0102-9
Eliminated--Not related to
ED specifically

Hintzsche, K. (2018).
Subanesthetic-dose ketamine to
decrease emergence delirium in
the surgical patient with
posttraumatic stress disorder.
AANA Journal. 86(3). 220-224.
A lack of research supporting
best practice in the treatment
of ED in patients with PTSD
has driven the need for
examination of the
pathophysiological pathways
that occur in ED and PTSD to
support potential
pharmacologic prophylactic
treatments.

Literature
Review
Glutaminergic dysfunction is
present in both ED and PTSD,
suggesting that ketamine, which
modulates glutamate
neurotransmission via N-methyl-
D-aspartate receptor agonism,
may be successful at decreasing
ED when administered at a
subanesthetic dose
intraoperatively.

-Glutamate is the most abundant
excitatory neurotransmitter in the
central nervous system.
-Glutamate neurotransmission is
increased in times of stress; PTSD
and ED are provoked by stress.
-Increased levels of glutamate
result in alterations in the areas of
the brain responsible for fear,
excitation and stress behaviors.
-Reducing available glutamate
binding sites on NMDA receptors
and inhibiting further release of
glutamate, should be effective at

EMERGENCE DELIRIUM IN AMERICAN VETERANS

35
reducing ED in patients with
PTSD.
-Ketamine modulates glutamate
neurotransmission via N-methyl-
D-aspartate receptor agonism and
may be successful at decreasing
ED when administered at a
subanesthetic dose
intraoperatively.
Kilpatrick, D., Resnick, H.,
Milanak, M., Miller, M., Keyes,
K., Friedman, M. (2013). National
estimates of exposure to traumatic
events and PTSD prevalence
using DSM-IV and DSM-5
criteria. Journal of Traumatic
Stress, (26)5.

The National Stressful Events
Survey was conducted with 2,
953 U.S. adults to evaluate
PTSD rates. PTSD lifetime
prevalence - per the DSM-V
diagnosis criteria - in the
United states is estimated to
be 8.6% after conducting a
survey of 2,953 adult
individuals.
Quantitative Purposive
Convenience
Sampling
PTSD prevalence in civilian
population is estimated to be
8.6% with the new DSM-V
diagnosing criteria.
Lee, S.H., Lee, C.Y., Lee, J.G.,
Kim, N., Lee, H.M., Oh, Y.J.
(2016). Intraoperative
dexmedetomidine improves the
quality of recovery and
postoperative pulmonary function
in patients undergoing video-
assisted thoracoscopic surgery.
Medicine. 95(7). doi
10.1097/MD.000000000002854
Eliminated--Not related to
ED specifically

EMERGENCE DELIRIUM IN AMERICAN VETERANS

36
Lepouse, C., Lautner, L., Liu, P.,
Gomis, P., & Leon, A. (2006).
Emergence delirium in adults in
the post-anaesthesia care unit.
British Journal of Anaesthesia.
96(6). 747-53.

First examination of
incidence and risk factors of
ED in adult population.
Defines ED as acute, short-
lived postoperative delirium
in the PACU after general
anesthesia.

[Non-PTSD, combat veteran
specific]

[Excludes patients <15 years
old, patients with diagnosed
dementia and those receiving
loco-regional Anaesthesia]
Quantitative Design:
Prospective
Study
(N=1359)
Riker
agitation-
sedation scale
used to
evaluate
delirium in the
PACU
(excellent
inter-rater
reliability,
though not
established in
the PACU)

Severe
preoperative
anxiety judged
by a physician
with a y/n
binary
evaluation

Regression
analysis of
multi-variables
4.7% developed ED in the PACU.
Preoperative use of benzos, breast
surgery, abdominal surgery, and
long duration of surgery all
increased the risk of ED
occurrence.
Previous history of illness, long-
term treatment by antidepressants
decreased the risk of ED (long
half-life covers duration of
surgery).
Severe preoperative anxiety was
positively correlated to ED
(evaluated by MD y/n response;
no scale used)
Longer mean length of stay in the
PACU
Required 2-3 staff members to
restrain and calm (max 6); 3.7%
attempted to self-extubate, 6%
removed catheters (bladder and
IV), 3% patients injured, 4.5%
staff injured.
Seminal article; cited in most
consequent articles.

