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Posttraumatic Stress Disorder: A Special Case of Emergence Delirium and Anesthetic Alternatives

Shoum, Steven M. MD

doi: 10.1213/XAA.0000000000000078
Case Reports: Case Report

Two anesthesia cases are presented involving patients with a history of posttraumatic stress disorder (PTSD). The first patient experienced a prolonged dangerous flashback during emergence. In the second patient, after a thorough review of PTSD and the anesthesia literature, emergence was uneventful. A history of PTSD should be considered a risk factor in the assessment of every patient and anesthetic management designed to best avoid serious and potentially harmful reactions.

From the Department of Anesthesiology, South Nassau Communities Hospital, Oceanside, New York.

Accepted for publication January 20, 2014.

Funding: None.

The author declares no conflicts of interest.

Address correspondence to Steven M. Shoum, MD, Department of Anesthesiology, South Nassau Communities Hospital, One Healthy Way, Oceanside, NY 11572. Address e-mail to

Posttraumatic stress disorder (PTSD) is an anxiety reaction after exposure to a traumatic event with symptoms of re-experiencing, emotional numbing, persistent arousal, and avoidance. Such patients undergoing anesthesia and surgery may exhibit flashback phenomena in which they suffer the illusion of re-experiencing the original trauma during emergence from deep sedation or general anesthesia. Anesthesiology clinicians should have a working knowledge of the symptoms, therapies, and comorbidities of this disorder to diminish the risk of evoking PTSD flashback in the perioperative period.

The patients and the patients’ families were informed that the 2 patients would be included in a published case report and granted permission.

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Case 1

An otherwise healthy law enforcement officer 190.5 cm tall, weighing 84.5 kg, with a history of gastroesophageal reflux disease and an anesthetic history positive for agitation upon emergence from a prior sedation was scheduled for an esophagogastroduodenoscopy under IV sedation. The hospital security department was notified of the risk of agitation for this patient. Standard American Society of Anesthesiologists (ASA) monitors were applied. He received 2 mg midazolam, a total of 420 mg propofol IV, and O2 via nasal cannula. Immediately upon a gentle, unstimulated awakening, the patient became disoriented, combative, and agitated. He ripped off the electrocardiogram electrodes, the blood pressure cuff, and the IV catheter and ran from the procedure room. I accompanied him as he ran in his underwear down the hall, and I continuously attempted to verbally reorient him. He never acknowledged my presence or made eye contact. He repeatedly reached for his imaginary belt-holstered weapon and cursed when he came up empty-handed. He stopped in front of several wall-mounted alcohol hand gel dispensers and smashed them with his fists or palms. He ran down the fire escape stairs, picked up a steel chair by 1 leg, ran through 2 hospital parking lots, and crossed the paths of oncoming cars on 3 streets in front of the hospital, holding the chair above his head. After 15 minutes of continuously attempting to communicate with him as we ran, pursued by the entire security department and hospital chaplain, among others, 2 police vehicles responded. He then recognized his wife’s best friend and neighbor who was there to drive him home, and who witnessed the emergence flashback. He asked her “What are you doing here?” She asked him to put down the chair, told him that no one would hurt him, and that we were doctors and nurses. He hugged her and said “Don’t worry, I will save you!” After she reoriented him and accompanied him to the postanesthesia care unit, he described seeing her in a small expanding circle of light, in an otherwise black nightmare. He asked why his fists were bleeding and if he had fallen down, and I explained what had transpired; he apologized profusely and after further questioning admitted he experienced intense nightmares most nights after having been stabbed at the age of 16 years old. He had never sought psychiatric help.

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Case 2

A 67-year-old woman had fallen the night before and suffered a right hip fracture. She was scheduled for an urgent total hip replacement. She was interviewed in the presence of her daughter. She experienced chronic pain, depression, transient ischemic attacks twice in the past 5 years, migraine headaches, emphysema, hypothyroidism, and gastroesophageal reflux disease and was 10 years status post ovarian cancer. She had been a recovering alcoholic for 9 years until she drank alcohol the night before. She had undergone multiple surgeries including neck spine fusion, bilateral oophorectomy, and left knee arthroscopy. When asked if she had any untoward anesthesia reactions, her daughter recounted that she emerged “fighting and punching.” When asked if she experienced sleep disorders, the patient admitted to having frequent nightmares. Her daughter then revealed that the patient experienced PTSD as a result of a sexual assault. The patient denied flashbacks, but her daughter stated that they occurred frequently. She was under a psychiatrist’s care for trauma-focused therapy. Her medications included a fentanyl 50 mcg/h transdermal patch every 72 hours, ativan, fluoxetine, butalbital/aspirin/caffeine, levothyroxine, and pantoprazole.

On physical examination, she appeared older than her stated age. She was 167 cm tall and weighed 84.5 kg. When first offered a spinal anesthetic, she refused. After explaining the risks of flashback on emergence following general anesthesia and the benefits of regional with ketamine for sedation to avoid emergence delirium, she and her daughter agreed to the proposed anesthetic plan.

In the operating room, with ASA monitors applied and while breathing oxygen via nasal cannula, she received divided doses of ketamine, 30 mg total, and while lying on her right side received a hyperbaric tetracaine spinal anesthetic (6 mg plus 0.1 mg epinephrine) via a 25-gauge Whitacre needle. During surgery lasting 105 minutes, she received an additional 40 mg of ketamine and tolerated the procedure without any complications. On arrival in the postanesthesia care unit, she was alert and oriented with no complaints or complications.

