PTSD/Emergence Delirium Training & Education Team: Michael Boland, MSEd; David Julian, MEd; Amanda Beckstead, BSN,RN; and William Pileggi, MSN, CRNA
Veterans Administration, Pittsburgh Health System
“Go to sleep in Pittsburgh and wake up in combat, in Afghanistan…” This is one nurse anesthetist’s description of the experiences he was having with many of his patients. Emergence delirium (ED) is a postanesthetic phenomenon occurring immediately after emergence from anesthesia and is characterized by agitation, confusion, and violent behavior (McGuire, 2012). Combat veterans suffering with post-traumatic stress disorder (PTSD) are at a higher risk of experiencing emergence delirium (25% overall) and surgical staff at the VA Pittsburgh Healthcare System reported episodes occurring weekly. Lack of specialized knowledge and skills to manage emergence delirium, especially in an operating room, has the potential to lead to injuries to patients and staff. Based on their experience with behavioral emergency response, surgical staff input, and current literature, a team of two training specialists, a nurse anesthetist, and a graduate nurse anesthesia student designed specialized training to carefully assess the needs of veterans most at risk for emergence delirium. This mandatory training includes a focus on trauma exposure of both combat- and noncombat-related experiences, including childhood and military sexual trauma: specifically, the identification of patient-preferred methods for safe reorientation to the environment, adaptations within the surgical environment (dim lights, no noise), and a coordinated team response should the patient exhibit any dangerous behaviors.
The implementation of this training has mediated symptoms of both combat-related PTSD and noncombat-related PTSD. One remarkable case involved a young woman with a history of sexual abuse by a family member and a self-reported history of ED presenting for a procedure requiring general anesthesia. The rapid recognition of her undocumented PTSD allowed her anesthesia providers to alter the anesthetic plan to include avoidance of benzodiazepine sedation and implementation of adjunct anesthetic agents that have terrific efficacy in prevention of ED. The environment was kept quiet and dark for her emergence from anesthesia and a female anesthesia provider talked to the patient calmly as she awoke. Her emergence was smooth, without any delirium episodes, and she expressed tremendous relief to her providers. Instances such as these show the promise this training holds for all victims of trauma with PTSD.