Excluded patients with prior
history of anxiety, use of
antidepressants and those on
benzodiazepine regimen during
Univariate and multi-variate
regression analysis. Still found

EMERGENCE DELIRIUM IN AMERICAN VETERANS

37
Benzos, breast and abdominal
surgery to be risk factors.

Authors feel that anxiety is at the
heart of the issue.
Other potential contributing
factors: ET tube, residual
neuromuscular block, untreated
pain, urinary retention, urge to
urinate despite indwelling
catheter.
Univariate analysis: increased risk
with inhalation anesthetic (not
seen in multi-variate analysis).

Li, X., Yang, J., Nie, X., Zhang,
Y., Li, X., Li, L., Wang, D., &
Ma, D. (2017). Impact of
dexmedetomidine on the
incidence of delirium in elderly
patients after cardiac surgery: A
randomized controlled trial.
PLOS ONE. 1-15.
10.1371/journal.pone.0170757
Eliminated--Not related to
ED specifically

Loeffler G, Capobianco M.
(2012). Resuming
electroconvulsive therapy (ECT)
after emergence of asymptomatic
atrial fibrillation during a course
of right unilateral ECT. J ECT,
28(1):68-9. doi:
10.1097/YCT.0b013e318238f032.

Eliminated--Not related to
ED specifically

EMERGENCE DELIRIUM IN AMERICAN VETERANS

38
Lovestrand, D., Lovestrand, S.,
Beaumont, D.M., & Yost, J.G.
(2016). Management of
emergence delirium in adult
PTSD patients: Recommendations
for practice. Journal of
PeriAnesthesia Nursing. 32(4).
356-366.
Without standardized
guidelines in existence to
guide emergence delirium
(ED) care in post-traumatic
stress disorder (PTSD)
patients, this article
synthesized the available
literature to create an initial
set of guidelines for ED
treatment in accordance with
EBP principles from different
disciplines.

Literature
Synthesis

Recommendations:
Pre-Op Management: Pre-op
screening for: PTSD/anxiety,
prior reactions/problems with
anesthesia or surgery; build
rapport with patient to improve
trust; accurate medication
reconciliation; notify staff of high
ED risk.
IntraOp Management:
If ED s/s 1st treat physio causes;
anesthesia provider set treatment
plan a priori for ED/anxiety/ pain
management; a2 agonist meds
may prevent and also be used as
rescue med; ketamine may
prevent (give early); avoid
benzos; avoid noxious stimuli;
use complementary therapy.
Post Op Management: Early
detection; If ID’d: treat physio
causes, control environment to
reduce anxiety, admin rescue med
when appropriate, reorient; after
ED resolves - recap situation;
accurate documentation for
prevalence assessment.
Discharge Planning
Must meet D/C criteria; get
behavioral health personnel input
(may need referral); community
resources; routine follow up call;

EMERGENCE DELIRIUM IN AMERICAN VETERANS

39
family/friend involvement in care;
med reconciliation.

APA Reference Summary of Main Concept
Quantitative
or Qualitative
Research?
Methods
(Design,
instruments,
questionnaires
)
Main Findings of the Study
Read, M. D., Maani, C.V., &
Blackwell, S. (2017).
Dexmedetomidine as a rescue
therapy for emergence delirium in
adults: A case series. International
Anesthesia Research Society.
9(1). 20-23.

Three case descriptions of
patients with whom the use of
dexmedetomidine as a rescue
medication was
advantageous. All three
patients had previous
diagnosis of PTSD, but no
history of complications with
anesthesia. All three patients
received midazolam
preoperatively. All three
patients experienced a
resolution of ED symptoms
within two hours after a bolus
dose of dexmedetomidine
was administered in
conjunction with a continuous
gtt.
Qualitative Case Study

RAAS and
Aldrete scores
were utilized
upon
emergence and
upon resolution
of ED.
Dexmedetomidine has favorable
pharmacokinetic and
pharmacodynamic profile suited
to treat ED. This study shows the
utility and efficacy of
dexmedetomidine as a rescue
therapy for adults with ED in the
PACU.

First published examination of
dexmedetomidine as a rescue
med.

EMERGENCE DELIRIUM IN AMERICAN VETERANS

40
McGuire, J. (2012). The incidence
of and risk factors for emergence
delirium in U.S. military combat
veterans. Journal of
PeriAnesthesia Nursing. 27(4).
236-245.

Due to US military conflicts
in the Middle East, there is an
increased prevalence of post-
traumatic stress disorder
(PTSD) diagnoses amongst
combat veterans. PTSD
places vets at an increased
risk for emergence delirium
(ED). The lack of literature
on ED in PTSD combat vets
presents a challenge for
PACU staff. This article
implemented new adult ED
screening tools to assess for
contributing factors of ED in
combat veterans.

