Perioperative Anesthesia for Patients with Post Traumatic Stress

Report
David Stamps
CoANA Spring Meeting
4 May, 2013
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PTSD: Post-traumatic stress disorder is a severe anxiety
disorder that can develop after exposure to any event that
results in psychological trauma
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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)
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Hyperarousal symptoms
• Difficulty sleeping
• Irritability/anger outbursts
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response
Hamblen, PhD
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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
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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
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Early 1990's
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Interviews of a representative national
sample of 8,098 Americans
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Age 15 to 54 years
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Lifetime PTSD was 7.8% general population
• Women (10.4%)
• Men (5%)
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Lifetime PTSD prevalence = 6.8%
• 9.7% women
• 3.6% men
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Current past year PTSD prevalence = 3.6%
• 5.2% women
• 1.8% men
Kessler et al, 2005.
We never know who our PTSD pts are going to
be or what they will look like
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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
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20% of exposed women and 8% of exposed
men develop PTSD
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Trauma most likely to cause development
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Rape
Physical abuse
Molestation
Threat (weapon)
Sudden loss of a loved one
Kessler et al. 2005
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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
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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
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Emergence Delirium (ED)
• Psychomotor agitation
• Ranging from frequent, nonpurposeful
movement to overt physical aggressiveness
• Immediately or shortly after emergence from
anesthesia
• Self-limited, may last from minutes to hours
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Postoperative Cognitive Dysfunction
 Decline in cognitive functioning that manifests
after surgery
 Patient must demonstrate new-onset impaired
functioning that:
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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
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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
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Emergence delirium is associated with
multiple adverse outcomes
• Self-extubation, unintended removal of lines/tubes,
injury to patient/staff, longer stays PACU
• Not associated with greater postoperative mortality
in a population of mixed ages (unlike postoperative
delirium)
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Can you devise an anesthetic plan for your
PTSD Pt?
• We’ll build toward this
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What research is out there to guide you?
• Little to none
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Can you treat PTSD with anesthesia?
• Lets address this first
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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, Siroko MK.
• Cervical sympathetic blockade in a patient with
posttraumatic stress disorder: a case report. Ann Clin
Psychiatry. 2008;20:227–228.10
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PTSD causes an increase in nerve growth
factor (NGF)
• NGF: protein important part of the development/
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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
1. Precipitating event, estrogen decrease, nerve
trauma, PTSD triggering event
2. NGF increase
3. Retrograde transport of the NGF
1. NGF increase in the stellate ganglion
2. Sprouting of the sympathetic fibers distally
3. Increase in the brain norepinephrine
1. Stellate ganglion block
2. Reduction of NGF decrease in sprouting,
reduction of brain norepinephrine and
resolution of symptoms
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Study Objective: Report the successful use of
stellate ganglion blocks (SGBs) in two patients
experiencing symptoms PTSD
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The Post-traumatic Stress Disorder Checklist
(PCL)
• 17-item psychometric test commonly used to screen
for PTSD
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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
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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
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10 enemy combatants were killed at close range
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Briefly rendered unconscious from an explosion
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The patient was not visibly injured in the assault
In the care of a psychiatrist for over one year
o Medications
• Sertraline, quentiapine, trazadone, venlafaxine, and
zolpidem
• Quentiapine was prescribed to control PTSD-related
nightmares
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Never diagnosed with any type of thought disorder
or other psychotic condition
o Initial pre-injection PCL score was 76/85
o He recounted that since his trigger event he could
not recall a time when he slept for more than 2 to 3
hours
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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
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In the care of a psychiatrist for 1 year before his SGB
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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
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Medications
• Mirtazapine, sertraline, and zolpidem
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His pre-SGB PCL score was 54/85
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Both patients experienced immediate,
significant and durable relief as measured by
the PCL (score minimum 17, maximum 85)
• Pt 1:
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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
First time since his symptoms started (18 years ago) he was
able to sleep for 6 to 7 hours
• Nightmares diminished in both intensity and frequency
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Pt 2:
• Post- injection PCL score =24
• Seven months after SGB, PCL score consistent 24.
