Measuring Emergence Delirium in the Wounded Warrior: An Emerging Problem

Emergence delirium (ED) is a postoperative phenomenon that occurs in the operating room (OR) and /or the post-anesthesia care unit (PACU) following exposure to general anesthesia. ED is characterized by psychomotor agitation ranging from frequent, non-purposeful movement to overt physical aggressiveness. Military anesthesia providers and PACU nurses have observed an alarming increase in the number of patients with combat exposure emerging from general anesthesia confused, agitated, angry, verbal, and/or combative. A growing number of these patients develop severe ED with flashbacks to their combat experience that manifest as aggressive disoriented behavior in the operating room and continues for several hours in the PACU. These behaviors place the patient and their caregivers at risk for serious injury. One of the major challenges in studying this phenomenon is the absence of an instrument to identify ED and quantify its severity in the military “wounded warrior” population. The need for a specific, valid, reliable instrument to measure ED in wounded warriors is underscored by the fact that ED in military patients is undamentally different than that exhibited by adult civilian patients. The specific aims of this study are to: 1) identify the behaviors associated with ED in wounded warriors; 2) develop a valid and reliable instrument to measure ED in the wounded warrior population and; 3) to conduct a feasibility test of the instrument in the military perioperative environment.  The specific aims of the study will be addressed in 3 phases.  In Phase I the Delphi process for achieving convergence of opinion among a group of experts will be used to identify ED behaviors in wounded warriors.  In Phase II the identified behaviors will be examined for content validity and a scoring system will be developed.  In Phase III the instrument and the scoring system will be field tested in a military setting.  Standard psychometric tools will be used to examine face validity, scoring criteria, and reliability of the instrument with respect to internal consistency and interrater agreement. The long term goal of this work is to produce an instrument which will enable the systematic quantification of the incidence of ED and assessment of interventions to reduce or eliminate its expression.