Quantitative Design:
Prospective,
descriptive,
correlational
design (n
=135)
Instruments:
Pediatric
Anesthesia
Emergence
Delirium
(PAED) Scale:
used to assess
ED
postoperatively

State-Trait
Anxiety
Inventory
PHQ-9
(Depression)
PCL-M (PTSD
Military
Checklist)

The study revealed the incidence
of ED was high amongst PTSD
patients. It also identified anxiety,
PTSD, and depression as high risk
factors. Regression modeling
suggested that state-anxiety
served as the best predictor. These
findings increase clinicians’
understanding of ED among
combat veterans and give
direction to future studies that
focus on preventive treatment.

STAI, PHQ-9, PCL-M used
preoperatively when obtaining
consent, correlated with PAED
postoperatively

McGuire, J.M., & Burkard, J.F.
(2010). Risk factors for
emergence delirium in U.S.
Military Members. Journal of
PeriAnesthesia Nursing. 25(6).
392-401.

Emergence delirium is a
phenomenon found in
pediatric patients and elderly
patients as well as in combat
veterans.
Qualitative

Literature
Review
Incidence in pediatric population
is 18-57%. Risk factors include
environmental, social and
biological factors. Parental
anxiety, patient anxiety,
adjunctive medications, age, and
type of surgery seem to play an

EMERGENCE DELIRIUM IN AMERICAN VETERANS

41
There is an increasing
incidence among US military
surgical population attributed
to operations in the Middle
East. ED is an emerging
health concern as it creates a
dangerous situation with the
potential of injury and
requirement of increased
resources directed towards
managing the patient with ED
and away from other patients
in the PACU setting.
Distinctions are drawn
between postoperative
delirium and emergence
delirium.
important role. Effective
treatment includes intranasal
fentanyl and caudal clonidine.

Incidence in adult population
4.7%.
No studies to date link cognitive
impairment in the elderly
specifically to ED, however
postoperative delirium has been
well documented.
CRNAs in the military self-report
incidence of ED symptoms at
27%. ED occurs with greater
incidence among combat veterans
compared to general military
population of the same age.
Risk factors: 1) medication 2)
physical trauma requiring surgical
intervention 3) pain 4) traumatic
brain injury 5) psychological
trauma
TBI in 10-20% of combat-
exposed population
PTSD in 23% of trauma survivors
1-year post. Both are
underreported.
Rapid emergence may elicit
PTSD response
Examines a number of differential
diagnoses:

EMERGENCE DELIRIUM IN AMERICAN VETERANS

42
Central anticholinergic Syndrome
(CAS)
Hypoxia/hypercapnia
Embolus/seizure
Intraoperative use of ketamine
resulting in hallucinations.
McGuire JM, Wilson JT. (2013).
Reply: possible confounding by
mefloquine in the association of
emergence delirium with PTSD
and TBI among combat veterans.
J Perianesth Nurs., 28(6):335-6.
doi: 10.1016/j.jopan.2013.09.007

Letter of concern by Wilson
and response by McGuire.
Addressing the possibility of
the use of mefloquine as a
confounding factor in
associating ED with PTSD,
TBI and combat veterans.

Letter to the
Editor
Wilson believes that the high use
of Mefloquine ( ~ 30% ) by
military personnel and its
subsequent side effects in some
individuals, may contribute to
misdiagnosis of ED. McGuire
replies that mefloquine use may
be a confounding factor, but notes
that prescriptive use of
mefloquine is declining, yet
incidence of ED is a frequent
complication. McGuire reiterates
that anxiety continues to be a
major predictor and notes the
need for further research into the
potential relationship between
mefloquine and ED.

McLott, J., Jurecic, J., Hemphill,
L., & Dunn, K. (2013).
Development of an
amygdalocentric neurocircuitry-
reactive aggression theoretical
model of emergence delirium in
posttraumatic stress disorder: An
Exposure to traumatic events
causes irreversible structural
changes to PTSD patients’
amygdalocentric
neurocircuitry (AN)
impairing their ability to
rationalize sensory input and
increases aggressive
behavior. When undergoing

Literature
Review
Development of an
amygdalocentric neurocircuitry
theoretical model to explain the
proposed synergistic effects of
PTSD and general anesthetics in
increasing the likeliness of
patients developing emergence
delirium.

EMERGENCE DELIRIUM IN AMERICAN VETERANS

43
integrative literature review.
AANA Journal. 81(5). 379-384.
general anesthesia, these
patients have further impaired
AN and increases the
probability of developing
emergence delirium
postoperatively.
Munk, L., Anderson, G., Moller,
A.M. (2016). Post-anaesthetic
emergence delirium in adults:
incidence, predictors and
consequences. Acta
Anaesthesiologica Scandinavica.
60. 1059-1066.

