NCANA PTSD EMERGENCE DELIRIUM
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Transcript of NCANA PTSD EMERGENCE DELIRIUM
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PTSD,Emergence Delirium, and the PACU
LTC Denise Beaumont, CRNA
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ObjectivesParticipants will be able to:
1. Verbalize the definitions of PTSD, emergence delirium and their implications in the perioperative setting.
2. Identify current evidence on emergence delirium and PTSD.
3. Integrate strategies presented into his/her own anesthesia practice.
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1 How we got here
Definitions
Plan of Care
What the future holds
2
3
4
PTSD and Emergence Delirium
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1 2 3 4
Army PACU Gap in Literature
Standard InterventionsIneffective
Wilson and McGuireBy 2013 we knew
• ED is a problem• Gap existed in
LiteratureMulti-Disciplinary
Approach
PTSD and Emergence Delirium
How we got here…
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Do no Harm
Question
Observation
and Analysis
Document
Discovery/Evidence1
2
3
4 Process, outcome, Evaluation
Practice Integration
Translation to guidelines
PTSD and Emergence Delirium
Star Model *
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Preoperative PACU DischargeIntraoperative
Improved
patient
outcomes
Evidence-Based Guidelines
PTSD and Emergence Delirium
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PTSD and Emergence Delirium
– CMDR Jason McGuire USN
– LTC Tyler WilsonUS Army
- LCDR Ken Wofford USN, et al
• Donna Lovestrand et al
• Jason Mc Lott, CRNA et al
• Plus…
“How we got here” team
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?
Emergence Delirium• Emergence agitation
• Post operative delirium• Emergence deliriumDefinitions
PTSD and Emergence Delirium
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Emergence
Agitation - Pediatric
?
Emergence Delirium• Emergence agitation
• Post operative delirium• Emergence deliriumDefinitions
PTSD and Emergence Delirium
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Emergence
Agitation - Pediatric
Post-Op Delirium -
ICU
?
Emergence Delirium• Emergence agitation
• Post operative delirium• Emergence deliriumDefinitions
PTSD and Emergence Delirium
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Emergence
Agitation - Pediatric
Post-Op Delirium -
ICU
?
Emergence
Delirium - PTSD
Emergence Delirium• Emergence agitation
• Post operative delirium• Emergence deliriumDefinitions
PTSD and Emergence Delirium
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Delirium Scale?
Emergence
Agitation - Pediatric
Post-Op Delirium -
ICU
?
Emergence
Delirium - PTSD
Emergence Delirium• Emergence agitation
• Post operative delirium• Emergence deliriumDefinitions
PTSD and Emergence Delirium
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PTSD and Emergence DeliriumDelirium Scale- Pediatric• Eye contact• Purposeful actions• Awareness of
surroundings• Restlessness• Ability to console
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PTSD and Emergence DeliriumDelirium Scale- Pediatric• Eye contact• Purposeful actions• Awareness of
surroundings• Restlessness• Ability to console
Adult Delirium• Purposeful eye contact• Flashbacks/
hallucinations
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PTSD and Emergence Delirium
Tyler Wilson, 2014 [12]
Definition
• The scenario of a combat veteran who is emerging from general anesthesia and is subsequently seen thrashing around in a violent manner (to include pulling at monitoring equipment, intravenous catheters, endotracheal tubes, drains, Foley catheter, etc.), screaming, speaking incoherently, hitting, biting, or attempting to leave the OR…encompassing any time frame from the end of surgery to discharge from the PACU”
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1
PTSD
2
3
PTSD and Emergence Delirium
Definitions
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1
Hyper-
arousal
PTSD
2
3
PTSD and Emergence Delirium
Definitions
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1
Hyper-
arousal
PTSD
2
Avoidance
3
PTSD and Emergence Delirium
Definitions
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1
Hyper-
arousal
PTSD
2
Avoidance
3
Intrusion Symptoms
PTSD and Emergence Delirium
Definitions
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Psychotherapy (e.g.
CBT)
PharmacotherapyExposure/
Relaxation
Trusting
Relationship
Treatment of PTSD as outpatient
PTSD and Emergence Delirium
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Hypervigilant,
Sensitivity to
noises,
Preoccupied with
surroundings
Hyperarousal
Prazosin or
clonidine
SSRI/SNRI
hydroxyzine
Medication Rec
Safety
Known triggers?
Seeing therapist?
Nightmares/
Psych hx
What type of
anesthesia?
