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Perioperative Anesthesia for Patients with Post-Traumatic Stress Disorder

Perioperative Anesthesia for Patients with Post-Traumatic Stress Disorder

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Perioperative Anesthesia for Patients with Post-Traumatic Stress Disorder

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  1. Perioperative Anesthesia for Patients with Post-Traumatic Stress Disorder David Stamps CoANA Spring Meeting 4 May, 2013

  2. PTSD Defined • PTSD: Post-traumatic stress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma • DSM: development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1)

  3. PTSD DSM • Hyperarousal symptoms • Difficulty sleeping • Irritability/anger outbursts • Difficulty concentrating • Hypervigilance • Exaggerated startle response Hamblen, PhD

  4. PTSD DSM • Re-experiencing symptoms • Recurrent recollections of event • Recurrent distressing dreams of event • Acting or feeling as if event were occurring • Psy distress at cues resembling event • Psy reactivity to cues Hamblen, PhD

  5. PTSD DSM • Avoidance/numbing symptoms • Avoiding thoughts/feelings/conversations • Activities/places/people that cause reminders • Inability to recall part of trauma • Decreased interest in activates • Estrangement • Restricted range of affect • Sense of foreshortened future Hamblen, PhD

  6. National Comorbidity Survey • Early 1990's • Interviews of a representative national sample of 8,098 Americans • Age 15 to 54 years • Lifetime PTSD was 7.8% general population • Women (10.4%) • Men (5%)

  7. PTSD Prevalence (NCS-R) • Lifetime PTSD prevalence = 6.8% • 9.7% women • 3.6% men • Current past year PTSD prevalence = 3.6% • 5.2% women • 1.8% men Kessler et al, 2005.

  8. We never know who our PTSD pts are going to be or what they will look like

  9. Prevalence Among Children and Adolescents • No population-based epidemiological studies • Studies examined prevalence of PTSD high-risk children; experienced specific traumatic events, such as abuse or natural disasters • May have a higher prevalence of PTSD than adults in the general population • (2003) – Prevalence of PTSD among adolescents • National Survey of Adolescents • Household probability sample of 4,023 adolescents between the ages of 12 and 17 • DSM-IV criteria for PTSD: • Six-month prevalence was estimated to be 3.7% for boys and 6.3% for girls National Center for PTSD

  10. Conditional Risk • 20% of exposed women and 8% of exposed men develop PTSD • Trauma most likely to cause development • Rape • Physical abuse • Molestation • Threat (weapon) • Sudden loss of a loved one Kessler et al. 2005

  11. Combat Exposure • NCS-R • Lifetime prevalence of PTSD = 39% Male combat veterans • Male combat vs all other male trauma • Higher lifetime PTSD prevalence • Greater likelihood of delayed prevalence • Greater likelihood of unresolved symptoms Keesler et al 2005

  12. OR/PACU

  13. Post-Operative Definitions • Postoperative Delirium • Acute change in cognition • 24 to 72 hours after surgery • Decreased ability to focus, sustain, or shift attention • Not explained by preexisting/evolving disorder i.e. dementia or psychosis

  14. Definitions • Emergence Delirium (ED) • Psychomotor agitation • Ranging from frequent, nonpurposefulmovement to overt physical aggressiveness • Immediately or shortly after emergence from anesthesia • Self-limited, may last from minutes to hours

  15. Definitions • Postoperative Cognitive Dysfunction • Decline in cognitive functioning that manifests after surgery • Patient must demonstrate new-onset impaired functioning that: • Affects at least 2 cognitive processes • Persisted for at least 2 weeks, • Has been confirmed by some form of objective testing • Accompanies a general medical condition or nervous system dysfunction • Not better explained by the presence of • Delirium, dementia, or amnestic disorder

  16. Incidence of ED • Emergence Delirium • 4.7% to 21.3% of adults after general anesthesia • Identified risk factors • Preoperative administration of benzodiazepines • Untreated postoperative pain • PTSD NOT mentioned • Emergence delirium is associated with multiple adverseoutcomes • Self-extubation, unintended removalof lines/tubes, injury to patient/staff, longer stays PACU • Not associated with greater postoperative mortality in a population of mixed ages (unlike postoperative delirium)

  17. Anesthetic Care of PTSD Pts • Can you devise an anesthetic plan for your PTSD Pt? • We’ll build toward this • What research is out there to guide you? • Little to none • Can you treat PTSD with anesthesia? • Lets address this first