ED incidence, independent
predictors and clinical
consequences were examined.
Quantitative Study Design:
Prospective
observational
cohort study
(n=1970)
RASS used to
assess ED with
RASS >=1
definition ED.
NRS
(numerical
rating scale)
used to assess
pain.
Stats:
Fisher’s exact,
logistic
regression and
multivariate
analysis

Male sex, ETT and volatile
anesthetic were found to be
significantly related to developing
ED after anaesthesia.
In 20 cases (31%) additional staff
were needed to restrain the
agitated patient.
ED incidence of 3.7%
immediately upon emergence,
dropping to 1.3% in the PACU.
Interesting multivariate analysis
to rank relation with ED:
1. (worst) ETT/volatile
2. ETT/TIVA
3. LM/TIVA (least)
Second study ever to look at
clinical consequences.

EMERGENCE DELIRIUM IN AMERICAN VETERANS

44
APA Reference Summary of Main Concept
Quantitative
or Qualitative
Research?
Methods
(Design,
instruments,
questionnaires
)
Main Findings of the Study
Nguyen, S., Pak, M., Paoli, D., &
Neff, D. (2016). Emergence
delirium with post-traumatic
stress disorder among military
veterans. Cureus. 8(12). DOI
10.7759/cureus.921

Two case studies of pts with
PTSD, comparing
intervention with
intraoperative
dexmedetomidine and verbal
coaching vs standard of care
with propofol.
Qualitative Case Series Case One:
58-year old male with PTSD and
history of wild wake-ups.
Agitated and hallucinatory upon
emergence. Treated with propofol
and presence of spouse. ED
resolved ~12 minutes after
waking from propofol dose.
Case 2:
63 -year old male with PTSD with
history of “violent wakeups” on
multiple prior surgeries. 25-mcg
of dexmedetomidine given
intraoperatively over ten minutes.
Bolus dose of 75 mcg given prior
to emergence over 30 minutes.
Aroused with verbal coaching,
with controlled noise levels in the
OR. No s/s of ED upon
emergence.
Excluded the use of
benzodiazepines in both cases.
Both cases had anxiety and
depression as co-diagnoses.

EMERGENCE DELIRIUM IN AMERICAN VETERANS

45
PTSD was diagnosed due to
military combat exposures.

Pharmacological,
nonpharmacological, and
multicomponent interventions should
be considered to prevent ED in this
population.
Radtke, F. M., Franck, M.,
Hagemann, L., Seeling, M.,
Wernecke, K. D., & Spies, C. D.
(2010). Risk factors for
inadequate emergence after
anesthesia: emergence delirium
and hypoactive emergence.
Minerva anestesiologica, 76(6),
394-403.

Qualitative Prospective
Observational
Study
“Preventable risk factors for
emergence delirium were
induction of anesthesia with
etomidate, premedication with
benzodiazepines and higher
postoperative pain scores.
Hypoactive emergence was less
frequent than emergence delirium
and was associated with a longer
post- operative hospital stay.”

Read, M.D., Maani, C.V., &
Blackwell, S. (2017).
Dexmedetomidine as a rescue
therapy for emergence delirium in
adults: A case series. A&A Case
Reports. 9. 20-23.

Describes three case studies
of patients with previous
diagnoses of PTSD who were
successfully treated with
dexmedetomidine as a rescue
medication.
Qualitative Case Series

RAAS score
(Richmond
Agitation and
Sedation) used
to assess
postoperatively

Aldrete Score
given upon
arrival to the
Case 1: RAAS of +2.
Aldrete of 5/10.
Bolus of 0.5 mcg/kg
Infusion of 0.5 mcg/kg/h started
and titrated off over 1 hours.
Case 2: RAAS of +4.
Aldrete of 5/10.
Bolus of 1 mcg/kg

EMERGENCE DELIRIUM IN AMERICAN VETERANS

46
PACU and
upon
discharge. Max
score 10.
Infusion of 0.5 mcg/kg/h started
and titrated off over 2 hours.
Case 3: RAAS +4.
Aldrete of 4/10.
Bolus of 1 mcg/kg
Infusion of 0.7 mcg/kg/h started
and increased to 1 mcg/kg/h.
Titrated off over 2 hours.
All RAAS scores 0 and Aldrete
scores 10 upon discontinuation of
dexmedetomidine and dc from
PACU.
RAAS/Aldrete Scoring
Dexmedetomidine as rescue med
→ first time in literature
Shoum, S. (2014). Posttraumatic
stess disorder: A special case of
emergence delirium and
anesthetic alternatives. A&A Case
Reports. 3. 58-60.

