Evidence-Based Management of Emergence Delirium in Adults with PTSD: A Scoping Review

Saleh Mizyed, RN, DNP, CRNA

DNP Nurse Anesthesia

Evidence-Based Management of Emergence Delirium in Adults with PTSD: A Scoping Review

Project Category:  

Project Team: Saleh Mizyed, DNP, CRNA Erick McCormick, DNP, CRNA Peter Kallio, CRNA, DNP (Advisor)

Abstract

Background: Emergence Delirium, also referred to as Emergence Agitation (EA) which can be used interchangeably, is a common postoperative complication characterized by symptoms of inattention, agitation, aggression, and an abnormal perception of reality (Su et al., 2018). Symptoms of ED may present immediately after the termination of anesthesia or within the first 24-72 hours following surgery (Lovestrand et al., 2021). Several populations are frequently affected by ED including pediatrics, military veterans, and the elderly (Seok-jin et al., 2020). As reported by authors Dasgupta et al. (2006), the incidence of ED occurs between 5.1% and 52.5% among patients aged 65 years or older. Further, the incidence of ED among pediatrics has been reported to range between 20% to 80% (Manning et al., 2020). For patients who experience emergence delirium, subsequent injury complicating surgical recovery may ensue leading to systemic effects including falls, surgical site disruption, unintentional removal of catheters, drains, or IV lines, respiratory compromise, and increased medical expenses for both patient and healthcare organization (HCO). Further, author Franco et al. (2001), identified that the onset of postoperative delirium directly contributed to $12,000 in added expenses between O.R time and ICU admission. Although the exact pathophysiological mechanism of ED remains unknown, numerous risk factors have been identified contributing to the onset of ED including age, history of anxiety, untreated post-operative pain or a pre-existing psychiatric condition such as post-traumatic stress disorder (PTSD) related to childhood trauma, military service, or combat exposure. For patients diagnosed with PTSD, the likelihood of experiencing emergence delirium is heightened (Lovestrand et al., 2021). 

Post-traumatic stress disorder is defined as a psychological disturbance manifested through various forms of physical or mental insult (Mayo Clinic, 2021). Following a traumatic event, a person may be overwhelmed with feelings of anxiety or fear. According to the National Center for PTSD (2019), 7-8% of the adult U.S population will experience a form of PTSD within their lifetime. Without timely recognition and intervention, the progression of this disorder may turn debilitating. Chronic and untreated symptoms are accompanied with lifelong effects, leading to dysfunctional coping mechanisms and episodes in which victims vividly reenact traumatic experiences as if it were happening once again, in real time. These events are referred to as flashbacks. In surgical patients with PTSD, symptoms of particular concern are related to changes in physical and emotional reactions where patients may become easily startled or frightened. Intrusive memories are also a perioperative concern. Reminders of a previously lived traumatic event may be unintentionally triggered by several factors including environment, unanticipated touch, pain or discomfort. The onset of a psychiatric event in patients with PTSD can result in a disruption of care and a delay in the surgical schedule. The estimated costs associated with a delay in surgical start times for a hospital is approximately $100 per minute, or $9.6 million annually (Access, 2018). Researchers have also determined that patients with a diagnosis of PTSD assume higher health care costs while spending nearly $20,000 annually on related care. The study notes that costs can vary depending on specific mechanisms of insult which potentiated a traumatic experience (Von der Warth et al., 2020). Further, author Tolly et al. (2021) reports the experience of ED is perceived by 40% of Army anesthesia providers as a moderate-to-high safety risk to patients and staff.  As a result, patients may suffer increased morbidity, extended recovery times, and hospitalization. Compared to non-agitated patients, patients expressing symptoms of agitation experienced an extended PACU stay with an average admission time between 50 to 960 minutes (Lepousé et al., 2006). Additionally, the onset of ED poses a risk of inadvertent injury to all parties involved. 

