Falling off the Table: Emergence Delirium in the Military Veteran

Emergence Delirium (ED) is a post-anesthetic phenomenon which occurs immediately after emergence from general anesthesia and is defined by behavioral symptoms of restlessness, confusion, and possible combative or violent actions upon waking from general anesthesia.1 ED associated disorientation and violent thrashing create a dangerous situation for patients and health care providers.2 Due to the American military involvement in Iraq and Afghanistan, combat veterans continue to serve on active duty and the traumatic effects from the battlefield carry over into the healthcare environment.1,3 Interest in ED has developed among military anesthesia professionals because of its increasing incidence within their surgical population.2

Falling off the Table: Emergence Delirium in the Military Veteran Chad Weston Butler, BSN Westminster College December 13, 2013 [e-mail] Keywords: emergence delirium, post traumatic stress disorder, anesthesia, military veteran Emergence Delirium (ED) is a post-anesthetic phenomenon which occurs immediately after emergence from general anesthesia and is defined by behavioral symptoms of restlessness, confusion, and possible combative or violent actions upon waking from general anesthesia.1 ED associated disorientation and violent thrashing create a dangerous situation for patients and health care providers.2 Due to the American military involvement in Iraq and Afghanistan, combat veterans continue to serve on active duty and the traumatic effects from the battlefield carry over into the healthcare environment.1,3 Interest in ED has developed among military anesthesia professionals because of its increasing incidence within their surgical population.2 Case Report A 90kg, 42-year-old male United States Military Veteran presented for a Right Shoulder Arthroscopy with Rotator Cuff Repair. The patient's medical history included allergic rhinitis, hypertension, incomplete left bundle branch block, occasional alcohol use, and gastro esophageal reflux disease (GERD). The patient's mental history revealed panic disorder, insomnia, and post traumatic stress disorder (PTSD). The patient also reported having had a previous Computerized Tomography (CT) scan of the head related to frequent severe headaches which was found to be within normal limits. The patient's medications included: zolpidem, loratadine, gabapentin, paroxetine, hydrochlorothiazide, lisinopril, omeprazole, and ranitidine. All laboratory values were within normal limits and the patient had no known drug allergies. Based on the American Society of Anesthesiologists (ASA) guidelines, the patient was designated a physical status classification of II. All standard ASA monitors were applied to the patient and oxygen was administered via nasal cannula in preparation for Right Interscalene Brachial Plexus Block. The block was administered under ultrasound guidance via 22 gauge 2" nerve stimulator needle. A local anesthetic mixture was used for the block which was placed easily and without complications. The patient was rolled to the operating room and general anesthesia with tracheal intubation was induced without complication. The patient was rolled into the lateral surgical position. The surgical procedure proceeded without complication. During the case all vital signs were stable. Following closure and dressing of the surgical site, the patient was rolled supine to evaluate extubation criteria. Anesthetic gas was turned off and the patient was suctioned above the endotracheal tube. Tidal volume, respiratory rate, and oxygen saturation levels all met appropriate extubation requirements. All vital signs were stable. The patient manifested movement of all extremities to command and a sustained head lift of greater than 5 seconds. The patient was then extubated. Immediately following extubation, the patient arched his back and rolled off the left side of the table, hitting the operating room floor. The patient was quickly assessed by operating room personnel and was found to be awake, stable, and apologizing for jumping off the table stating, "I was trying to escape." The patient reported having a bad dream and felt the urge to "escape." The patient was lifted onto a stretcher by operating room personnel and taken to the post anesthesia care unit (PACU). The patient vital signs were stable in PACU and no injury from the fall was found to be present. Discussion A recent qualitative study defined ED within military personnel with PTSD as "any occurrence in which the patient awakens in a violent or thrashing manner with attempts at self-extubation, breath holding, intravenous line displacement, assault on the operating room staff, and/or the want to flee or the risk of falling from the narrow operating room table."3 The patient in this case would clearly meet the definition of ED with consideration of his mental history and surgical events. Another recent investigation suggested that there was a correlation between anxiety, depression, PTSD, and ED in a sample of combat veterans.1 Other studies have demonstrated that members of the military with deployment/combat history often emerge from general anesthesia restless and confused causing anesthesia