Two cases are presented
involving non-military
patients with a history of
PTSD. The first experienced
a dangerous flashback leading
to running from the hospital
and the second had an
uneventful emergence after
the anesthesia plan was
modified to address the PTSD
risk factor.

From Department of
Anesthesiology, South
Nassau Communities
Qualitative Case Series The first patient had no
preparation, while the second was
appropriately prepared. Both
patients had PTSD; one untreated,
the other treated.
Eliciting a complete psychiatric
history and the addition of
measures to avoid emergence
delirium can lead to a safe,
smooth anesthetic course. You
should ask about history of PTSD
and sleep disturbance, and know
that use of prazosin (med for
nightmares) may be an indicator
of PTSD. You should avoid

EMERGENCE DELIRIUM IN AMERICAN VETERANS

47
Hospital, Oceanside, New
York
anesthetic techniques that induce
loss of consciousness or
disorientation; topical, peripheral,
or major regional anesthesia
should be used to avoid general
anesthesia or deep sedation.
Ketamine alone, should be titrated
for sedation, when necessary;
something “profound” occurs
with ketamine in these patients.
Do not assume pt is being treated
for depression when you see an
SSRI in med rec; these meds are
often used for PTSD. Having a
family member or close friend
during emergence is often helpful
and may restore orientation.
Dexmedetomidine may be useful,
though it is not standard of care.
PTSD should be included in
medical history assessment.
Use of ketamine with a
“profound” effect
Thomsen JL, Nielsen CV,
Eskildsen KZ, Demant MN,
Gätke MR. (2015). Awareness
during emergence from
anaesthesia: significance of
neuromuscular monitoring in
patients with
butyrylcholinesterase deficiency.
Eliminated--Not related to
ED specifically

EMERGENCE DELIRIUM IN AMERICAN VETERANS

48
Br J Anaesth. 2015 Jul;115 Suppl
1:i78-i88. doi:
10.1093/bja/aev096
Umholtz, M., Cilnyk, J., Wang,
C., Porhomayon, J., Pourafkari,
L., & Nader, N. (2016).
Postanesthesia emergence in
patients with post-traumatic stress
disorder. Journal of Clinical
Anesthesia. 34, 3-10.

Examination of ED incidence
in patients with PTSD.
Quantitative Retrospective
Cohort
(n= 1763)
4.7% of patients with PTSD and
1.5% of the non-PTSD group
experienced ED.
PTSD was an independent
predictor of ED.
Longer duration of stay in PACU
in PTSD group.
States etomidate is associated
with incidence of ED.
Wheat, L.L, Turner, B.S., Diaz,
A., & Maani, C.V. (2018).
Military service members and
emergence delirium screening: An
evidence based practice project.
Journal of PeriAnesthesia
Nursing. 33(5). 608-615.

Evaluation of a screening tool
based on available evidence
of ED risk factors.
Quantitative Retrospective
chart review
(n= 100) with
prospective
data collection
post tool
implementatio
n (n=241).
Tool: 13
questions,
some with sub
questions.
Takes approx.
5 minutes to
complete.
Includes pre-op
Identification rates for at-risk
patients rose from 5% to 21-
22.5% using the tool.
Completion rate was ~30%. Some
patients were unsure of why they
needed to fill out an additional
form. Some patients not
comfortable disclosing history on
a separate piece of paper.
Anesthesia providers reported
minimal impact on current
workflow.
PACU nurses at this facility
estimate 8-10 occurrences of ED
per month in the PACU. Actions

EMERGENCE DELIRIUM IN AMERICAN VETERANS

49
anxiety self-
report. Score of
>4= high
anxiety.
Overall score
of 3 or more
items = at risk
for ED. Was an
optional, self-
administered
tool.
to address risk factors broken into
four categories:
1. Environment Management
2. Pain & NV Control
3. Regional and non-opioid
4. Normothermia

Recommends inclusion of these
questions into the current
anesthesia record to increase
completion rates.

Wilson, J.T. (2013). Army
anesthesia providers’ perceptions
of emergence delirium after
general anesthesia in service
members. AANA Journal, 81(6).
Active military service
anesthesia providers, both
anesthesiologists and
CRNAs, were surveyed
online - after IRB approval -
to assess their perceptions,
experiences, and behaviors
with emergence delirium in
providing general anesthesia
with active military veterans.
Quantitative
and Qualitative
Descriptive
Correlational
Study with
Online Survey
87 active military service
anesthesia providers responded to
the survey.

