Effects of Sevoflurane and Propofol on Posttraumatic Stress Disorder After Emergency Trauma: A Double-Blind Randomized Controlled Trial

Early pharmacological interventions for prevention of post-traumatic stress disorder (PTSD) in individuals experiencing acute traumatic stress symptoms

BACKGROUND

Acute traumatic stress symptoms may develop in people who have been exposed to a traumatic event. Although they are usually self-limiting in time, some people develop post-traumatic stress disorder (PTSD), a severe and debilitating condition. Pharmacological interventions have been proposed for acute symptoms to act as an indicated prevention measure for PTSD development. As many individuals will spontaneously remit, these interventions should balance efficacy and tolerability.

OBJECTIVES

To assess the efficacy and acceptability of early pharmacological interventions for prevention of PTSD in adults experiencing acute traumatic stress symptoms.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trial Register (CCMDCTR), CENTRAL, MEDLINE, Embase and two other databases. We checked the reference lists of all included studies and relevant systematic reviews. The search was last updated on 23 January 2023.

SELECTION CRITERIA

We included randomised controlled trials on adults exposed to any kind of traumatic event and presenting acute traumatic stress symptoms, without restriction on their severity. We considered comparisons of any medication with placebo, or with another medication. We excluded trials that investigated medications as an augmentation to psychotherapy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Using a random-effects model, we analysed dichotomous data as risk ratios (RR) and calculated the number needed to treat for an additional beneficial/harmful outcome (NNTB/NNTH). We analysed continuous data as mean differences (MD) or standardised mean differences (SMD). Our primary outcomes were PTSD severity and dropouts due to adverse events. Secondary outcomes included PTSD rate, functional disability and quality of life.

MAIN RESULTS

We included eight studies that considered four interventions (escitalopram, hydrocortisone, intranasal oxytocin, temazepam) and involved a total of 779 participants. The largest trial contributed 353 participants and the next largest, 120 and 118 participants respectively. The trials enrolled participants admitted to trauma centres or emergency departments. The risk of bias in the included studies was generally low except for attrition rate, which we rated as high-risk. We could meta-analyse data for two comparisons: escitalopram versus placebo (but limited to secondary outcomes) and hydrocortisone versus placebo. One study compared escitalopram to placebo at our primary time point of three months after the traumatic event. There was inconclusive evidence of any difference in terms of PTSD severity (mean difference (MD) on the Clinician-Administered PTSD Scale (CAPS, score range 0 to 136) -11.35, 95% confidence interval (CI) -24.56 to 1.86; 1 study, 23 participants; very low-certainty evidence), dropouts due to adverse events (no participant left the study early due to adverse events; 1 study, 31 participants; very low-certainty evidence) and PTSD rates (RR 0.59, 95% CI 0.03 to 13.08; NNTB 37, 95% CI NNTB 15 to NNTH 1; 1 study, 23 participants; very low-certainty evidence). The study did not assess functional disability or quality of life. Three studies compared hydrocortisone to placebo at our primary time point of three months after the traumatic event. We found inconclusive evidence on whether hydrocortisone was more effective in reducing the severity of PTSD symptoms compared to placebo (MD on CAPS -7.53, 95% CI -25.20 to 10.13; I2 = 85%; 3 studies, 136 participants; very low-certainty evidence) and whether it reduced the risk of developing PTSD (RR 0.47, 95% CI 0.09 to 2.38; NNTB 14, 95% CI NNTB 8 to NNTH 5; I2 = 36%; 3 studies, 136 participants; very low-certainty evidence). Evidence on the risk of dropping out due to adverse events is inconclusive (RR 3.19, 95% CI 0.13 to 75.43; 2 studies, 182 participants; low-certainty evidence) and it is unclear whether hydrocortisone might improve quality of life (MD on the SF-36 (score range 0 to 136, higher is better) 19.70, 95% CI -1.10 to 40.50; 1 study, 43 participants; very low-certainty evidence). No study assessed functional disability.

AUTHORS' CONCLUSIONS

This review provides uncertain evidence regarding the use of escitalopram, hydrocortisone, intranasal oxytocin and temazepam for people with acute stress symptoms. It is therefore unclear whether these pharmacological interventions exert a positive or negative effect in this population. It is important to note that acute traumatic stress symptoms are often limited in time, and that the lack of data prevents the careful assessment of expected benefits against side effects that is therefore required. To yield stronger conclusions regarding both positive and negative outcomes, larger sample sizes are required. A common operational framework of criteria for inclusion and baseline assessment might help in better understanding who, if anyone, benefits from an intervention. As symptom severity alone does not provide the full picture of the impact of exposure to trauma, assessment of quality of life and functional impairment would provide a more comprehensive picture of the effects of the interventions. The assessment and reporting of side effects may facilitate a more comprehensive understanding of tolerability.

Intravenous Ketamine Exacerbating Symptoms of Acute Stress Disorder: A Case Report and Systematized Review of Existing Literature

BACKGROUND

Ketamine is an anesthetic and analgesic known for its psychotomimetic properties, such as dissociation and altered perception. Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) are characterized by unwanted memories, intrusive thoughts, and dissociative flashbacks following an acute traumatic event. It is unknown how analgesic ketamine affects the symptomatology of ASD when administered to patients in the posttraumatic period.

