Lisa A. Reed, RN, BSN Augustina Manuzak, MD, MPH, PhD Management of Emergence Delirium in Military Patients With Post Traumatic Stress Disorder Lisa A. Reed, RN, BSN Augustina Manuzak, MD, MPH, PhD

Circumstance It is estimated that throughout the Global War on Terrorism (GWOT), since September 11, 2001, there have been more than 2.3 million American military members that have been a part of the fight in Operations Iraqi Freedom (OIF), New Dawn (OND), and Enduring Freedom (OEF) (IAVA.org, 2014). Throughout the past thirteen years, the United States of America has been involved in its longest fight on foreign soil. As a result of the prolonged fight, many stressors have been placed on the troops and have been a cause of long-acting consequences with mental and physical health.

Post-Traumatic Stress Disorder & Emergence Delirium Post Traumatic Stress Disorder (PTSD) is a mental health condition that is triggered by a terrifying event and can includes symptoms such as flashbacks, nightmares and severe anxiety Emergence Delirium (ED) is postoperative event immediately after emergence from anesthesia (general/conscious sedation) patient presents with marked disorientation, non-purposeful movements, restlessness, incoherence, agitation, or unresponsiveness Post Traumatic Stress Disorder (PTSD) is an anxiety disorder, which is classified in the DSM-IV-TR, and is described as an exposure to a traumatic event followed by a triad of symptoms clusters, including re-experiencing, avoidance/numbing and hyper-arousal (McGuire & Burkard, 2010). With military members, it is common in combat to witness injury or death, experience injury, or experiencing the threat of a traumatic event. Once that event has occurred, the member may continue to relive the event through nightmares or intrusive events. The person can then develop hyper-arousal symptoms, with cognitive biases, that can cause them to perceive as dangerous and can cause harm(McGuire & Burkard, 2010). Emergence Delirium (ED) is a post-anesthesia phenomenon that can occur in any age group. ED is defined as postoperative event immediately after emergence from general anesthesia , where the patient presents with marked disorientation, nonpurposeful movements, restlessness, incoherence, agitation, or unresponsiveness. It is a mental disturbance consisting of hallucinations, delusions, and confusion as evidenced by moaning, restlessness, involuntary physical activity, and thrashing about in bed (McGuire & Burkard, 2010). According to the DSM-IV-TR, ED falls under the subtype of “Delirium Not Otherwise Specified” because of the lack of a clear understanding of its etiology (McGuire & Burkard, 2010).  Some cases of ED can happen from IV sedatives not only general anesthetic. See: http://ccn.aacnjournals.org/content/23/1/66.full.pdf

Epidemiological Model of Emergence Delirium Host - Veterans with PTSD - Advance age - Genetic predisposition - Nutrition Causative Agent - Medications (for PTSD) - Behavioral symptoms prior surgical procedure - Stressors as combat soldiers: severe injury, trauma, live thread Environment - Surgery - Anesthetic drugs

Risk Factors for Development of Post-operative Delirium Preexisting dementia or other mental disturbances (PTSD) Advancing age (>65 years old) Alcohol use Poor nutritional status Poor functional status Hearing or vision impairment Presence of a urinary catheter or endotracheal tube Orthopedic (esp femoral neck fracture repair), ophthalmologic or cardiac surgeries Surgical blood loss with post-op Hct <30%

Age as Risk Factor Age is another factor that may be a risk factor for ED. Many military medical personnel believed that ED was more prevalent in the younger military population. This may be due to the younger troops are more on the front line of combat, in greater numbers, and can be more susceptible to PTSD and/or Traumatic Brain Injuries (TBI) (Wilson & Pokorny, 2012). At times, pain and ED symptoms can look the same and be confused for each other. In the pediatric population, it has been shown in studies that the administration of an opioid analgesic, Fentanyl, reduced the incidence of ED in children from 21% to 7% (McGuire & Burkard, 2010). Patients who complained about more pain in the Post Anesthesia Care Unit (PACU), presented with more symptoms of ED. Combat veterans who received minimal Fentanyl in the OR and PACU had less incidence of ED (McGuire, 2012).