practitioners to develop phrases such as "wild wake-up" and "post-anesthetic wind-up" to describe ED in this population.2 Risk factors for ED in the military population have been identified and a review of the patients history and psychological disorders may have alerted the operating room personnel in this case to a possible delirious episode after anesthesia. Potential Risk factors for ED within the military surgical population have been categorized into four main areas: environmental (light, noise), social (lack of social support), biological (physical trauma requiring surgery, pain, traumatic brain injury (TBI)), and psychological (PTSD, anxiety, depression).2 It is unknown exactly which of these factors played the largest role in the ED of this particular case. Operating rooms typically have plenty of lights and are often noisy with equipment, tools, monitors, phones, people and conversations. The operating room in this case was no exception. The social support of this particular patient was unknown. Identifiable risk factors for this patient would seem to be more apparent within the biological and psychological categories. This patient presented with shoulder injury which was significant enough to require surgical correction. The stress response from surgery can result in overstimulation of the sympathetic nervous system, which in turn may present in the form of a behavioral response, manifesting as ED.2 Patients who have not been adequately treated for pain can appear much like a patient experiencing ED. In this case the patient had received an interscalene brachial plexus nerve block in preparation for expected perioperative and postoperative pain, in addition to a total dose of fentanyl 325mcg IV and ketorolac 30mg IV throughout the case. Untreated pain in the immediate postoperative period may cloud the diagnosis of ED, or it may be a direct cause.2 TBI is estimated to be between 10-20% of the combat exposed population and is often undiagnosed because the majority of TBI is closed, or referred to as a concussion or mild TBI.2 It is unknown whether this patient had an underlying TBI even though the patient previously had a normal head CT. This patient manifested with possible psychological risk factors for ED. He had previously been diagnosed with panic disorder, insomnia, and PTSD. A review of his medication list demonstrates treatment of insomnia with zolpidem and treatment of depression with paroxetine. Nearly 20% of returning combat veterans develop PTSD; the prevalence is even higher among injured veterans and a recent case study reported emergence flashback after general anesthesia in a patient with known diagnosis of PTSD and depression.2 PTSD has four types of symptoms: reliving the event (also called re-experiencing or a flashback), avoiding situations that remind you of the event, feeling numb, and feeling keyed up (also called hyperarousal).4 In order for a patient to be diagnosed with PTSD, they must meet criteria that includes: 1- exposure to a traumatic event that evoked feelings of fear, hopelessness, or horror; 2- demonstration of at least one significant symptom of re-experiencing, three clinically significant symptoms of avoidance or emotional numbing, and two clinically significant symptoms of persistent arousal; 3- symptoms that persist for at least one month; and 4- symptoms that adversely impact functioning.5 Another case reported on a woman who had developed PTSD from a physical assault and immediately upon emergence from general anesthesia became physically violent toward staff. She later reported that during the episode, she re-experienced her prior abuse and she thought that the operating room personnel were the original persecutors. The potential exists for surgery and anesthesia to exacerbate posttraumatic symptom severity when some aspect of the perioperative experience is similar to the traumatic experience.5 Manifestation of ED in this particular case could be related to several risk factors. This case report agrees with previous literature and studies claiming that ED is a multifactorial complication.1 This case report also demonstrates the need for the anesthesia care team to identify potential risk factors for ED in an effort to ensure a safe surgical experience for the military surgical population. Appropriate identification of potential ED patients can allow the anesthesia team to take safety precautions upon emergence from general anesthesia. References 1. McGuire JM. The incidence of and risk factors for emergence delirium in u.s. military combat veterans. J Perianesth Nurs. 2012;27(4):236-245. 2. McGuire JM, Burkard JF. Risk factors for emergence delirium in u.s. military members. J Perianesth Nurs. 2010;25(6):392-401. 3. Wilson JT, Pokorny ME. Experiences of military crnas with service personnel who are emerging from general anesthesia. AANA J. 2012;80(4):260-265. 4. Understanding PTSD. National Center for Posttraumatic Stress Disorder. http://www.ptsd.va.gov/public/understanding_ptsd/booklet.pdf Updated August 1, 2013. Accessed August 9, 2013. 5. Wofford K, Hertzberg M, Vacchiano C. The perioperative implications of posttraumatic stress disorder. AANA J. 2012;80(6):463-470. Mentor: Manardie F. Shimata, CRNA, MAE [e-mail]