OBJECTIVE AND METHODS

In this article, we present the case of a 26-year-old man who sustained gunshot wounds and developed worsened ASD after receiving analgesic ketamine. We also present a review of the current literature on peritraumatic ketamine and its subsequent effect on ASD and PTSD.

RESULTS

In 2 out of 3 articles examining ketamine and ASD, ketamine was associated with worsened symptomatology of ASD. There were 6 articles examining ketamine and PTSD. In 1 of 6 articles, ketamine was associated with increased incidence and/or severity of PTSD, and in 2 of 6, it was associated with decreased incidence and/or severity of PTSD. There was no relationship between ketamine and subsequent PTSD in 3 of 6 articles.

CONCLUSION

We conclude that ketamine's psychotomimetic properties may exacerbate the dissociative and perceptual symptoms of ASD, but its long-term effects on PTSD are still unclear. In patients with preexisting ASD, the potential risks and benefits of using analgesic ketamine must be weighed carefully.

Effect of Dexmedetomidine on Posttraumatic Stress Disorder in Patients Undergoing Emergency Trauma Surgery: A Randomized Clinical Trial

Importance

Posttraumatic stress disorder (PTSD) is common in people who have experienced trauma, especially those hospitalized for surgery. Dexmedetomidine may reduce or reverse the early consolidation and formation of conditioned fear memory and prevent the occurrence of postoperative PTSD.

Objective

To evaluate the effects of intraoperative and postoperative low-dose intravenous pumping dexmedetomidine on PTSD among patients with trauma undergoing emergency surgery.

Design, Setting, and Participants

This double-blind, randomized clinical trial was conducted from January 22 to October 20, 2022, with follow-up 1 month postoperatively, in patients with trauma undergoing emergency surgery at 4 hospital centers in Jiangsu Province, China. A total of 477 participants were screened. The observers were blinded to patient groupings, particularly for subjective measurements.

Interventions

Dexmedetomidine or placebo (normal saline) was administered at a maintenance dose of 0.1 μg/kg hourly from the start of anesthesia until the end of surgery and at the same rate after surgery from 9 pm to 7 am on days 1 to 3.

Main Outcomes and Measures

The primary outcome was the difference in the incidence of PTSD 1 month after surgery in the 2 groups. This outcome was assessed with the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (CAPS-5). The secondary outcomes were the pain score within 48 hours and 1 month postoperatively; incidence of postoperative delirium, nausea, and pruritus; subjective sleep quality; anxiety; and occurrence of adverse events.

Results

A total of 310 patients (154 in the normal saline group and 156 in the dexmedetomidine group) were included in the modified intention-to-treat analysis (mean [SD] age, 40.2 [10.3] years; 179 men [57.7%]). The incidence of PTSD was significantly lower in the dexmedetomidine group than in the control group 1 month postoperatively (14.1% vs 24.0%; P = .03). The participants in the dexmedetomidine group had a significantly lower CAPS-5 score than those in the control group (17.3 [5.3] vs 18.9 [6.6]; mean difference, 1.65; 95% CI, 0.31-2.99; P = .02). After adjusting for potential confounders, the patients in the dexmedetomidine group were less likely to develop PTSD than those in the control group 1 month postoperatively (adjusted odds ratio, 0.51; 95% CI, 0.27-0.94; P = .03).

Conclusions and Relevance

In this randomized clinical trial, the administration of intraoperative and postoperative dexmedetomidine reduced the incidence of PTSD among patients with trauma. The findings of this trial support the use of dexmedetomidine in emergency trauma surgery.

Trial Registration

Chinese Clinical Trial Register Identifier: ChiCTR2200056162.

Anesthesia and the neurobiology of fear and posttraumatic stress disorder

PURPOSE OF REVIEW

Dysfunction of fear memory systems underlie a cluster of clinically important and highly prevalent psychological morbidities seen in perioperative and critical care patients, most archetypally posttraumatic stress disorder (PTSD). Several sedative-hypnotics and analgesics are known to modulate fear systems, and it is theoretically plausible that clinical decisions of the anesthesiologist could impact psychological outcomes. This review aims to provide a focused synthesis of relevant literature from multiple fields of research.

RECENT FINDINGS

There is evidence in some contexts that unconscious fear memory systems are less sensitive to anesthetics than are conscious memory systems. Opiates may suppress the activation of fear systems and have benefit in the prevention of PTSD following trauma. There is inconsistent evidence that the use of propofol and benzodiazepines for sedation following trauma may potentiate the development of PTSD relative to other drugs. The benefits of ketamine seen in the treatment of major depression are not clearly replicated in PTSD-cluster psychopathologies, and its effects on fear processes are complex.

SUMMARY

There are multiple theoretical mechanisms by which anesthetic drugs can modulate fear systems and clinically important fear-based psychopathologies. The current state of research provides some evidence to support further hypothesis investigation. However, the absence of effectiveness studies and the inconsistent signals from smaller studies provide insufficient evidence to currently offer firm clinical guidance.