  18. PTSD/Stellate Ganglion Block (SGB) • History • 2003, a published report demonstrated a reduction in PTSD-associated anxiety by clipping the sympathetic ganglia, via an endoscopic sympathetic block (ESB) at the second thoracic vertebra (T2) • Most recently, the first successful use of a stellate ganglion block (SGB) for the treatment of PTSD was reported in 2008.Lipov EG, Joshi JR, Lipov SG, Sanders SE, SirokoMK. • Cervical sympathetic blockade in a patient with posttraumatic stress disorder: a case report. Ann ClinPsychiatry. 2008;20:227–228.10

  19. PTSD/SGB • PTSD causes an increase in nerve growth factor (NGF) • NGF: protein important part of the development/ survival of nerve cells, especially sensory neurons like those that transmit pain, touch and temperature • An elevation in NGF has been linked to episodes that stimulate adrenaline • Growth of nerve shoots/sprouts in the brain=increase in norepinephrine levels • Lead to the development of pathological states • Local anesthetic injected near the stellate ganglion reverses this domino effect by lowering NGF concentration

  20. Precipitating event, estrogen decrease, nerve trauma, PTSD triggering event NGF increase Retrograde transport of the NGF

  21. NGF increase in the stellate ganglion Sprouting of the sympathetic fibers distally Increase in the brain norepinephrine

  22. Stellate ganglion block Reduction of NGF decrease in sprouting, reduction of brain norepinephrine and resolution of symptoms

  23. PTSD/SGB • Study Objective: Report the successful use of stellate ganglion blocks (SGBs) in two patients experiencing symptoms PTSD • The Post-traumatic Stress Disorder Checklist (PCL) • 17-item psychometric test commonly used to screen for PTSD • The PCL administered day prior to treatment, to establish a baseline, day after treatment. The PCL was also utilized during follow-up visits to quantify the patient’s symptomotology

  24. PTSD/SGB: Case 1 • 46-year-old Hispanic male recently retired from the military. Symptoms commenced in the first Gulf War following a close-quarters combat event in an Iraqi-held bunker • 10 enemy combatants were killed at close range • Briefly rendered unconscious from an explosion • The patient was not visibly injured in the assault

  25. PTSD/SGB: Case 1 • In the care of a psychiatrist for over one year • Medications • Sertraline, quentiapine, trazadone, venlafaxine, and zolpidem • Quentiapinewas prescribed to control PTSD-related nightmares • Never diagnosed with any type of thought disorder or other psychotic condition • Initial pre-injection PCL score was 76/85 • He recounted that since his trigger event he could not recall a time when he slept for more than 2 to 3 hours

  26. PTSD/SGB: Case 2 • 36 year old white male active duty service member • Battle of Fallujah during Operation Iraqi Freedom • Engaged in killing enemy combatants at close range exposed to “hundreds” of civilian and combatant dead • In the care of a psychiatrist for 1 year before his SGB • Symptoms included • Pronounced anxiety symptoms-shortness of breath, heart palpitations, poor sleep, and nightmares • The patient’s anxiety symptoms were in direct response to a triggering event, and do not appear to be related to a co-morbid diagnosis • Medications • Mirtazapine, sertraline, and zolpidem • His pre-SGB PCL score was 54/85

  27. PTSD/SGB: Case Study Results • Both patients experienced immediate, significant and durable relief as measured by the PCL (score minimum 17, maximum 85) • Pt 1: • PCL=25, after 7 months PCL=67 • Repeat SGB brought PCL to 23, leveled out at 34 • Five minutes after SGB “a cloud had lifted” from his mind • Global feelings of anxiety 8 out of 10 to a 2 out of 10 • Great deal of satisfaction • Firsttime since his symptoms started (18 years ago) he wasable to sleep for 6 to 7 hours • Nightmares diminished in both intensity and frequency

  28. PTSD/SGB: Case Study Results • Pt 2: • Post- injection PCL score =24 • Seven months after SGB, PCL scoreconsistent 24. • Patient’s spontaneous comments • “I feel at peace” • “I’m juststarting to be aware of how much anxiety I have beenliving with” • “My mind is not racing” • He reports feeling like himself, and no longerfeels “like an unpleasant person” • His erectile dysfunctionresolved when he discontinued medications

  29. PTSD/SGB: Case Study Results • In both instances, the pre-treatment score suggested a PTSD diagnosis whereas the post-treatment scores did not • Both patients discontinued all antidepressant and antipsychotic medications while maintaining their improved PCL score

  30. Anesthetic Care of PTSD Pts • Can you devise an anesthetic plan for your PTSD Pt? • We’ll build toward this • What research is out there to guide you? • Little to none • Can you treat PTSD with anesthesia? • Lets address this first

  31. PTSD Study/Military CRNA’s • Aug 2012 Qualitative study • Describe experiences of 3 Army CRNA’s • Pts with Traumatic Brain Injury (TBI)/PTSD • All pts undergoing general anesthesia • All cases post 9/11 • CRNA’s observed cases of pts awakening in Delirium (10%) • Describe your experiences • Thought processes as to why delirium occurs

