Anesthesia and the AddictAnesthesia and the Addict

Howard F. Armour CRNA, MSHoward F. Armour CRNA, MS

DefinitionsDefinitions

• Substance Abuse – Self Administration deviating from accepted medical or social use.

• Physical dependence – drug is necessary for normal physiological function or to prevent withdrawal.

• Withdrawal – rebound in physiological systems modified by drug.

• Tolerance – increased doses of drug required to produce same effects as smaller doses did previously.

Problems

Cross Tolerance

Chronic Abuse – Increased requirements

Acute Abuse – Decreased requirements

Withdrawal

Drug OverdoseDrug Overdose

Leading cause of unconsciousness in ERLeading cause of unconsciousness in ER

Secure Airway – cuffed tubeSecure Airway – cuffed tube

Monitor Temperature for HypothermiaMonitor Temperature for Hypothermia

HemodialysisHemodialysis

AlcoholAlcohol

Disease – genetic, psychosocial and Disease – genetic, psychosocial and environmental factorsenvironmental factors

Affects 10,000,000 Americans – 200,000 Affects 10,000,000 Americans – 200,000 deaths annuallydeaths annually

Up to 1/3 of adult patients have medical Up to 1/3 of adult patients have medical problems related to alcoholproblems related to alcohol

Risk FactorsRisk Factors

Male GenderMale Gender

Family HistoryFamily History

TreatmentTreatment

AbstinenceAbstinence

DisulframDisulfram

Side effectsSide effects

Drug InteractionsDrug Interactions

Withdrawal SyndromeWithdrawal Syndrome

Early SymptomsEarly Symptoms

Treatment – resume alcohol ingestion or Treatment – resume alcohol ingestion or administer a barbiturate or benzodiazipineadminister a barbiturate or benzodiazipine

Protect the AirwayProtect the Airway

Delerium TremensDelerium Tremens

Management of AnesthesiaManagement of Anesthesia

Disulfram Disulfram

Hepatoxicity Hepatoxicity

Drug InteractionsDrug Interactions

HypotensionHypotension

PolyneuropathyPolyneuropathy

Avoid Alcohol Skin PrepAvoid Alcohol Skin Prep

Management of AnesthesiaManagement of Anesthesia

Pathophysiological ChangesPathophysiological ChangesEnzyme Induction/inhibitionEnzyme Induction/inhibition

AnemiaAnemiaThrombocytopeniaThrombocytopeniaHypoprotinemiaHypoprotinemiaEsophageal VaricesEsophageal VaricesCardiomyopathyCardiomyopathyDecreased PlasmacholinesteraseDecreased PlasmacholinesteraseElevated TransaminasesElevated Transaminases

Management of AnesthesiaManagement of Anesthesia

Intoxicated PatientIntoxicated Patient

Increased Risk of Aspiration – RSIIncreased Risk of Aspiration – RSI

Decreased Anesthetic RequirementsDecreased Anesthetic Requirements

CocaineCocaine

30,000,000 have used cocaine30,000,000 have used cocaine

5,000,000 use it regularly5,000,000 use it regularly

Extremely addictiveExtremely addictive

Side EffectsSide Effects

Due to enhanced sympathetic nervous Due to enhanced sympathetic nervous system activitysystem activity

Lung Damage associated with smokingLung Damage associated with smoking

Nasal atrophyNasal atrophy

Death from apnea, seizures or cardiac Death from apnea, seizures or cardiac dysrhythmiasdysrhythmias

Management of AnesthesiaManagement of Anesthesia

If intoxicated – consider vulnerability to If intoxicated – consider vulnerability to ischemia or dysrhytmiasischemia or dysrhytmias

Intoxicated – Increased MACIntoxicated – Increased MAC

ThrombocytopeniaThrombocytopenia

Use Neosynephrine for hypotensionUse Neosynephrine for hypotension

Maximum dose of Cocaine topically is Maximum dose of Cocaine topically is

1.5 mg/kg for nasotracheal intubation1.5 mg/kg for nasotracheal intubation

OpioidsOpioids

Possible to become addicted in less than Possible to become addicted in less than 14 days if drug is administered in 14 days if drug is administered in increasing dosesincreasing doses

Numerous associated medical problemsNumerous associated medical problemsCellulitisCellulitis

TetanusTetanus

EndocarditisEndocarditis

HepatitisHepatitis

AIDSAIDS

OpioidsOpioids

ToleranceTolerance

Overdose – Respiratory depressionOverdose – Respiratory depression

Withdrawal SyndromeWithdrawal Syndrome

Prevention – Narcotics or MethadonePrevention – Narcotics or Methadone

ClonidineClonidine

Management of AnesthesiaManagement of Anesthesia

Preop – Narcotics or MethadonePreop – Narcotics or Methadone

IV AccessIV Access

Volatile Anesthetic with NarcoticsVolatile Anesthetic with Narcotics

Hypotension ?Hypotension ?Lighten AnesthesiaLighten AnesthesiaFluidsFluidsVasopressorVasopressorSteroidsSteroidsNarcoticsNarcotics

BarbituatesBarbituates

Not associated with major Not associated with major pathophysiological changespathophysiological changes

Tolerance – Lethal dose does not increase Tolerance – Lethal dose does not increase at the same rateat the same rate

Withdrawal - seizuresWithdrawal - seizures

Management of AnesthesiaManagement of Anesthesia

Cross tolerance to anesthetics?Cross tolerance to anesthetics?

Acute administration decreases anesthetic Acute administration decreases anesthetic requirementsrequirements

Microenzyme inductionMicroenzyme induction

Venous access is a problem in IV Venous access is a problem in IV barbituate usersbarbituate users

BenzodiazipinesBenzodiazipines

Symptoms of withdrawal slower to develop Symptoms of withdrawal slower to develop than with Barbituatesthan with Barbituates

Anesthetic considerations similar to those Anesthetic considerations similar to those of chronic barbiturate userof chronic barbiturate user

Specific antagonist - FluazemilSpecific antagonist - Fluazemil

AmphetaminesAmphetamines

Stimulate release of catecholaminesStimulate release of catecholamines

Chronic abuse results in depletion of Chronic abuse results in depletion of catecholaminescatecholamines

Management of AnesthesiaManagement of Anesthesia

Intoxicated patient may exhibit Intoxicated patient may exhibit hypertension, tachycardia, increased hypertension, tachycardia, increased temperature and increased MACtemperature and increased MAC

Chronic use depletes catecholamines – Chronic use depletes catecholamines – may attenuate response to indirect may attenuate response to indirect vasopressorsvasopressors

Treat hypotension with fluids and Treat hypotension with fluids and neosynephrineneosynephrine

MarijuanaMarijuana

Increased sympathetic nervous systemIncreased sympathetic nervous system

TachycardiaTachycardia

Chronic use may lead to pulmonary Chronic use may lead to pulmonary problemsproblems

May have plasmacholinesterase May have plasmacholinesterase deficiencydeficiency

Management of AnesthesiaManagement of Anesthesia

Treat tachycardia with beta bockersTreat tachycardia with beta bockers

Barbiturate and ketamine sleep time Barbiturate and ketamine sleep time prolongedprolonged

Opioid respiratory depression potentiatedOpioid respiratory depression potentiated