• Patient’s spontaneous comments
• “I feel at peace”
• “I’m just starting to be aware of how much anxiety I have
been living with”
• “My mind is not racing”
• He reports feeling like himself, and no longer feels “like an
unpleasant person”
• His erectile dysfunction resolved when he discontinued
medications
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In both instances, the pre-treatment score
suggested a PTSD diagnosis whereas the
post-treatment scores did not
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Both patients discontinued all antidepressant
and antipsychotic medications while
maintaining their improved PCL score
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Can you devise an anesthetic plan for your
PTSD Pt?
• We’ll build toward this
o
What research is out there to guide you?
• Little to none
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Can you treat PTSD with anesthesia?
• Lets address this first
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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
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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
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Five themes emerged
• Emergence delirium (ED) exists, and to a greater
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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
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)
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
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”
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
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
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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/Se
rtraline/Trazadone
• KNDA
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Med Hx
• Tobacco/HTN/GERD/Arthritis
• PTSD/TBI
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Surg Hx
• Appy/Lipoma
• Hx of “waking up” during procedure
• Hx of “combative” wakeup
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Anesth plan
• LMAC
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Anesthetic
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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
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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
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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
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Negative impact
• Time, personnel, danger to self and others
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66 y/o male, ASA III, Prostate Bx
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Violent wake-ups last 2 anes (2 OR
personnel to ER)
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Med Hx:
OSA/COPD/CAD/HTN/DM/Bipolar/PTSD
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Surg Hx: Cardiac Stent ‘01/Colonoscopy ’12
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Hx of Military assassin/hand to hand
combat
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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”
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35 y/o male, ASA II, gang cyst exc right wrist
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Discussed anes options:
• IV Nl surg pref, Lmac not option(per pt), GA
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Med Hx:Tobacco/DM type
2/PTSD/Depression
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Surg Hx: knee arthroscopy ’09, no A/C
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Pt and wife both express concerns about
any alternative other than GA (preference)
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Pre-op with 2mg Versed/Fentanyl 100mcg
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1402-Induction Propofol 200mg/lidocaine 50mg/Ketamine
50mg. iGel placed (BIS at 20)
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1417-Propofol/Ketamine at 80mcg/kg/min
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1425 BIS at 29 and pt light, increased infusion to
125mcg/kg/min
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1438 infusion off
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1444 surgery complete
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1449 pt extubated, stable, SV, to PACU calm/alert Total
Propofol 400mg/Ketamine 100mg
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Ketorolac 30mg at end of case
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PACU stay uneventful with D/C to home
within 1.5 Hrs. Follow up in AM showed no
ill effects with high satisfaction with
anesthesia
o
Can you devise an anesthetic plan for your
PTSD Pt?
• We’ll now explore this
o
What research is out there to guide you?
• Little to none
o
Can you treat PTSD with anesthesia?
• Lets address this first
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Comorbidities
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Substance abuse
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Chronic pain
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Psychoactive meds
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Anxiety concerns
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Cognitive function
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Comorbidities
• Cardiac risk factors (lifestyle factors)
• HTN/DM/HLP
• COPD/OSA/GERD/Obesity
• Depression
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36% in PTSD pts
3.5% non
PTSD pts
PTSD/Depression may share common genetic basis
Substance abuse (veteran study)
• Tobacco 3X
• ETOH 5X
• MJ
• Medical/Rec
• Illegal drugs 3X
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Chronic pain
• Encourage Nx staff to educate pt on taking opioids
preop
• Pain eval DOS ASAP
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Psychoactive meds
• Careful consideration of medication list
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SSRI
SNRI
MAO’s
TCA
Alpha antagonists
Anticonvulsants/Benzo’s
Anitpsychotics