ED cases personally
experienced in service members
< 5 18 (26.5)
5-10 19 (27.9)
11-20 18 (26.6)
> 20 13 (19.1)

Over time, have ED cases
decreased,
stayed the same, or increased?
31% believed ED cases have
increased in prevalence.

EMERGENCE DELIRIUM IN AMERICAN VETERANS

50

How much of a problem is ED?
40% of respondents believed ED
was a moderate to severe
problem.

Risk of injury to service
members
exhibiting ED
45% of respondents believed ED
was a moderate to high risk to
service members exhibiting ED.

Risk of injury to OR or PACU
staff from ED
40% of respondents believed ED
was a moderate to high risk to OR
or PACU staff.
Wilson, J.T. (2014).
Pharmacologic, physiologic, and
psychological characteristics
associated with emergence
delirium in combat veterans.
AANA Journal. 82(5). 355-362.
American Army anesthesia
providers surveyed regarding
their observations and
experiences with emergence
delirium and the
pharmacological, physiologic
and psychological
characteristics they perceived
to be associated with ED.
Quantitative Descriptive
correlational.
Employs
electronic
survey.
No statistical
analysis tools
described by
authors.
- Ketamine and volatile
anesthetics are the
pharmacological agents most
implicated by survey respondents.
- 65% of survey respondents
believe that administering
benzodiazepines help alleviate
symptoms of ED.

EMERGENCE DELIRIUM IN AMERICAN VETERANS

51
Survey responses analyzed
for correlations.
- Over 90% of respondents
believe that verbal explanations
and reassurance help prevent ED.

Wilson, J.T., Pokorny, M. (2012).
Experiences of military CRNAs
with service personnel who are
emerging from general anesthesia.
AANA Journal. 80(4). 260-265.
Face-to-face interviews
conducted with 3 CRNA
study participants regarding
their experiences and
perceptions of ED among
military veterans.
Qualitative In-depth
interviews
conducted with
3 male CRNA
study
participants.
Interview
recordings
transcribed
verbatim and
analyzed using
Colaizzi’s
method in
order to
organize/synth
esize interview
statements into
themes.
Themes that have emerged from
interviews-
- Emergence delirium occurs at a
much higher degree among
military veterans vs. general
population.
- ED is more prevalent in younger
military population.
- TIVA is a superior method for
patients diagnosed/suspected to
have PTSD and/or TBI
- Encouraging open
communication between patient
and provider (nicknamed by
respondents as “vocal local”) is
vital for smooth emergence.
Yang, E., Kreuzer, M., Hesse, S.,
Davari, P., Lee, S.C., & Garcia,
P.S. (2018). Infrared pupillometry
helps to detect and predict
delirium in the post-anesthesia
care unit. J Clin Moint Comput.
32. 359-368.
Eliminated--Not related to
Military/PTSD specifically

EMERGENCE DELIRIUM PREVENTION

52

Appendix B: Appraisal of Literature

AUTHORS KEY WORD STUDY
DESIGN
APPRAISAL
TOOL
SCORE Level of
Evidence
INCLUSION
1 Avidan et
al. (2017)
Intraoperative
ketamine, delirium
Quantitative
Double Blind
RCT
RAPID 10/10 I Y
2 Lepouse et
al. (2006)
Emergence
delirium
Prospective
cohort
RAPID 9/10
0.9
III Y
3 McGuire
(2012)
Emergence
delirium, combat
veterans
Prospective
cohort,
descriptive,
correlational
RAPID 9/10
0.9
III Y
4 Munk et al.
(2016)
Emergence
delirium
Prospective
observational
cohort
RAPID 9/10
0.9
III Y
5 Radtke et al.
(2010)
Emergence
delirium
Prospective
observational
cohort
RAPID 8/10
0.8
III Y

6 Umholtz et
al. (2016)
Emergence, PTSD Retrospective
cohort
RAPID 3/10
0.3
III Y
7 Wheat et al.
(2018)
Emergence
delirium, military
service members
Retrospective
cohort (with
prospective post
intervention
analysis)
RAPID 8/10
0.8
III Y
8 Wilson
(2013)
Emergence
delirium, service
members
Descriptive
Correlational
*****

