Minimizing Anesthesia Emergence Delirium in Combat Veterans with
Post-Traumatic Stress Disorder
Point of Contact:
LTC Denise Beaumont, CRNA
Chief of Anesthesia Services
Bayne-Jones Army Community Hospital, Fort Polk, LA
(337) 531-3340; Denise.M.Beaumont.mil@mail.mil
Groups Involved with the Project:
Anesthesia Department
Operating Room
Post-Anesthesia Care Unit
Behavioral Health Department
Bayne-Jones Army Community Hospital, Fort Polk, LA
Submitted By:
Donald J. Stafford, CRNA
Army-Baylor University Healthcare Administration Resident, 2013-2014
Bayne-Jones Army Community Hospital, Fort Polk, LA
13 May 2014
Executive Summary: Post-traumatic stress disorder symptoms experienced by combat veterans
emerging from anesthesia may expose patient and staff to multiple risks. In addition,
perioperative administrative and operational efficiencies can be adversely affected. An
innovative, simple, no-cost protocol developed at Bayne-Jones Army Community Hospital
appears highly successful at minimizing these issues through astute identification of susceptible
patients, patient education, staff preparation, precise timing of specific anesthesia medications,
controlling environmental stimuli, and applying the theory of consistency to staff assignments.
While further research is needed to formally validate the preliminary findings, this protocol
provides significant improvements in overall satisfaction, safety, risk mitigation, quality of
surgical care, and associated components of perioperative productivity and staffing expenses.
Objective of the Best Practice: Agitation and delirium in combat veterans with post-traumatic
stress disorder (PTSD) emerging from anesthesia can be minimized through proper patient and
staff preparation and planning, specific anesthetic drug selection and timing, and minor
modification of environmental factors. Using the protocol developed at Bayne-Jones Army
Community Hospital (BJACH) for anesthetizing patients with PTSD, hospital staff can provide
the safest and highest-quality surgical experience for this patient cohort in a manner which
concurrently minimizes disruptions to planned surgical pavilion throughput and unplanned staff
overtime expenses.
Background: Anesthesia and post-anesthesia care unit (PACU) staff members at BJACH
noticed a disturbing pattern in the first half of 2012, following the return of one of Fort Polk’s
primary combat units from Afghanistan. While generalized harmless disorientation and
restlessness are seen in a small percentage of the general population when emerging from
anesthesia (easily managed in PACU), five combat veterans newly-returned from Afghanistan
demonstrated battlefield-specific combat behaviors when becoming semilucid in PACU. These
patients yelled fire team orders, screamed of “incoming RPGs,” looked around frantically for
their battle-buddy, pulling at PACU monitoring equipment, oxygen tubes, urinary drainage
catheters, and intravenous medication lines. These patients tried to get out of bed to aid their
downed comrades, putting great stress on surgical repair and stitches, and risking fall injury.
Staff interventions were met with physical violence and “combatives” maneuvers, putting both
staff and patients at great risk of injury. Traditionally-effective PACU nursing interventions
such as sedative medications, narcotic pain medications, continuous verbal reorientation and
reassurance, and even giving “direct orders” to the patients proved ineffective. A sedative
traditionally used on occasion in PACU for patient agitation (benzodiazepines) actually
worsened the situation by paradoxically increasing delirium. These issues also caused distress to
adjacent patients, separated only by privacy curtains in the open-bay PACU.
Four of the five patients eventually responded to additional medications (approaching the
threshold for potentially necessitating an unplanned overnight admission), but their PACU
discharge was delayed by 75 to 120 minutes (an 83-133% increase over anticipated PACU stay
of 90 minutes). One of the five patients did require unplanned admission for overnight
observation due to the interventions required to safely placate him. In addition, the management
of these unanticipated PTSD issues led to a reduction in operating room throughput and
productivity, caused by the logjam created in the small PACU by the PTSD patients'
significantly delayed discharge. The customary PACU nurse: patient ratio was unfavorably
impacted due to the unanticipated acuity of the PTSD patients, thus reducing the PACU’s ability
to accept other postoperative patients from the operating room in a timely manner. Anesthetists
were required to stay longer in the PACU to assist with their post-operative patient (beyond the
time normally needed to give report and transfer patient care to the PACU nurse), thus delaying
their availability to begin the next anesthetic scheduled for their particular operating room. This
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further delayed the surgical throughput. Staff RNs were required to stay beyond end-of-shift due
to the delayed discharge of the PTSD patients, causing unplanned overtime expense.