  32. Military CRNA’s • Emergence Delirium defined by study CRNA’s • Pt awakes in violent and thrashing manner • Attempts at self extubation, breath holding, IV line displacement, assault on OR staff, the want to flee • Behavior could occur at anytime from end of surgery to the end of PACU stay

  33. Military CRNA’s • Five themes emerged • Emergence delirium (ED) exists, and to a greater extent in military personnel. • ED more prevalent in younger population. • TIVA was superior GA for TBI/PTSD pts • Talking to pts pre induction and on emergence vital • Profound impact of Ketamine

  34. Military CRNA’s 1. ED exists and to higher degree in military than general population • All CRNA’s experienced ED in the target population • All have years of civilian experience and do not see this in that population (extent or degree)

  35. Military CRNA’s 2. ED more prevalent in younger population • Could be mere fact that young men are more prevalent in targeted population • Older personnel have greater experience and time to develop coping strategies

  36. Military CRNA’s 3. TIVA superior to potent inhalational anesthetic • All 3 CRNA’s would preferentially use TIVA for known PTSD/TBI • One says “less than 1% of my TIVA pts have ED”

  37. Military CRNA’s 4. Talking preoperatively/during emergence to Pts • All three CRNA’s agreed beneficial to offer reassuring words to pts before induction • Room quite, reorientation upon emergence • Things we all do but with a heightened awareness than our average pt

  38. Military CRNA’s 5. Ketamine for PTSD/TBI • Has role in alleviating ED • One CRNA uses 1mg Ketamine per 10mg Propofol and sufenta • Another uses 100mg Ketamine/100mg Propofol induction and then TIVA

  39. USAFA/VA PTSD/ED experience • Case Study of USAFA/VA pt with ED • 26 Y/O white male for excision lipomas • VSS, 70”, 235 lbs • Meds • Cyclobenzaprine/Gabapentin/Omeprazole/Prazosin/Sertraline/Trazadone • KNDA

  40. USAFA/VA PTSD/ED experience • Med Hx • Tobacco/HTN/GERD/Arthritis • PTSD/TBI • SurgHx • Appy/Lipoma • Hx of “waking up” during procedure • Hx of “combative” wakeup • Anesth plan • LMAC

  41. USAFA/VA PTSD/EDexperience • Anesthetic • Midazolam2mg/Fentanyl 100Mcg Preop • Propofol infusion, 350mg total • Total case time 58 min • Fast track to ASU as pt appeared to be GTG • 1443 shortly after arrival to ASU • Pt flashback to Iraq war, not orientated to current date, place, or situation. Taken to PACU for observation

  42. USAFA/VA PTSD/ED experience • PACU Stay • Immediately given 2mg Midazolam • Usable to take initial vital signs as pt combative and trying to get out of gurney • Asking for location of other soldiers/blood identification • Pts escort brought to bedside, 2:1 care, constant reorientation to place/time/situation • Back to ASU at 1448

  43. USAFA/VA PTSD/ED experience • Discharge from SDS center • 1622 • Orientated to place/time/situation • Call back 0955 next day • Slept well • No recall of ED event or any events that happened after initial midazolam dose preop • Negative impact • Time, personnel, danger to self and others

  44. USAFA/VA PTSD/ED Case 1 • 66 y/o male, ASA III, Prostate Bx • Violent wake-ups last 2 anes (2 OR personnel to ER) • Med Hx: OSA/COPD/CAD/HTN/DM/Bipolar/PTSD • SurgHx: Cardiac Stent ‘01/Colonoscopy ’12 • Hx of Military assassin/hand to hand combat

  45. USAFA/VA PTSD/ED Case 1 • Anes plan:Propofol/ketamine heavy sedation • 15 min procedure with local most stimulating • Load 100mg Propofol/50mg Ketamine, followed by 2-3cc bolus strait Propofol • Stopped dosing when local in (10 more minutes) • Total 200mg Propofol/50mg Ketamine • Fast tracked to ASU, awake, reports “best anes I've had. I don’t feel angry or scared” • Pain 0/10, Sao2 99% • D/C to home within 1 hr, no ill effects over night, was “out of it for 24 hrs”

  46. USAFA/VA PTSD/ED Case 1 • 35 y/o male, ASA II, gang cyst exc right wrist • Discussed anes options: • IV Nlsurgpref, Lmac not option(per pt), GA • Med Hx:Tobacco/DM type 2/PTSD/Depression • SurgHx: knee arthroscopy ’09, no A/C • Pt and wife both express concerns about any alternative other than GA (preference)