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NCANA PTSD EMERGENCE DELIRIUM

NCANA PTSD EMERGENCE DELIRIUM

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NCANA PTSD EMERGENCE DELIRIUM

  1. 1. PTSD, Emergence Delirium, and the PACU LTC Denise Beaumont, CRNA
  2. 2. Objectives Participants 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.
  3. 3. 1 How we got here Definitions Plan of Care What the future holds 2 3 4 PTSD and Emergence Delirium
  4. 4. 1 2 3 4 Army PACU Gap in Literature Standard Interventions Ineffective Wilson and McGuireBy 2013 we knew •ED is a problem •Gap existed in Literature Multi-Disciplinary Approach PTSD and Emergence Delirium How we got here…
  5. 5. Do no Harm Question Observation and Analysis Document Discovery/Evidence Process, outcome, Evaluation Practice Integration Translation to guidelines PTSD and Emergence Delirium Star Model *
  6. 6. Preoperative PACU DischargeIntraoperative Improved patient outcomes Evidence-Based Guidelines PTSD and Emergence Delirium
  7. 7. PTSD and Emergence Delirium – CMDR Jason McGuire USN – LTC Tyler Wilson US Army - LCDR Ken Wofford USN, et al • Donna Lovestrand et al • Jason Mc Lott, CRNA et al • Plus… “How we got here” team
  8. 8. ? Emergence Delirium •Emergence agitation •Post operative delirium •Emergence delirium Definitions PTSD and Emergence Delirium
  9. 9. Emergence Agitation - Pediatric ? Emergence Delirium •Emergence agitation •Post operative delirium •Emergence delirium Definitions PTSD and Emergence Delirium
  10. 10. Emergence Agitation - Pediatric Post-Op Delirium - ICU ? Emergence Delirium •Emergence agitation •Post operative delirium •Emergence delirium Definitions PTSD and Emergence Delirium
  11. 11. Emergence Agitation - Pediatric Post-Op Delirium - ICU ? Emergence Delirium - PTSD Emergence Delirium •Emergence agitation •Post operative delirium •Emergence delirium Definitions PTSD and Emergence Delirium
  12. 12. Delirium Scale? Emergence Agitation - Pediatric Post-Op Delirium - ICU ? Emergence Delirium - PTSD Emergence Delirium •Emergence agitation •Post operative delirium •Emergence delirium Definitions PTSD and Emergence Delirium
  13. 13. PTSD and Emergence Delirium Delirium Scale- Pediatric • Eye contact • Purposeful actions • Awareness of surroundings • Restlessness • Ability to console
  14. 14. PTSD and Emergence Delirium Delirium Scale- Pediatric • Eye contact • Purposeful actions • Awareness of surroundings • Restlessness • Ability to console Adult Delirium • Purposeful eye contact • Flashbacks/hallucinations
  15. 15. 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”
  16. 16. 1 PTSD 2 3 PTSD and Emergence Delirium Definitions
  17. 17. 1 Hyper- arousal PTSD 2 3 PTSD and Emergence Delirium Definitions
  18. 18. 1 Hyper- arousal PTSD 2 Avoidance 3 PTSD and Emergence Delirium Definitions
  19. 19. 1 Hyper- arousal PTSD 2 Avoidance 3 Intrusion Symptoms PTSD and Emergence Delirium Definitions
  20. 20. Psychotherapy (e.g. CBT) Pharmacotherapy Exposure/ Relaxation Trusting Relationship Treatment of PTSD as outpatient PTSD and Emergence Delirium
  21. 21. 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
  22. 22. Identification of Patients Preop 1 2 3 4 Management PTSD and Emergence Delirium
  23. 23. Diff diagnosis 1 Meds 2 TIVA/Volatile 3 PTSD specific 4 Plan of Care Anesthesia
  24. 24. Anesthesia Ketamine/Versed/dex/clonidine Identification of Patients Preop 1 2 3 4 Management PTSD and Emergence Delirium
  25. 25. 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
  26. 26. Anesthesia Ketamine/Versed/dex/clonidine PACU Low stim/rescue Identification of Patients Preop 1 2 3 4 Management PTSD and Emergence Delirium
  27. 27. Plan of Care PACU Risk? Consistency Low Stim Validate/talk D C B A Begin the healing Amydalocentric Staffing/Security Know your patient PTSD and Emergence Delirium
  28. 28. Document, document, document refines definitions, aids in research
  29. 29. Disch RESPECT-Mil Anesthesia Ketamine/versed/dex/clonidine PACU Low stim/rescue Identification of Patients Preop 1 2 3 4 Management PTSD and Emergence Delirium
  30. 30. 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
  31. 31. 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
  32. 32. References 1. 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.
  33. 33. References 12.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.
  34. 34. References 21.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.
  35. 35. PTSD and Emergence Delirium Questions
  36. 36. PTSD and Emergence Delirium Name: LTC Denise Beaumont Email: denise.m.beaumont.mil@mail.mil Phone: (210) 295-4356

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NCANA PTSD EMERGENCE DELIRIUM

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