EMERGENCE AGITATION IN PATIENTS WITH POSTTRAUMATIC STRESS DISORDER - LITERATURE REVIEW

Keywords: Emergence Agitation, Emergence Delirium, PTSD, Posttraumatic Stress, General Anaesthesia

Abstract

Emergence agitation (EA) is an acute condition, characterised by confusion, and restlessness, occurring in the early recovery phase from general anaesthesia. EA can have significant clinical impact, including patient distress, injury, increased morbidity, and increased healthcare costs, as well as possible long-term consequences. Though the pathophysiology of emergence agitation remains unknown, it is believed to involve a multifactorial mechanism, including heightened sympathetic nervous system activation, and psychological factors such as posttraumatic stress disorder (PTSD). PTSD, a psychiatric disorder resulting from exposure to trauma, may predispose individuals to emergence agitation. This literature review aims to examine the relationship between EA and PTSD, highlighting possible mechanisms, prevalence and risk factors involved, as well as discuss possible prevention methods and pharmacological interventions. A comprehensive understanding of the pathophysiology and risk factors of emergence agitation in PTSD patients is critical for developing suitable prevention and anaesthesia management strategies.

References

Avidan, M. S., Maybrier, H. R., Abdallah, A. B., Jacobsohn, E., Vlisides, P. E., Pryor, K. O., Veselis, R. A., Grocott, H. P., Emmert, D. A., Rogers, E. M., Downey, R. J., Yulico, H., Noh, G.-J., Lee, Y. H., Waszynski, C. M., Arya, V. K., Pagel, P. S., Hudetz, J. A., Muench, M. R., … Yulico, H. (2017). Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: An international, multicentre, double-blind, randomised clinical trial. The Lancet, 390(10091), 267–275. https://doi.org/10.1016/S0140-6736(17)31467-8

Back, S. E., Jarnecke, A. M., Norman, S. B., Zaur, A. J., & Hien, D. A. (2024). State of the Science: Treatment of comorbid posttraumatic stress disorder and substance use disorders. Journal of Traumatic Stress, 37(6), 803–813. https://doi.org/10.1002/jts.23049

Bonhomme, V., Boveroux, P., Brichant, J. F., Laureys, S., & Boly, M. (2012). Neural correlates of consciousness during general anesthesia using functional magnetic resonance imaging (fMRI). Archives Italiennes De Biologie, 150(2–3), 155–163. https://doi.org/10.4449/aib.v150i2.1242

Bremner, J. D. (2006). Traumatic stress: Effects on the brain. Dialogues in Clinical Neuroscience, 8(4), 445–461. https://doi.org/10.31887/DCNS.2006.8.4/jbremner

Card, E., Pandharipande, P., Tomes, C., Lee, C., Wood, J., Nelson, D., Graves, A., Shintani, A., Ely, E. W., & Hughes, C. (2015). Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit. British Journal of Anaesthesia, 115(3), 411–417. https://doi.org/10.1093/bja/aeu442

Choi, G. J., Baek, C. W., Kang, H., Park, Y. H., Yang, S. Y., Shin, H. Y., Jung, Y. H., Woo, Y. C., & Lee, U. L. (2015). Emergence agitation after orthognathic surgery: A randomised controlled comparison between sevoflurane and desflurane. Acta Anaesthesiologica Scandinavica, 59(2), 224–231. https://doi.org/10.1111/aas.12435

Dahmani, S., Delivet, H., & Hilly, J. (2014). Emergence delirium in children: An update. Current Opinion in Anaesthesiology, 27(3), 309–315. https://doi.org/10.1097/ACO.0000000000000076

Du, J., Diao, H., Zhou, X., Zhang, C., Chen, Y., Gao, Y., & Wang, Y. (2022). Post-traumatic stress disorder: A psychiatric disorder requiring urgent attention. Medical Review (2021), 2(3), 219–243. https://doi.org/10.1515/mr-2022-0012

Fields, A., Huang, J., Schroeder, D., Sprung, J., & Weingarten, T. (2018). Agitation in adults in the post-anaesthesia care unit after general anaesthesia. British Journal of Anaesthesia, 121(5), 1052–1058. https://doi.org/10.1016/j.bja.2018.07.017

Hernandez, B. A., Lindroth, H., Rowley, P., Boncyk, C., Raz, A., Gaskell, A., García, P. S., Sleigh, J., & Sanders, R. D. (2017). Post-anaesthesia care unit delirium: Incidence, risk factors and associated adverse outcomes. British Journal of Anaesthesia, 119(2), 288–290. https://doi.org/10.1093/bja/aex197

Huang, J., Chopra, N., Yepuri, N., & Kinthala, S. (2023). Emergence Agitation and Anesthetic Considerations in the Management of Patients With Post-Traumatic Stress Disorder: A Report of Two Cases and a Review of the Literature. Cureus. https://doi.org/10.7759/cureus.33794

Lee, S.-J., & Sung, T.-Y. (2020). Emergence agitation: Current knowledge and unresolved questions. Korean Journal of Anesthesiology, 73(6), 471–485. https://doi.org/10.4097/kja.20097

Lee, Y. S., Kim, W. Y., Choi, J. H., Son, J. H., Kim, J. H., & Park, Y. C. (2010). The effect of ketamine on the incidence of emergence agitation in children undergoing tonsillectomy and adenoidectomy under sevoflurane general anesthesia. Korean Journal of Anesthesiology, 58(5), 440. https://doi.org/10.4097/kjae.2010.58.5.440