Concerned by these trends, the anesthesia and PACU staffs began to brainstorm
alternative ways to prevent and/or effectively treat post-anesthesia “combat” PTSD symptoms in
consultation with a BJACH clinical psychologist. The chief of anesthesia (a veteran of two
overseas combat tours) contacted several peers at other military hospitals, as did other staff
anesthetists. Not a single hospital had an anesthesia protocol to use with combat-veteran PTSD
patients; neither did the Veterans Administration. This writer reflected back to his personal
experience since 9/11 at various military medical centers with a significant number of combatwounded soldiers (including Walter Reed, Landstuhl, and Bethesda), and was unable to recall
PTSD-specific anesthesia technique in use, in formal research, or under discussion. The Army
anesthesia consultant had no PTSD-specific protocol or “best practice” to suggest, and knew of
none under research or development. The Army Graduate Program in Nurse Anesthesia
(USAGPAN) had neither faculty nor students currently researching this issue. The PACU chief
nurse contacted several nursing peers at other hospitals, and also came up empty-handed.
The anesthesia and PACU staffs decided to research all Food and Drug Administrationapproved usages for drugs currently on the anesthesia formulary, especially those in what could
be considered “approved but seldom-used” categories, looking for a possible way to
pharmacologically prophylax against PTSD post-emergence delirium. In addition, an exhaustive
literature search revealed a huge void on this particular topic.
Literature Review: The body of scientific knowledge on PTSD is replete with information on
causes, symptoms, and therapeutic strategies in general; however, there is essentially no
professional literature specific to anesthesia techniques tailored for patients with PTSD.
Similarly the anesthesia literature contains numerous references to commonly seen, benign, and
easily-managed disorientation experienced by a small percentage of the general population while
emerging from anesthesia. In contrast just two references were discovered which discussed
anesthesia and PTSD patients, and which were only peripherally helpful. The first reference
(McGuire, 2012) addresses risk factors and incidence rates, but does not suggest specific
anesthetic techniques for PTSD patients. The other reference (Wilson & Pokorny, 2012)
provides a broad review of military anesthetists’ experiences with emergence delirium, and only
begins to hint at potential anesthetic techniques optimized for PTSD patients.
Implementation Methods: The anesthesia staff used medications already on the hospital
formulary, in ways approved by the Food and Drug Administration (FDA), and in consultation
with a hospital clinical psychologist. There was no differentiation between control and
experimental groups. Institutional Review Board (IRB) approval was not required for this
informal project, nor was anything beyond the standard anesthesia consent required.
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During the preoperative patient consultation and teaching, conducted several days prior to
surgery, anesthesia and nursing providers began to pay particular attention to patients' (and
spouses’ if present) body language, looking for signs suggestive of hyperarousal or self-harm.
Questions about recent onset of sleep disturbances and/or nightmares were added to the patient
preoperative questionnaire. Some medications currently on the patient's profile, especially
certain antidepressants and Prazosin (for nightmares) raised a high degree of PTSD suspicion,
even if the patient did not have a formal PTSD diagnosis. Patient spontaneous verbal report of
nightmares, whether on Prazosin or not, also served as a warning sign. Preoperative teaching,
presented in a gentle, supportive, and nonjudgmental manner, included topics of PTSD
flashbacks and how staff would care for the patient if they felt threatened.
On the day of surgery, all team members involved in the pre-identified potential PTSD
patient's care were briefed on the need to conscientiously minimize environmental stimuli
normally found in a typical operating room (harsh bright lights, multiple conversations taking
place simultaneously, clanging instrument trays, enforcing quiet in the operating room while
anesthesia was being induced); similar considerations were taken in the PACU regarding
lighting, ambient noise, conversational tones, nearby foot traffic, and liberal use of pain
medication. Several other soldiers from the patient's unit were present in the PACU, on stand-by
if needed for the patient's reorientation, reassurance, and safety.
