Postanesthesia Emergence in Patients With Post-traumatic Stress Disorder

Abstract

Posttraumatic stress disorder (PTSD) is a psychiatric condition common among veterans that is marked by symptoms of reexperiencing, avoidance, and hyperarousal following a stressful or traumatic event. Military nurse anesthetists have recently reported an increased prevalence of emergence delirium (EDL) in US combat veterans. Emergence delirium is characterized by psychomotor agitation or combativeness upon emergence from general anesthesia. It is more common in children than in adults but has a prevalence of 3.0% to 21.3% in the adult population after general anesthesia. The aim of this study was to examine whether surgical patients with a history of PTSD had a higher incidence of EDL than did patients without PTSD. The authors also examined whether duration of stay in the postanesthesia care unit (PACU) was higher in patients with a history of PTSD. In this retrospective cohort study conducted at a US military combat veteran surgical population at Veterans Administration Medical Center in Buffalo, NY, 1763 consecutive cases requiring general anesthesia for surgical procedures were collected. A total of 317 patients were identified with a history of PTSD and grouped together, and the 1446 patients without this history were placed in the control group. Postanesthesia care unit nursing notes were reviewed for the presence of the following phrases to indicate agitation: “attempting to sit up,” “agitated,” “pulling intravenous lines,” “trying to remove surgical dressing,” “climbing over bed rail,” “physically pushing or pulling staff,” “moving side-to-side,” “does not calm or follow verbal reminding,” and “requires physical restraints.” Emergence delirium was reported in 37 cases (2.1%) after general anesthesia; EDL was identified in 15 of the 317 patients with a history of PTSD and 22 of the 1446 patients without a history of PTSD (P = 0.002). After propensity matching, there were 8 patients with EDL in the PTSD group and only 2 patients with EDL among controls. Patients with a history of PTSD had higher incidence of EDL with varying degrees of agitation in the PACU compared with those without this diagnosis (odds ratio, 3.22; 95% confidence interval, 1.65–6.27; P = 0.002). Furthermore, PTSD was found to be an independent predictor of EDLwith an odds ratio of 6.66 and a 95% confidence interval of 2.04 to 21.72 (P = 0.002). The duration of stay in the PACU was not significantly different between the groups (P = 0.137). Despite important limitations to this study including the use of International Classification of Diseases, Ninth Revision codes to identify the diagnosis of PTSD and a retrospective, nonblinded design, the authors conclude that PTSD is an important risk factor for confusion and agitation in the early postanesthesia recovery period. Careful history taking and the development of a PTSD registry involving all veterans could help