Emergence Delirium Subsequent to General Anesthesia in Service Members Who Served During the Global War on Terrorism by John Tyler Wilson December, 2011 Under the direction of Marie E. Pokorny PhD, RN College of Nursing The primary aims of this study were to investigate, through active duty Army anesthesia provider’s perceptions, the following: 1) the extent and seriousness of emergence delirium (ED) in service members; 2) effects of ED on the safety of service members and OR/PACU personnel and 3) behaviors relevant to ED in service members. In addition to these primary aims, the study also focused on identifying through provider’s perceptions, the following potential factors which may lead to the development of ED or to the alleviation of ED: 1) type of anesthetic agents; 2) physiological factors; 3) psychological factors; and 4) interventions used for alleviating the symptoms of ED. A final aim was to investigate from provider’s perceptions, the relationship between perceived seriousness of ED and reported case experience, behaviors and consequences relevant to ED, and physiological and psychological factors related to the development or alleviation of ED symptoms. This research utilized a descriptive correlational study design with a questionnaire survey and a convenience sampling technique totaling 89 active duty Army anesthesia providers. This study found that over 78% of active duty Army anesthesia providers have witnessed ED in their particular practice. Approximately 38% of the respondents felt that ED was a moderate problem. There was a statistically significant association between perceived severity of ED and ED case experience. The behaviors which were often seen or always seen included hyperactive motor behavior, pulling at the monitoring equipment, and making disruptive movements. The current study found that the majority of anesthesia providers with ED case experience believed ED could be related to the anesthetic used. The anesthetic identified most strongly as potentially related to ED were potent inhalation agents (PIA’s). Most of the providers with ED case experience believed physiological factors and psychological factors were related to ED. Over ninety percent of the providers with ED case experience reported that they intervened when their patients showed behaviors related to ED with the majority of the providers stating they talked to the patient during the ED episode. EMERGENCE DELIRIUM SUBSEQUENT TO GENERAL ANESTHESIA IN SERVICE MEMBERS WHO SERVED DURING THE GLOBAL WAR ON TERRORISM A Dissertation Presented to The Faculty of the College of Nursing East Carolina University In Partial Fulfillment of The Requirements for the Degree Doctor of Philosophy by John Tyler Wilson December, 2011 EMERGENCE DELIRIUM SUBSEQUENT TO GENERAL ANESTHESIA IN SERVICE MEMBERS WHO SERVED DURING THE GLOBAL WAR ON TERRORISM by John Tyler Wilson APPROVED BY: DIRECTOR OF DISSERTATION: ________________________________________________ Marie E. Pokorny, PhD, RN COMMITTEE MEMBER: _______________________________________________________ Bonnie Benetato, PhD, RN, MBA COMMITTEE MEMBER: _______________________________________________________ David Cistola, MD, PhD COMMITTEE MEMBER: _______________________________________________________ Melvin Swanson, PhD DEAN OF THE COLLEGE OF NURSING: _______________________________________________________ Sylvia Brown, EdD, RN DEAN OF THE GRADUATE SCHOOL: ______________________________________________________ Paul J. Gemperline, PhD ACKNOWLEDGEMENTS I am grateful to have attended East Carolina University which has at its core, great faculty. I am appreciative for the time and energy my committee members spent molding me into both a researcher and nurse scholar. I am thankful for the guidance and constructive criticism offered by David Cistola, MD, PhD, and Bonnie Benetato, FNP, PhD, MBA. My statistician, Melvin Swanson, PhD, who spent countless weekend hours fine tuning my work and offering countless suggestions for improvements, I am extremely appreciative. Lastly, I would like to acknowledge my mentor, Marie Pokorny, PhD, RN. Dr. Pokorny encompasses the very idea of what a nurse is and should be. Her devotion to my project is unparalleled as is her commitment to all students in the PhD program. She was always available and provided me with advice, knowledge, and most importantly, words of encouragement. Words simply do not do justice to the deep feeling of gratitude I have for the entire nursing faculty at the East Carolina College of Nursing and I feel honored to have graduated from the Pirate Nation! DEDICATION With a great deal of love, I would like to thank the late Mary Evans Hutchison Moss Denman (“Mimi”) who showed more through her actions than her words, what patience and devotion are all about. To my parents, Mary Nelson White and John T Wilson M.D., who have always supported my endeavors no matter the potential risks involved. I am grateful to have had two parents who always put their children’s needs first and have been there when we needed them most. I would also like to thank James F. White (“Uncle Jimsy”) and Catherine Jacobs Wilson (“Curls”) for their support and love for my parents. My parents need you and you both have never failed them. To my four children, Taylor Brooke Wilson, Alan Scott Wilson, Lauren Brooke Smith and Charles Carson Smith who keep me young at heart and who are always able to make me smile. I hope one day you will be able to read this dissertation and better yet, understand it. With all that I am, I love you ALL so much and am blessed to be a Daddy. This dissertation is dedicated to my wife April, who has endured listening to the woes of being a doctoral student and the late nights writing, I love you. I am grateful to have you in my life and appreciate the unwavering support you have provided not only me, but also my children. I certainly could not have made it though this difficult time without you by my side and for that and many more reasons, I say: Thank you April! I would also like to recognize and honor the 48,830 wounded and the 6,281 service men and women who have sacrificed everything while serving in Operations Enduring and Iraqi Freedoms. Words simply do not do homage to their sacrifices while protecting, what we all too often, take for granted. TABLE OF CONTENTS LIST OF FIGURES……………………………………………………………………... x LIST OF TABLES………………………………………………………………………. xi CHAPTER 1: INTRODUCTION……………………………………………………… 1 Background to the Problem……………………………………………………… 1 Emergence Delirium (ED)……………………………………………………….. 3 Statement of the Problem………………………………………………………... 5 Purpose of the Study…………………………………………………………….. 5 Theoretical Perspective………………………………………………………….. 6 Clinical Model for Emergence Delirium………………………………………… 9 CHAPTER 2: REVIEW OF THE LITERATURE……………………………………... 14 Delirium in the Critical Care Setting without General Anesthesia……………… 16 Physiology of General Anesthesia………………………………………………. 17 Tools to Measure Emergence Delirium………………………………………….. 18 Emergence Delirium Studies: A Critical Analysis……………………………… 20 Pharmacologic Interventions and Emergence Delirium…………………………. 26 Traumatic Brain Injury (TBI)……………………………………………………. 29 Post Traumatic Stress Disorder (PTSD)…………………………………………. 31 TBI and PTSD risk factors for ED………………………………………………. 32 Ketamine: Review of the Current Literature……………………………………. 34 Ketamine, Pediatrics and Emergence Agitation……………………………….… 37 TBI and/or PTSD, Anesthesia and Ketamine…………………………………… 39 CHAPTER 3: METHODOLOGY……………………………………………………… 44 Research Design…………………………………………………………………. 44 Setting and Sample………………………………………………………………. 45 Instrumentation………………………………………………………………….. 46 Professional designation………………………………………………… 47 Gender…………………………………………………………………… 47 Experience level…………………………………………………………. 47 Practice site……………………………………………………………… 48 Months deployed………………………………………………………… 48 Routine screening………………………………………………………... 48 Benzodiazepine administration…………………………………………... 48 Ketamine administration………………………………………………… 48 Analgesic administration………………………………………………… 49 Anesthetics used while deployed………………………………………... 49 TIVA versus PIA in regards to observed differences waking up………... 49 Personal experience with ED with service members during the GWOT... 50 Number of ED cases experienced by the provider………………………. 50 ED cases decreasing, not changing or staying the same………………… 50 ED behaviors are a problem, risk for injury to themselves, and risk of injury to the provider or PACU/OR staff…………………… 50 ED related to the anesthetic used………………………………………... 51 Anesthetics used and there potential role in ED………………………… 51 Potential physiological factors related to ED………………………….… 51 Potential psychological factors related to ED…………………………… 52 Interventions used to treat ED…………………………………………… 52 ED behaviors…………………………………………………………….. 53 Data Collection Plan…………………………………………………...………… 54 Data Analysis Plan………………………………………………………………. 56 Summary………………………………………………………………………… 57 CHAPTER 4: RESULTS……………………………………………………………….. 58 Characteristics of the Sample……………………………………………………. 58 Demographic Characteristics……………………………………………………. 59 Practice Characteristics………………………………………………………….. 59 Primary Aims 1 and 2: Extent, Seriousness, and Safety Risk of ED……………. 63 Primary Aim 3: Behaviors Relevant to ED in Service Members………………... 63 Secondary Aim: Anesthetics Related to ED…………………………………….. 66 Secondary Aim: Physiologic Factors Related to ED……………………………. 66 Secondary Aim: Psychological Factors Related to ED…………………………. 66 Secondary Aim: Interventions That May Alleviate ED Symptoms Arising during Anesthesia……………………………………………………………….. 70 Secondary Aim: Interventions That May Reduce or Prevent ED before Anesthesia………………………………………………………………... 70 Secondary Aim: Relationship of Perceived Seriousness of ED and Reporting of Case Experience, ED Behaviors, and Physiological/Psychological factors Related ED………………………………... 70 CHAPTER 5: DISCUSSION…………………………………………………………... 79 Practice Characteristics………………………………………………………….. 80 Primary Aim: Extent, Seriousness, and Safety Risk of ED in Service Members.. 81 Primary Aim: Behaviors and Behavioral Consequences Related to ED……….. 82 Secondary Aim: Anesthetic Implications for ED………………………………. 83 Secondary Aim: Physiological and Psychological Factors Related to ED……... 83