Unless contraindicated by a co-existing medical condition or allergy, the selection and
timing of specific anesthesia drugs anticipated to lessen/eliminate PTSD symptoms (already on
formulary, and already as approved by the FDA) included intraoperative dexamethasone steroid,
liberal injection of subcutaneous local anesthesia by the surgeon pre-incision, and no
intraoperative or postoperative administration of benzodiazepines. Small intraoperative doses of
ketamine and droperidol were given. One primary modification featured intraoperative
administration of clonidine, a sympatholytic drug which decreases the "fight-or-flight" response
by blocking release of endogenous norepinephrine catecholamine. The other primary
modification combined inhalational anesthetic gas (at reduced concentration) with continuous
intravenous administration of diprivan (the primary anesthesia induction agent). This was done
to minimize the risk of emergence delirium, sometimes seen in the general population following
a gas-only anesthetic.
The final implementation component utilized the theory of consistency, a key feature of
outpatient PTSD therapy. On the day of surgery, all efforts were made to assign to the patient's
care the same anesthetist and nurse who conducted the preoperative teaching consultations. In
addition, several soldiers from the patient’s unit accompanied the patient on the day of surgery,
providing an additional sense of support, camaraderie, and safety. They received a debriefing
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Q&A prior to departure; they were encouraged to monitor and seek help if they perceived PTSD
behaviors in themselves or platoon mates with no stigma attached.
In summary, the protocol consists of preoperative identification of at-risk patients,
maximum reduction of controllable environmental stimuli, use and specific timing of selected
anesthesia medications, patient and staff education, and applying consistency. None of these
components created any additional expenses. The only additional administrative requirement
was coordinating with the patient’s unit to have several soldiers accompany the patient on day of
surgery.
Results: The preliminary experience with this BJACH project (N = 1) was accepted for
publication last year (Lovestrand, Phipps, & Lovestrand, 2013). Since then, approximately 40
more PTSD patients were anesthetized using this protocol at BJACH with 100% success.
Anesthesia staff, PACU staff, and patients are universally pleased with the preliminary
outcomes. There has been no discernible combat PTSD anesthesia emergence agitation, no staff
or patient safety issues, no delays in discharge from PACU, no slowdown in operating room
throughput attributable to PTSD-related logjam in the PACU, no PTSD-associated RN overtime
expense, no unplanned overnight admissions, and no reports of untoward post-discharge issues.
The BJACH anesthesia department was recently asked by the Army anesthesia consultant to
develop a local standard operating procedure for Army Medical Command review.
Conclusions: (1). This measurable, efficient, and effective outcomes-based protocol, developed
at BJACH, requires minimal adjustment to standard perioperative practices with no increase in
cost, utilizes drugs already on the typical anesthesia formulary in ways which are considered
current standard of care, and has universal applicability to both the military and civilian
healthcare systems. Patient and staff safety and satisfaction are positively impacted by the
protocol, the patient receives a comfortable and high-quality anesthetic, and PTSD-related
disruptions to perioperative productivity and nursing payroll budgets are greatly minimized
through this innovative yet simple care plan; (2). A current BJACH anesthesia staff member
transfers this summer to a large military medical center. He plans to seek IRB approval for a
formal study of BJACH's protocol, utilizing experimental and control groups with double-blind
data gathering; (3). The protocol was developed at a small Army community hospital which saw
~20 patients per operating room per year with pre-existing PTSD. A large tertiary facility with
high-acuity patients, such as San Antonio Military Medical Center (with 28 operating rooms),
might see > 600 PTSD surgical patients in a year. If validated through formal research,
extrapolating the application of this simple and anecdotally-effective PTSD anesthesia protocol
across the entire Military Health System, Veterans Administration Health System, and private
sector could yield significant improvements in overall satisfaction, safety, quality of surgical
care, and associated perioperative administrative and staffing aspects of this patient cohort.
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References
Lovestrand, D., Phipps, P. S., & Lovestrand, S. (2013). Posttraumatic stress disorder and
anesthesia emergence. American Association of Nurse Anesthetists Journal, 81, 199-203.
McGuire, J. M. (2012). The incidence of and risk factors for emergence delirium in U.S. military
combat veterans. Journal of Perianesthesia Nursing, 27, 236-245.
Wilson, J. T., & Pokorny, M. E. (2012). Experiences of military CRNAs with service personnel
who are emerging from general anesthesia. American Association of Nurse Anesthetists Journal,
80, 260-265.
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