Genetics Stathmin, is a protein needed to form fear memories – no production = mice froze to danger, had less innate fear than normal mice Gastrin-releasing Peptide (GRP), which is a signaling chemical in the brain, which is released during an emotional event - +GRP = control of fear response Female, having other mental health problems (anxiety, depression), and having first-degree relatives with mental health issues (PTSD, depression) Those previously diagnosed with a psychological disorder had a higher rate of ED, 50%, than those who did not, 17%

Anesthetic Drugs and other Medications In past research, volatile anesthetics have been found to be contributing factors into ED. Specifically, the most insoluble of volatile anesthetics, Sevoflurane and Desflurane, have been found to excite the CNS-stimulating side effects, thus causing post-op excitement and ED. Other medications that may contribute to the incidence of ED are anticholinergics, barbiturates, benzodiazepines, droperidol and metoclopramide. Midazolam has also been known to cause severe paradoxical excitement and thrashing (McGuire & Burkard, 2010).

Environmental Factors Environmental characteristics such as noise, light and temperature can exacerbate the patient’s symptoms upon emergence from general anesthesia. The excessive noise and bright lights will over-stimulate the Central Nervous System (CNS) and can lead to confusion and then agitation

Pathophysiology of ED Exact pathophysiology of ED is poorly understood. There are several hypotheses: Oxidative metabolism of the brain decreases neurotransmitter levels and cause mental dysfunction. Specific neurotransmitter acetylcholine is crucial as it plays a role in awareness and arousal. Example of this: elderly patients are relatively deficient in acetylcholine and are therefore more sensitive to anticholinergic drugs. occurrence of ED is associated with the perioperative condition of the patients, in this case the veterans, especially those with PTSD. This probably due to medication they take prior to surgery, or other psychological conditions in PTSD. It is also thought that metabolic derangements, infectious processes and disturbed sleep-wake cycles could be causes of ED (McGuire & Burkard, 2010).

Mortality & Morbidity Delirium is regarded as a form of acute brain organ dysfunction that is independently associated with worse clinical outcomes Patient is at an increased risk of prolonged cognitive dysfunction and have a 3-fold higher mortality rate. With each additional day of delirium, a patient can have an increase in their mortality by 10% and can tend to have higher degrees of cognitive decline when evaluated one year after delirium According to Goldstein & Morrison (2012), there are many negative outcomes that are associated with delirium. With delirium, there is a much greater risk in mortality, can result in longer stays in the hospital and can decrease the ability to care for self. Delirium is regarded as a form of acute brain organ dysfunction that is independently associated with worse clinical outcomes ("Brainorgan.pptx,"). Of those worse clinical outcomes, patients can have longer hospitalizations, if on ventilators, can have longer periods of dependence, and can have an increase of inpatient readmissions. They also state that the patient is at an increased risk of prolonged cognitive dysfunction and have a 3-fold higher mortality rate. With each additional day of delirium, a patient can have an increase in their mortality by 10% and can tend to have higher degrees of cognitive decline when evaluated one year after delirium ("Brainorgan.pptx,").

Gaps in Knowledge The focus of research has been on the pediatric and geriatric groups Over 2.3 million OIF/OND/OEF veterans, 8.2 million Vietnam veterans 15% of the Vietnam Veterans who had PTSD close after the end of the war. It is now estimated that number has risen to 30%, even after 20-25 years after the conflict Not having a standard way of defining this condition and a common tool, that has been proven to work, then the incidence of ED is left to the medical person’s own perception.

Prevention & Intervention Can help prevent symptoms by asking patients what their job involves, and what they have done In the past Screen for PTSD, anxiety, depression Medication reconciliation Help to control the environment that the patient will be in when receiving treatment

Other Preventive Measures Regional anesthesia, such a nerve blocks, can be utilized, which may help the patient wake up with little to no pain to the surgical site and may help to not trigger a severe pain response, which would lead to the possibility of ED.

Further Study The incidence of ED in the combat veteran population is higher (20%) than compared to the general adult population (5%) Now that the wars are winding down, the military forces are yet again going to begin a drawdown

References Iraq and afghanistan veterans of america. (2014). Retrieved from http://iava.org  Mayo clinic. (1999-2014).  Retrieved from http://www.mayoclinic.org/diseases-conditions/post- traumatic-stress-disorder/basics/definition/con-20022540 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 National institute of mental health - post traumatic stress disorder. (2013). Retrieved from http://www.nimh.nih.gov/health/topics/post-traumatic- stress-disorder-ptsd/index.shtml

References Brainorgan.pptx. (n.d.). Retrieved from med.mui.ac.ir/clinical/bihoshi/brainorgan.pptx Prigerson, H. G., Maciejewski, P. K., & Rosenheck, R. A. (2002). Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposure among us men. American Journal of Public Health, 92(1), 59-63. Wilson, J. T., & Pokorny, M. E. (2012). Experiences of military crnas with service personnel who are emerging from general anesthesia. AANA JOurnal, 80(4), 260-265.