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Anxiety considerations
• Establishing trust and full explanations
• Avoidance of loud noises
• Wake pt with verbal stimulus vs touch
• Elicit and known triggers
• Elicit known wake-up patterns
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Cognitive function
• PTSD has worse preoperative cognitive function
• Measures of verbal memory
• Cognitive function found to be inversely related
to PTSD symptoms
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Retain/learn new info for short period
Manipulate the info in meaningful way
Produce response based on manipulated info
Decreased cognitive reserve (vs overall intelligence)
Pts vulnerable to post-op cognitive decline
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PTSD NOT a predictor of:
• Length of hospital stay
• Readmission rate
• Certain surgery specific outcomes
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PTSD NOT known to exacerbate symptoms
• Studies limited
• Only anecdotal cases of surgery exacerbating
symptoms when aspects of perioperative exp
similar to the pts traumatic experience
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Preoperative evaluation
 Elicit history of PTSD Dx, sleep
disturbances/nightmares
▪ Amitriptyline/sertraline
 Younger troops much more common than older
Vets to have ED
 Elicit history of previous anesthetic experiences
of ED
 Plan care with PACU for this PTSD pt
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Anesthetic Plan
 Regional L/MAC if possible
 TIVA for GA
▪ Avoidance of Midazolam
▪ Propofol/ketamine mix
▪ Adequate pain control; especially as many are chronic
pain pts
▪ Consider NSAID and long acting opioid ie: morphine
▪ Consider an alpha 2 agonist (dexmetatomidine)
▪ Decreases sympathetic tone/cascade
▪ Awake with verbal stimulus/avoid touching head for
stimulus
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One-on-one care if possible
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Quiet, non-stimulating environment(good luck)
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Family in PACU if possible
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Frequent reorientation
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Consider avoidance of midazolam for emergence delirium
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Tends to make pts worse or have no effect
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Developing Anesthesia as Post Traumatic
Stress Disorder (PTSD) Therapy
Southern California Institute for Research and Education
National Institute of Mental Health (NIMH)
• Purpose This preclinical phase 1 development study in healthy
volunteers seeks to identify if low doses of commonly used nontriggering anesthetic agents might have clinical utility for
modulating emotional memory processing and to understand the
nature of the brain mechanisms of drug action. Optimally, a drug,
dose and brain mechanism of action will be identified that will form
the foundation for future use in clinical studies of patients with
PTSD
• Drug: Dexmedetomidine
Drug: Propofol
Drug: Ketamine
Drug: Nitrous Oxide
• A low dose of medication is used during scanning after dose piloting
outside the scanner for memory effects and tolerability
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Ketamine as a Rapid Treatment for Posttraumatic Stress Disorder (PTSD) (KetPTSD)
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Dennis Charney
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Collaborator:
• Department of Defense
• Purpose The objective of the proposed study is
to test if a single IV dose of ketamine (0.5
mg/kg) decreases symptoms of PTSD
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Modafinil in the Treatment of PTSD
(Posttraumatic Stress Disorder)
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Biomedical Research Foundation
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National Center for Research Resources (NCRR)
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National Institute of General Medical Sciences
(NIGMS)
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The purpose of this study is to determine if modafinil
is more effective than placebo in the treatment of
posttraumatic stress disorder (PTSD) in male combat
veterans who have been deployed to Iraq or
Afghanistan
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Eszopiclone for the Treatment of
Posttraumatic Stress Disorder
Rush University Medical Center
o National Institute of Mental Health (NIMH)
o The purpose of this study is to determine if eszopiclone
relative to placebo (sugar pill) is effective and tolerable
for people with posttraumatic stress disorder (PTSD)related sleep disturbance. The investigators will also
examine the impact of treatment on sleep patterns,
memory recall bias, and level of inflammatory markers
(cytokines). The investigators predict eszopiclone will
lead to greater improvement than placebo in measures
of PTSD symptoms, memory recall bias, and level of
inflammatory markers
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J $100M PTSD and TBI Study
In a press release from September 19, 2012,
the VA and DoD announced they are investing
more than $100 million in research to improve
diagnosis and treatment of mild traumatic
brain injury (mTBI) and (PTSD)
“At VA, ensuring that our veterans receive
quality care is our highest priority,” said
Secretary of Veterans Affairs Eric K. Shinseki.
“Investing in innovative research that will lead
to treatments for PTSD and TBI is critical to
providing the care our veterans have earned
and deserve.”
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An executive order, signed by the President on
August 31, 2012, was designed to improve
access to mental health services for our
veterans, service members, and military
families. In that order, the President directed
the DoD, the VA, HHS, and the Department of
Education to develop a National Research
Action Plan that will include strategies to
improve early diagnosis and treatment effectiveness for TBI and PTSD

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