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Two cases of patients with a history of PTSD who were administered anesthesia are presented. The first patient had no specific preparation, while the second was appropriately prepared because this anesthesiologist had been forewarned. Anesthesiologists must consider the nature of the surgery, all pathophysiology of a patient, the patient’s preferences, and the surgeon’s preferences when selecting the anesthetic plan. Their patients’ cardiovascular and respiratory histories often receive more attention than their psychiatric histories. However, each of the patients had a psychiatric history positive for PTSD: the first untreated and the second receiving therapy. The first case demonstrates the dangerous consequence of not inquiring about psychiatric diagnoses, while the second case demonstrates a safe, smooth anesthetic course that follows eliciting a complete psychiatric history and the addition of measures to avoid emergence delirium.

Necessary background knowledge for the care of patients with PTSD includes an understanding of emergence delirium, a severe form of agitation occurring in approximately 5% of adults1 upon awakening from deep sedation or general anesthesia. Its consequences can be dangerous to the patient, with complications including extremity injuries; hemorrhage; unintended tracheal extubation; and traumatic removal of venous, arterial, epidural, and urinary catheters. Preoperative benzodiazepines and breast and abdominal surgery, especially those of long duration, are risk factors for the most serious form of agitation, emergence delirium; however, inhaled anesthetics cause more agitation on emergence than those conducted with IV propofol.1

Additional risk factors include extremes of age; hip, abdominal, and cardiac surgery; alcohol abuse; preexisting cognitive dysfunction; sleep deprivation; malnutrition; duration and type of anesthesia; re-operation; pain; and hypoxia.2

PTSD was first associated with military combatants and recognized by psychiatrists formally in the 1968 Diagnostic and Statistical Manual, 2nd Edition (DSM-II)3 as “combat fatigue,” a “fear associated with military combat and manifested by trembling, running and hiding.” In 1980, DSM-III4 redefined PTSD as “outside the range of usual human experience and…markedly distressing to almost anyone.” It was thought to be rare. Not until 1995 did the National Comorbidity Survey find that 50% of adults would experience a traumatic event in their lives with a consequential lifetime prevalence of PTSD of 7.8% and that women are twice as likely as men to develop PTSD.5DSM-IV6 defined PTSD as the “development of characteristic symptoms after exposure to an extreme traumatic stressor…the person’s response involves intense fear, helplessness, or horror….” The event may be witnessed or experienced by the individual and threatens his or her life or body integrity.

Experience with military service personnel emerging from general anesthesia revealed emergence delirium incidence much more frequent than that in the general population. Total IV anesthesia was superior to general anesthesia in patients with PTSD. Talking to patients before and on emergence was vital for smooth emergence. In addition, something “profound” was happening regarding ketamine for these patients.7 Ketamine is believed to cause memory disruption by its action on N-methyl-D-aspartate, opioid, and monoaminergic receptors.8 For this reason, ketamine was selected to sedate the patient in case 2.

Most relevant to civilian anesthesia practices are single-incident blunt or penetrating traumas usually secondary to motor vehicle accidents, assaults, falls, gunshot wounds, and stabbings. The incidence of PTSD in such cases is 13.6%.9,10 Patients with a history of psychiatric problems are even more vulnerable to PTSD. A prior psychological disorder more than doubled the incidence of PTSD in 130 postoperative military surgical patients at the Naval Hospital at Camp Pendleton: those with a negative history had a 17.5% incidence, while those with a positive history experienced a 50% incidence.11

To prevent emergence delirium in these patients, PTSD must first be identified. Members of populations at high risk for PTSD should be directly asked if they have a history of PTSD. Sleeping disorders or frequent nightmares are indicative of PTSD. Patients prescribed prazosin, a medication specifically indicated to treat nightmares, should be suspected of actually suffering from PTSD. Prevention is best achieved by avoiding anesthetic techniques that induce loss of consciousness or disorientation. When possible, topical, peripheral, or major regional anesthesia should be used to avoid general anesthesia or deep sedation. If sedation is needed, ketamine alone should be titrated to achieve sedation. There are 2 types of treatment for PTSD: psychological and pharmacologic. Selective serotonin reuptake inhibitors and many classes of antidepressants are used, and trazodone is often used to facilitate sleep. Perioperative withdrawal of selective serotonin reuptake inhibitors is associated with a greater risk of delirium.12 The anesthesiologist should not assume that the patient is being treated for depression when these classes of medications are included in the patient’s list of current medications because they might have been prescribed to treat PTSD. If patients have not been diagnosed and treated for PTSD but in fact are afflicted by the disorder, they may admit to frequent nightmares and family members may report that the patient experiences flashbacks, as occurred in case 2.

When deep sedation or general anesthesia is required, the anesthesiologist should be prepared to deal with delirium and flashback. Should prevention fail, the presence of a trusted family member or friend during emergence may help restore orientation of the affected patient.13 Although not a standard of care, one army medical center uses dexmedetomidine which inhibits norepinephrine release, thus decreasing sympathetic tone.

In cases during which the patient has experienced agitation or delirium upon emergence in the past (as in case 1), it may be prudent to use voluntary physical restraints and apply them with the patient’s and family’s consent before induction of anesthesia, insuring the patient’s familiarity with their presence to avoid harm or elopement upon emergence if other preventative measures fail.

In conclusion, anesthesiologists should include PTSD in their pursuit of a thorough medical history. The outcome of the 2 cases presented differed markedly: in the first case the diagnosis of PTSD was not elicited and the anesthesia was not modified appropriately. In the second case, the patient’s list of antidepressants was characteristic of therapy for PTSD, and her family member revealed the patient’s history of PTSD. This allowed education of the patient and family member regarding emergence delirium in patients with PTSD and facilitated modification of the anesthetic plan, resulting in a safe regional anesthetic with smooth sedation and emergence.

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