Assurance of care
History of
“Agitated Wake-ups”
1 2 3 4
Plan of Care
Preoperative Interview
PTSD and Emergence Delirium
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Identification of Patients
Preop
1 23
4
Management
PTSD and Emergence Delirium
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Diff diagnosis
1
Meds
2
TIVA/Volatile
3PTSD specific
4
Plan of Care Anesthesia
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Anesthesia
Ketamine/Versed/dex/clonidine
Identification of Patients
Preop
1 23
4
Management
PTSD and Emergence Delirium
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Auditory stimulation
Inappropriate retrieval of
memories (sounds)
Inhibit accurate
interpretation and
categorization of memories
ED and AN
GA- Produces amnesia, ?
hyperarousal
Benzos- amnesia, ?
hyperarousal
Anesthesia and AN
PTSD and AN
Free flow of fear to
amygdala
Hippocampus- cannot accurately place fears in context – benign vs.
dangerous
Amygdalocentric neurocircuitry
(AN)
PTSD and Emergence Delirium
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Anesthesia
Ketamine/Versed/dex/clonidine PACU
Low stim/rescue
Identification of Patients
Preop
1 23
4
Management
PTSD and Emergence Delirium
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Plan of Care
PACU
Risk?
Consistency
Low Stim
Validate/talkD
C
B
A
A
B
C
D Begin the healing
Amydalocentric
Staffing/Security
Know your patient
PTSD and Emergence Delirium
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Document, document, document
refines definitions, aids in research
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DischRESPECT-Mil
Anesthesia
Ketamine/versed/dex/clonidine PACU
Low stim/rescue
Identification of Patients
Preop
1 23
4
Management
PTSD and Emergence Delirium
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Volatile vs TIVA
α2-adrenergic
agonists
Ketamine
vocal local
Intraop
Consistency
Medications
Validate
Psychotherapy
Delirium scale
Dex study
Research
Guidelines
Disseminate info
Future
Identify Patient
Med Rec
History
Prepare for
discharge
Preop
Low stim
Pain control
Avoid touch
Document
PACU/Discharge
PTSD and Emergence Delirium
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PTSD and Emergence Delirium
• What the future holds– Delirium Scale for adults– Research on dexmedetomidine -
begun in January, 2015; Other medications?
– Dissemination of data– Cognitive Behavioral training for
staff?– Evidence-based guidelines
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References1. J. Wilson, "Army anesthesia providers' perceptions of emergence delirium after general
anesthesia in service members," AANA Journal, vol. 81, no. 6, pp. 443-440, 2013.2. J. McGuire, "The incidence of and risk factors for emergence delirium in US military combat
veterans," Journal of Perianesthesia Nursing, vol. 27, no. 4, pp. 236-245, 2012.3. J. Thomas, J. Wilk, L. Riviere, D. McGurk, C. Castro and C. Hoge, "Prevalence of mental health
problems and functional impairment among active component and national guard soldiers 3 and 12 months following combat in Iraq," Archives of General Psychiatry, vol. 67, no. 6, pp. 614-623, 2010.
4. K. Wofford, M. Hertzberg and C. Vacchiano, "The perioperative implications of posttraumatic stress disorder," AANA Journal, vol. 80, no. 6, pp. 463-470, 2012.
5. J. McLott, J. Jurecic, L. Hemphill and K. Dunn, "Development of an amygdalocentric neurocircuitry-reactive aggression theoretical model of emergence delirium in posttraumatic stress disorder: An integrative literature review," AANA Journal, vol. 81, no. 5, pp. 379-384, 2013.
6. T. Olszewski and J. Varrasse, "The neurobiology of PTSD: implications for nurses," Journal of Psychosocial Nursing, vol. 43, no. 6, pp. 41-47, 2005.
7. K. Wofford, M. Hertzberg, S. Silva and C. Vacchiano, "Effect of elective surgery on subjective health in veterans with chronic posttraumatic stress disorder," AANA Journal, vol. 82, no. 4, pp. 285-292, 2014.
8. D. Lovestrand, S. Phipps and S. Lovestrand, "Posttraumatic stress disorder and anesthesia emergence," AANA Journal, vol. 81, no. 3, pp. 199-203, 2013.
9. S. Shoum, "Posttraumatic stress disorder: a special case of emergence delirium and anesthetic alternatives," A&A Case Reports, vol. 3, no. 5, pp. 58-60, 2014.
10.T. Wilson and S. Graves, "Pediatric considerations in a postanesthesia care unit," Journal of Post Anesthesia Nursing, vol. 5, no. 1, pp. 16-24, 1990.
11. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, DC: Author, 1994.
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References12.J. Wilson, "Pharmacologic, physiological and psychological characteristics associated with
emergence delirium in combat veterans," AANA Journal, vol. 82, no. 5, pp. 355-362, 2014.13.K. Wofford and C. Vacchiano, "Sorting through the confusion: adverse cognitive change after
surgery in adults," AANA Journal, vol. 79, no. 4, pp. 335-342, 2011.14.American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition, Arlington, VA: Author, 2013.15.C. Lepouse, C. Lautner, L. Liu, P. Gomis and A. Leon, "Emergence delirium in adults in the post-
anaesthesia care unit," British Journal of Anesthesia, vol. 96, no. 6, pp. 747-753, 2006.16.N. Sikich and J. Lerman, "Development and psychometric evaluation of the pediatric emergence
delirium scale," Anesthesiology, vol. 100, no. 5, pp. 1138-1145, 2004..17.Z. Kain, A. Caldwell-Andrews, I. Maranets, B. McClain, D. Gaal, L. Mayes, R. Feng. and H.
Zhang, "Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors," Anesthesia and Analgesia, vol. 99, pp. 1648-1654, 2004.
18.M. Raskind, E. Peskind, D. Hoff, K. Hart, H. Holmes, D. Warren, J. Shofer and e. al., "A parallel group placebo controlled study of prazosin for trauma nightmares and sleep disturbance in combat veterans with post-traumatic stress disorder," Biological Psychiatry, vol. 61, pp. 928-934, 2007.
19.A. Alao, J. Selvarajah and S. Razi, "The Use of clonidine in the treatment of nightmares among patients with co-morbid PTSD and traumatic brain injury," International Journal of Psychiatry and Medicine, vol. 44, no. 2, pp. 165-169, 2012.
20.R. Gertler, H. Brown, D. Mitchell and E. Silvus, "Dexmedetomidine: A novel sedative-analgesic agent," Proceedings of the Baylor University Medical Center, vol. 14, no. 1, pp. 13-21, 2001.
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References21.J. Wilson and M. Pokorny, "Experiences of military CRNAs with service personnel who are
emerging from general anesthesia," AANA Journal, vol. 80, pp. 260-265, 2012. 22.J. Sneyd, "Droperidol: past, present and future," Aanesthesia [serial online], vol. 64, pp. 1161-
1164, 2009. 23.T. Thurston, C. Williams and S. Foshee, "Reversal of a paradoxical reaction to midazolam with
flumazenil," Anesthesia and Analgesia, vol. 83, no. 1, p. 192, 1996.24.F. Radtke, M. Frank, L. Hagemann, M. Seeling, K. Wernecke and C. Spies, "Risk factors for
inadequate emergence after anesthesia: emergence delirium and hypoactive emergence," Minerva Anestesiological, vol. 76, no. 6, pp. 304-403, 2010.
25.A. Magaw, "A report of 245 cases of anesthesia by nitrous oxide gas and ether," St. Paul Medical Journal, vol. 3, pp. 231-233, 1901.
26.S. Keogh, K. Fry, E. Mbugua, M. Ayallo, H. Quinn, G. Otieno and N. T.D., "Vocal local versus pharmacological treatments for pain management in tubal ligation procedures in rural Kenya: a non-inferiority trial," BMC Women's Health, vol. 14, p. 21, 2014.
27.F. Nightingale, Notes on Nursing: What it is and What it is Not, New York: D. Appleton and Company, 1860.
28.Nursing Skills Fair, Mosby's Nursing Skills, Maryland Heights, MO: Elsevier, 2012. http://app44webinservice.com.NursingSkills/Legal/AboutNursingSkills.aspx
29.A. Prins, R. Kimerling and G. Leskin, "PTSD in Iraq war veterans: implications for primary care," in Iraq War Clinician Guide - 2nd Edition, Washington, DC, National Center for PTSD and Department of Defense, 2011, Chapter 7.
30.C. Engel, T. Y. C. Oxman, D. Gould, S. Barry, P. Stewart, K. Kroenke, J. Williams and A. Dietrich, "RESPECT-Mil: Feasibility of a systems-level collaborative care approach to depression and post-traumatic stress disorder in military primary care," Military Medicine, vol. 173, no. 10, pp. 935-940, 2008.
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PTSD and Emergence Delirium
Questions
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PTSD and Emergence Delirium
Name: LTC Denise Beaumont
Email: [email protected]
Phone: (210) 295-4356