Management of Emergence Delirium in Adult PTSD Patients: Recommendations for Practice

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

“…30 Previous literature also suggests that patients with a history of post-traumatic stress disorder (PTSD) or trauma and who are administered midazolam are at a higher risk for emergence delirium. 6,[33][34][35] There is some debate among providers about the relation between midazolam/benzodiazepines and emergence delirium; 13 nevertheless, in our opinion, the previous studies and other literature collectively indicate that anesthesia providers may reduce the likelihood of emergence delirium by avoiding administration of midazolam/benzodiazepines.…”

“…Dexmedetomidine, an alternative to midazolam, 25,[36][37][38][39][40][41] is a sedative-analgesic (opioid-sparing) and a potent anxiolytic. 6,20,33,[42][43][44][45] Dexmedetomidine is an agonist of the alpha-2 adrenergic receptor and acts by reducing the sympathetic noradrenergic outflow and inhibits the central release of norepinephrine, thereby attenuates the hyperarousal state and fight-or-flight response. 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.…”

“…6,20,33,[42][43][44][45] Dexmedetomidine is an agonist of the alpha-2 adrenergic receptor and acts by reducing the sympathetic noradrenergic outflow and inhibits the central release of norepinephrine, thereby attenuates the hyperarousal state and fight-or-flight response. 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.…”

Perioperative Delirium/Agitation Associated With the Use of Anesthetics and/or Adjunct Agents: A Study of Patient Behaviors, Injuries, and Interventions to Mitigate Risk

“…• Avoid triggers by reducing noise (music and metallic sounds during cleanup), dimming lights, and using patient's preferred method for emergence (e.g., softer voice, gender preference of staff, tapped on shoulder). 20,25 • Decrease height of stretcher or bed to provide staff with greater leverage in case the patient must be manually restrained (staff's hands-on restraint). Also, place siderails up with padding to help protect the patient and consider use of approved mechanical restraints.…”

“…• Provide the patient with a prepared document to help them understand the bout of delirium/agitation and prior to discharge provide the patient with a referral to a mental health service. 20 Overall, assistance in helping the patient understand and mentally overcome the experience is important because patients who had a bout of delirium/agitation might be less likely to schedule a future procedure, which may have a long-term negative impact on their health (e.g., delayed diagnosis, treatment, and/or therapy). • File event report with patient safety office or risk management, and add a detailed note to the patient's EMR.…”