III Y
9 Wilson
(2014)
Emergence
delirium
Descriptive
Correlational
*****

III Y
10 Wilson
(2012)
Military CRNAs,
emergence
Qualitative RAPID 24/25
0.96
III Y
11 Burns
(2003)
Emergence
delirium
Case Study CARE 25/29
0.86
V Y
12 Crosby et
al. (2007)
Emergence
delirium, PTSD,
PTSD flashback
Case Study CARE 22/29
0.76
V Y
13 Gentili et al.
(2017)
Emergence, PTSD,
agitation
Case Study CARE 7/29
0.24
V Y
14 Nguyen, et
al. (2016)
Emergence
delirium, PTSD,
military veterans
Case Report CARE 23/29
0.79
IV Y
15 Read et al.
(2017)
Dexmedetomidine,
emergence
delirium
Case Report CARE 27/29
0.93
IV Y
16 Shoum
(2014)
Emergence
delirium
Case Study CARE 24/29
0.83
IV Y
17 Hintzsche
(2018)
Emergence
delirium, PTSD
Literature Review Critical
Appraisal of
Literature
Review Tool
10/10
1.0
IV Y
18 Lovestrand
et al. (2016)
Emergence
delirium, PTSD
Literature
Synthesis with
practice
recommendations
Critical
Appraisal of
Literature
Review Tool
10/10
1.0
IV Y
EMERGENCE DELIRIUM PREVENTION 53

19 McGuire et
al. (2010)
Emergence
delirium, US
military members
Literature Review Critical
Appraisal of
Literature
Review Tool
9/10
0.9
IV Y
20 McLott et
al. (2013)
Emergence
delirium, PTSD
Literature Review Critical
Appraisal of
Literature
Review Tool
9/10
0.9
IV Y
21 Kilpatrick et
al. (2013)
PTSD National Survey -
Quantitative
CEBM Survey
Appraisal
Tool
0.83 III Y
22 McGuire &
Wilson
(2013)
Emergence
delirium, PTSD
Letter & reply N/A

V Y
23 Gross &
Stern (2014)
Anesthesia,
emergence
ELIMINATED

N
24 Hipp & Ely
(2012)
Anesthesia,
emergence
ELIMINATED

N
25 Lee et al.
(2016)
Dexmedetomidine ELIMINATED

N
26 Li et al.
(2017)
Dexmedetomidine,
delirium
RCT-
ELIMINATED

N
27 Loeffler et
al. (2012)
Emergence ELIMINATED

N
28 Thomsen et
al (2015)
Emergence ELIMINATED

N
29 Yang et al.
(2018)
Delirium, PACU ELIMINATED

N
EMERGENCE DELIRIUM PREVENTION

54
Appendix C: Emergence Delirium Prevention Practice Recommendations

Emergence Delirium Prevention Practice Recommendations
Preoperative Recommendations Intraoperative Recommendations Postoperative Recommendations
Medical Record Evaluation
1. Identify surgical procedures associated with higher ED
prevalence (i.e. breast surgery, abdominal surgery,
prolonged procedures, and expected severe postoperative
pain).
2. Appraise available psychiatric consult notes and
screening tools for diagnoses and severity of PTSD (PSL-
M), anxiety (STAI), and major depression (PHQ-9).
3. Evaluate patient home medications noting
benzodiazepines (contribute to ED development) and
long-term SSRIs (reduce ED prevalence).
4. Review prior surgical and anesthesia records indicating
difficult emergence.
5. Assess social history for combat experience.

Preoperative Patient Interview
1. Perform psychiatric history intake further evaluating for
symptoms and severity of PTSD, anxiety, and depression.
2. Utilize validated assessment tools for high-risk veterans.
o STAI is the most sensitive identifier in
predicting ED.
o PHQ-9 scores greater than or equal to 10 have a
high specificity for depression which is an
independent predictor of ED.
o Higher PCL-M scores are associated with
increased ED prevalence.

Interdisciplinary Collaboration and Patient Education
1. Alert interdisciplinary OR team of veterans at high-risk of
developing ED and collaborate to create consistently
implemented tailored perioperative measures to reduce
ED risk via environmental control, noxious stimuli
reduction, and reassuring patient support.
2. Educate at-risk veterans and their support persons
regarding ED risks, prevention, and treatment.
1. Prioritize the use of anesthetic
techniques; allow patient to be awake if
a local anesthetic or and regional block
is appropriate. If possible, general
anesthesia and any medications that
induce loss of consciousness should be
avoided.
2. Benzodiazepines should be avoided in
all operative phases as they are
associated with a higher incidence of
ED.
3. TIVA is associated with less incidence
of ED and is preferred over the use of
volatile anesthetic gases during the
intraoperative phase.
4. Administer dexmedetomidine infusion
intraoperatively between 0.2 – 1.0
mcg/kg/hour to reduce the risk of ED.
5. Although Ketamine has been noted in
qualitative studies to be a potentially
useful agent, there is not enough
quantitative evidence to formulate a
recommendation regarding its
intraoperative use for veterans with
PTSD.
6. Avoid preventable physiological
noxious stimuli such as hypothermia,
hypoxia, hypercarbia, postoperative
nausea and vomiting, and uncontrolled
postoperative pain.
7. Address pain and control nausea and
vomiting early as these factors can lead
to the exacerbation of PTSD symptoms
upon emergence.