Lepousé, C., Lautner, C. A., Liu, L., Gomis, P., & Leon, A. (2006). Emergence delirium in adults in the post-anaesthesia care unit. British Journal of Anaesthesia, 96(6), 747–753. https://doi.org/10.1093/bja/ael094

Lovestrand, D., Lovestrand, S., Beaumont, D. M., & Yost, J. G. (2017). Management of Emergence Delirium in Adult PTSD Patients: Recommendations for Practice. Journal of PeriAnesthesia Nursing, 32(4), 356–366. https://doi.org/10.1016/j.jopan.2015.11.011

McCall, N. M., Wojick, J. A., & Corder, G. (2020). Anesthesia analgesia in the amygdala. Nature Neuroscience, 23(7), 783–785. https://doi.org/10.1038/s41593-020-0645-3

McGuire, J. M. (2012). The Incidence of and Risk Factors for Emergence Delirium in U.S. Military Combat Veterans. Journal of PeriAnesthesia Nursing, 27(4), 236–245. https://doi.org/10.1016/j.jopan.2012.05.004

McLott, J., Jurecic, J., Hemphill, L., & Dunn, K. S. (2013). Development of an amygdalocentric neurocircuitry-reactive aggression theoretical model of emergence delirium in posttraumatic stress disorder: An integrative literature review. AANA Journal, 81(5), 379–384.

Pal, N., Abernathy, J. H., Taylor, M. A., Bollen, B. A., Shah, A. S., Feng, X., Shotwell, M. S., & Kertai, M. D. (2021). Dexmedetomidine, Delirium, and Adverse Outcomes: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The Annals of Thoracic Surgery, 112(6), 1886–1892. https://doi.org/10.1016/j.athoracsur.2021.03.098

Radow, B., Anderson, N., & Richmond, B. K. (2025). Post-Traumatic Stress Disorder (PTSD) in Trauma Patients. The American Surgeon, 91(2), 292–299. https://doi.org/10.1177/00031348241290610

Read, M. D., Maani, C. V., & Blackwell, S. (2017). Dexmedetomidine as a Rescue Therapy for Emergence Delirium in Adults: A Case Series. A & A Case Reports, 9(1), 20–23. https://doi.org/10.1213/XAA.0000000000000510

Sauër, A. C., Veldhuijzen, D. S., Ottens, T. H., Slooter, A. J. C., Kalkman, C. J., & van Dijk, D. (2017). Association between delirium and cognitive change after cardiac surgery. British Journal of Anaesthesia, 119(2), 308–315. https://doi.org/10.1093/bja/aex053

Scott, G. M., & Gold, J. I. (2006). Emergence delirium: A re-emerging interest. Seminars in Anesthesia, Perioperative Medicine and Pain, 25(3), 100–104. https://doi.org/10.1053/j.sane.2006.05.013

Scott-Warren, V., & Sebastian, J. (2016). Dexmedetomidine: Its use in intensive care medicine and anaesthesia. BJA Education, 16(7), 242–246. https://doi.org/10.1093/bjaed/mkv047

Seal, K. H., Shi, Y., Cohen, G., Cohen, B. E., Maguen, S., Krebs, E. E., & Neylan, T. C. (2012). Association of Mental Health Disorders With Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan. JAMA, 307(9). https://doi.org/10.1001/jama.2012.234

Semple, W. E., Goyer, P. F., McCormick, R., Donovan, B., Muzic, R. F., Rugle, L., McCutcheon, K., Lewis, C., Liebling, D., Kowaliw, S., Vapenik, K., Semple, M. A., Flener, C. R., & Schulz, S. C. (2000). Higher brain blood flow at amygdala and lower frontal cortex blood flow in PTSD patients with comorbid cocaine and alcohol abuse compared with normals. Psychiatry, 63(1), 65–74. https://doi.org/10.1080/00332747.2000.11024895

Sikich, N., & Lerman, J. (2004). Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology, 100(5), 1138–1145. https://doi.org/10.1097/00000542-200405000-00015

Sprung, J., Roberts, R. O., Weingarten, T. N., Nunes Cavalcante, A., Knopman, D. S., Petersen, R. C., Hanson, A. C., Schroeder, D. R., & Warner, D. O. (2017). Postoperative delirium in elderly patients is associated with subsequent cognitive impairment. British Journal of Anaesthesia, 119(2), 316–323. https://doi.org/10.1093/bja/aex130

Tolly, B., Erbes, C. R., & Apostolidou, I. (2021). Posttraumatic stress disorder and anesthesia: Respect for the military veteran’s mind. Journal of Clinical Anesthesia, 71, 110242. https://doi.org/10.1016/j.jclinane.2021.110242

Tolly, B., Waly, A., Peterson, G., Erbes, C. R., Prielipp, R. C., & Apostolidou, I. (2021). Adult Emergence Agitation: A Veteran-Focused Narrative Review. Anesthesia and Analgesia, 132(2), 353–364. https://doi.org/10.1213/ANE.0000000000005211

Views:

54

Downloads:

22

Published
2025-06-01
Citations
How to Cite
Julia Kaszucka, Jakub Jędrychowski, Natalia Karpowicz, Kinga Kosiec-Stolarek, Oliwia Krzemień, Małgorzata Krzyżanowska, Iga Kwiecień, Natalia Pacocha, Agnieszka Raczyńska, & Marta Zgierska. (2025). EMERGENCE AGITATION IN PATIENTS WITH POSTTRAUMATIC STRESS DISORDER - LITERATURE REVIEW. International Journal of Innovative Technologies in Social Science, (2(46). https://doi.org/10.31435/ijitss.2(46).2025.3278

Most read articles by the same author(s)