Dexmedetomidine and the Prevention of Emergence Agitation in Military Veterans with Post-Traumatic Stress Disorder

Emergence agitation (EA) is a post-anesthetic complication that occurs when the patient is in a self-limited, nonfluctuating state of excitement while transitioning into a state of consciousness. EA can lead to negative adverse outcomes including, accidental invasive line removal, bleeding, respiratory depression, unintentional extubation, and injury to the staff and the patient. EA is often observed in military veterans who have a medical history of post-traumatic stress disorder (PTSD). For patients with a history of military exposure undergoing elective general anesthesia who also have PTSD, anxiety, and or depression, the incidence of EA was estimated to be around 27%. The pathophysiology of EA is unknown; however, a collection of risk factors has been associated with a higher incidence of EA. These risk factors include pre-operative anxiety, history of pre-existing mental disorders like PTSD, use of volatile agents with low solubility, age, sex, invasive lines and tubes, and the use of premedications like benzodiazepines and anticholinergics.There are currently no evidence-based guidelines or policies in place to properly manage and prevent the incidence of EA in military veterans with a history of PTSD scheduled for general anesthesia. Dexmedetomidine is an alpha-2 adrenoceptor agonist that produces sedation that resembles a patient's natural sleep without causing respiratory depression and allowing for patient arousal. The combination of high-risk identifying assessment tools including the DSM-5, the Richmond Agitation Sedation Scale (RASS), and the utilization of Dexmedetomidine in the peri-operative setting has been proven to decrease the incidence of EA in patients with a history of PTSD.