Detection of ED
1. Use the PAED scale as an early ED detection tool as it has been found to
measure the same behaviors of ED regardless of age.
2. Utilize the RAAS tool in determining the efficacy of rescue treatment and
when rescue interventions are necessary.
3. Utilize the Aldrete Score to determine readiness for discharge after the
resolution of an ED episode.
Environmental Control & Reorientation
1. Arouse patients with verbal coaching and controlled noise level in the OR
and PACU.
2. Allow supportive family member, friend, or other person known to the
patient to be present upon emergence to help ground patients at risk for
ED.
3. Revert to grounding methods and reorientation in lieu of medications to
prevent ED symptomatology when possible; pharmacological
interventions may exacerbate ED symptoms.
Rescue Medication
1. Avoid Benzodiazepine medications as they are unhelpful in the
amelioration of ED symptoms and may exacerbate delirious state.
2. Administer dexmedetomidine as a rescue medication. A bolus dose of
0.5 -1 mcg/kg in conjunction with a continuous infusion of 0.5-1
mcg/kg/h is recommended with dose titrated off over one to two hours
based on PAED, RAAS and Aldrete scores. The provider should be alert
for the development of bradycardia, hypotension, hypertension, and
hyperglycemia.
Further Postoperative Recommendations
1. Adequate staff and preparation. PACUs should anticipate the need of
additional staff to aid in reorientation, rapid medication administration
and should be trained in the use of the PAED, RAAS and Aldrete tools.
2. Patient and team debriefing after ED resolution. It is recommended that
involved perioperative staff discuss the event, the interventions taken, and
educate patients to inform future anesthesia providers regarding their ED
risk.
3. Accurate and comprehensive documentation is important for alerting
future providers, facilitate incidence data collection, and promote
continuity of care.

Abstract (if available)

Abstract Emergence delirium (ED) is an acute neurologic impairment that can occur directly following the discontinuation of general anesthesia (GA) characterized by altered cognition, agitated psychomotor movements, and reactive aggression potentially leading to complications such as: self-extubation, dislodgement of various indwelling catheters, patient and staff injury, and increased length of stay in the post anesthesia care unit (McLott et al., 2013). Recent studies have shown ED prevalence in the general adult population is estimated at 8.3% but rates as high as 31% in certain populations such as combat veterans diagnosed with post-traumatic stress disorder (PTSD) have been observed (Hintzsche, 2018). Additionally, veterans have a disproportionate incidence of PTSD due to the active military conflicts in the middle east such as Operation Iraqi Freedom and Operation Enduring Freedom (McGuire, 2012). The current literature is lacking updated standardized recommendations to prevent ED and to date there does not exist a standardized practice protocol for identifying, preventing, and treating emergence delirium in veterans with PTSD. ❧ This Doctoral Capstone provides knowledge concerning physiology of PTSD and summarizes practice recommendations synthesized from the latest evidence-based data available in an effort to guide anesthesia practice. Practice recommendations include preoperative assessment tools, premedication, pre-intra and post-operative management and rescue medication administration.

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Asset Metadata

Creator Roman, Kristen (author)

Core Title Emergence delirium prevention in American veterans diagnosed with post-traumatic stress disorder: a critical literature review with practice recommendations

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Publication Date 06/09/2020

Defense Date 06/08/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag anesthesia,delirium,emergence,OAI-PMH Harvest,post-traumatic stress disorder

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Bamgbose, Elizabeth (committee chair), Darna, Jeffrey (committee member), Griffis, Charles (committee member)

Creator Email kristenfrazier@gmail.com,romank@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-315845

Unique identifier UC11663535

Identifier etd-RomanKrist-8578.pdf (filename),usctheses-c89-315845 (legacy record id)

Legacy Identifier etd-RomanKrist-8578.pdf

Dmrecord 315845

Document Type Capstone project

Rights Roman, Kristen

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA