Emergence Delirium With Post-traumatic Stress Disorder Among Military Veterans

Abstract

The clinical characteristics of emergence delirium (ED) associated with post-traumatic stress disorder (PTSD) among military veterans encompass transient agitation, restlessness, disorientation, and violent verbal and physical behaviors due to re-experiencing of PTSD-related incidents. Two cases of ED after general anesthesia associated with PTSD are presented. Different anesthesia methods were applied for the two cases. A traditional medical approach appeared not to prevent the incidence of ED. In the second case, dexmedetomidine infusion along with verbal coaching was effective in preventing ED for a veteran known to have “wild wake-ups” with prior anesthetics. Further clinical studies in effectively utilizing dexmedetomidine in this population with PTSD at high risk for ED are warranted.

Emergence Agitation and Anesthetic Considerations in the Management of Patients With Post-Traumatic Stress Disorder: A Report of Two Cases and a Review of the Literature

“…After reversible causes are treated, repeat dexmedetomidine loading may also be helpful [ 3 , 4 , 6 , 16 ]. Low-dose propofol boluses may be used to smooth reemergence after a failed initial attempt [ 3 , 4 , 5 , 6 , 12 ]. Small doses of haloperidol may also be administered [ 3 , 4 , 9 ].…”

“…The mixed results of many treatment strategies have demonstrated the multifactorial nature of EA. However, it does appear that dexmedetomidine is consistently helpful in addressing the multifactorial nature of PTSD, as it provides both sedation and analgesia and smooths emergence [3,5,11]. Although expert opinion suggests avoiding benzodiazepines in patients with PTSD, midazolam has been used by most providers in these case reports with varying effects [3,4,6,[11][12][13][14][15].…”

“…Emergence agitation (EA) and emergence delirium (ED) are known phenomena that occur in the postanesthetic period. PTSD is closely associated with EA following anesthesia; moreover, EA in patients with PTSD can be severe and challenging to manage [3][4][5][6][7]. EA is believed to occur in 3.0% to 21.3% of adults after general anesthesia [8].…”

Online Supplement to “A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veteran Affairs Medical Center”

“…33,[43][44][45][46][47][48][49] Dexmedetomidine, when administered prior to emergence (preoperatively, intraoperatively, and/or at the end of surgery), will facilitate cooperative and tranquil patient behavior. 33,36,[38][39][40][41][43][44][45][46][47][49][50][51][52][53][54][55][56] Dexmedetomidine has an onset of 5-10 minutes and duration of 2-3 hours. 20,25 Numerous studies have shown that dexmedetomidine is effective in preventing emergence delirium, 31,[38][39][40][41]46,[48][49][50][51][52][53][54][55][56][57] while few studies indicate that it may be used to treat an episode of emergence delirium.…”

“…33,36,[38][39][40][41][43][44][45][46][47][49][50][51][52][53][54][55][56] Dexmedetomidine has an onset of 5-10 minutes and duration of 2-3 hours. 20,25 Numerous studies have shown that dexmedetomidine is effective in preventing emergence delirium, 31,[38][39][40][41]46,[48][49][50][51][52][53][54][55][56][57] while few studies indicate that it may be used to treat an episode of emergence delirium. 35,58,59 One study showed that preoperative and intraoperative administration of dexmedetomidine significantly reduced the incidence and severity of emergence delirium among anxiety afflicted combat veterans.…”