A primary consideration for anesthesia providers is the prevention of ED among patients with PTSD, minimizing the risk of avoidable systemic complications. Anesthesia providers are obligated to ensure safety through strategic planning tailored to the individual encounter. This can be achieved through identification of risk factors, early detection of hyperactivity upon emergence as well as through an individualized anesthetic plan. When caring for surgical patients with preexisting psychological complications such as PTSD, anesthesia providers must carefully outline strategies in preventing the onset of acute confusion and agitation. The identification of risk factors associated with PTSD and ED during the pre-operative interview is of great importance to provide comprehensive care across the surgical continuum. Misidentification of risk factors translates to worsened outcomes adding to current health complications, lengthened hospital admissions, higher medical expenses, and overall, a lowered quality of life and increased mortality (Zhang et al., 2020). To mitigate the consequences of improperly identified risk factors and the onset of ED, several recent randomized-control trials have successfully demonstrated that anesthetic adjuncts such as dexmedetomidine (DXM), propofol and ketamine, are effective in prophylactically preventing symptoms of ED in a dose-dependent fashion when compared to a placebo, at varying end points.  

Methods:  With the scarcity of available evidence-based literature supporting best practice guidelines in the pharmacological management of ED among adult surgical patients with a known diagnosis of PTSD, a scoping review was performed to synthesis evidence from a diverse body of data, to determine which anesthetic adjuvant is most efficacious in preventing the onset of emergence delirium among this subset population. The literature search for this scoping review collected evidence from the following databases: OVID MEDLINE, CINAHL Complete, and PubMed.

Results: A total of ten randomized controlled trials and two meta-analyses were included in the scoping review. The included articles resulted in a sample of 7,055 patients who were assessed in the prophylactic treatment of emergence delirium. The overall quality of the articles was judged by using the Joanna Briggs Institute Critical Appraisal Tool for each study design. Levels of evidence of the studies were assigned using the JBI Level of Evidence Guide. Nine of the studies included are randomized controlled trial studies JBI level 1.c, another article JBI level 3.c, and two meta-analyses, JBI level 2.a. The design in three of the RCT studies were retrospective. Additionally, two of twelve studies compared a dose-dependent response to DXM, while four articles compared DXM to a control group receiving a placebo, namely 0.9% normal saline. Dexmedetomidine was also trialed against MDZ and propofol in two separate studies.

Conclusion: Although much remains unknown and larger, more comprehensive studies are warranted to better establish formal pharmacological recommendations. The discovery of available literature surrounding the prophylactic treatment of emergence delirium included within this scoping review does serve to promote such advancements. However, there were both limitations and strengths associated with this study, 

Limitations

 Several limitations throughout the review exist. To date, a standardized adult delirium assessment scale does not exist (Lovestrand et al., 2016). Of the literature reviewed, three different scoring systems to assess for agitation and record incidence of delirium are utilized. Each scoring system has unique characteristics, while all aim to detect the onset of delirium. The Aono’s Four Point Agitation Scale is a simple and easy to use system, allowing providers to diagnose the presence of acute agitation in the PACU by means of the patient’s response to commands and level of calmness. Although this system appears intuitive it may be over generalized for patients with PTSD as symptoms may present in various ways such as calm and withdrawn or agitated but able to follow commands. Additionally, available research fails to account for the reliability of the Pediatric Anesthesia Emergence Delirium assessment scale for adult use, although it has been utilized in RCT studies and case reports. The Riker Sedation Agitation Scale is a detailed and comprehensive tool, matching behavioral observations with scale descriptors. The RSAS system characteristics would make it easy to titrate doses and assist agent selection per patient presentation. Seemingly, it appears the RSAS system would overall be a more appropriate tool of assessment in diagnosing emergence delirium in adults based on overt symptomology and ease of quantifying severity as noted in the narrative review by author Tolly et al. (2020). However, it is reasonable to believe that any of the assessment scales utilized throughout the literature to identify and treat ED in pediatrics is transferable to the adult population. When it comes to pharmacological agents investigated, DXM was the most widely examined. The large body of evidence surrounding a single agent may lead to selection bias. However, data does appear to favor DXM for its role in the prophylactic treatment of delirium. While some literature explored a head-to-head comparison of the various agents and doses, no study directly examined the targeted population of subjects with a known diagnosis of PTSD. This is the main limiting factor. Additional limitations of these studies include small sample sizes in several articles, and many sources were single center studies which can lead to poor reliability and transferability of results. Authors also failed to discuss the duration of surgical procedures and the influence this may have on emergence delirium. Furthermore, some studies utilized emergence agitation as a secondary outcome but were included due to its broad discussion and statistical findings supporting or refuting trialed interventions. While these limitations make it difficult for consumers to select the best agent, there were many strengths noted.

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