substance abuse 3/11 Flashcards
(42 cards)
objectives:
- identify possible symptoms of chemical abuse
- compare implications of acute and chronic substance abuse
- describe the pharmacological implications related to anesthesia for patients using
- etoh –canabis-opiates –hallucinogens
- stimulants –anabolic steroids
what are the biggest concerns of drug abuse regarding anesthesia?
- cardiac symptoms (tachycardia/ blood pressure)#1
- respiratory
- anesthetic need
chemical abuse needs to be addressed when?
during pre-op evaluation and preferably the day or more before the surgery
patients with known hx of drug abuse should be seen in pre op…
the day before surgery, to discuss withdrawl and plan of care.
alcohol:
1. what are they at risk for post op?
2. what comorbidities will you see?
- increased risk of infection & risk for withdrawl syndrome
2. Neuro, CV, resp, GI, endocrine, hematological
What are estimations on drug abuse?
• Estimated 30 million Americans (15%) have tried illegal drugs and 5 million admit to regular use
Drugs of Abuse by categories
CNS Depressants:
• CNS Depressants
– ETOH, benzodiazepines, barbiturates, others
Drugs of Abuse by categories
Opiates:
Opiates
– Heroin, morphine, codeine
Drugs of Abuse by categories
Cannabis:
• Cannabis
– Marijuana, hashish
Drugs of Abuse by categories
Stimulants:
Stimulants
– Cocaine/crack, amphetamines, methamphetamines, ecstasy
- symptoms of abuse ___ from drug to drug?
- what are some signs of abuse that you will see?
- what are the differences in pupil changes between opiates vs. cannibis or cocaine?
- Symptoms of Abuse VARY from drug to drug
- • Increased alertness, pupil contraction,
- -• Mood swings exhaustion, sleeplessness, confusion
- -• Hallucinations
- -• Increased HR, BP
- -• Confusion
- -• Euphoria
- -• Aggression
- -• Needle tracks
- -• Pupil changes - Dilated in cocaine &cannabis (also benzos); constricted in opiate (benzos=benzodilation; norcos=narconstriction)
Factors to Consider with substance abuse:
regarding amount etc.
Factors to Consider • Type and amount of drug(s) taken • Users experience (Chronic versus first time or infrequent user) • Route taken • Other circumstances – Where taken, with whom – Psychological, emotional stability – Simultaneous use or cross addiction-including ETOH
what drug abusing patient is not a cantidate for amublatory surgery?
• Not a candidate for ambulatory surgery if intoxicated or otherwise impaired due to risk of cardiovascular and autonomic response variability
- what are Main areas of concern with substance abuse patient?
- what should be considered regarding the whole surgical experience?
- Main areas of concern are CV, respiratory depression, CNS (confusion, combativeness, lethargy, coma)
- Consider means of postoperative analgesia – Local or regional may be desirable
Anesthetic implications of ETOH Abuse
- how does approach vary?
- what are some anesthetic issues they may have?
Anesthetic implications of ETOH Abuse
1• Vary based on clinical picture; acute, chronic, chronic with acute
2• Issues include;
–– enzyme induction
–– coexisting pathologies (i.e. hepatic, cardiovascular, esophageal, hematologic, CNS)
–– Increased risk of postop complications (impaired immune response- infection?)
–– Postoperative alcohol withdrawal syndrome (AWS)
Coexisting Diseases in ETOH Abuse: • Cardiovascular: • CNS: • GI/Endocrine: • Hematologic:
Coexisting Diseases in ETOH Abuse
• Cardiovascular
– Cardiomyopathy, HTN, conduction defects
• CNS
– Agitation, aggression, depression, disorientation, cortex and cerebellar degeneration, encephalopathy
• GI/Endocrine
– Esophagitis/varices, gastritis ulcers, fatty liver, hepatitis, cirrhosis, hypoglycemia, Hypoalbuminemia
• Hematologic
– Anemia, thrombocytopenia, decreased prothrombin, –Decreased WBC chemotaxis
Postoperative AWS (alcohol withdrawl syndrome)
- what is severity based on?
- what are the s/s
- DTs are sometimes resistant to what med? what meds are used to help with this?
Postoperative AWS
1• Severity related to severity of abuse
2• broad array of s/s
–• May cause increased catecholamines (increased HR, vasoconstriction, O2 consumption)
–• Tachypnea, work of breathing is increased
–• Symptoms of NV, anxiety, clouded sensorium, HA can occur postop
–• Other symptoms include sweats, agitation, tactile, auditory or visual disturbances
–• Tremors which may progress to DTs
3. DTs are often resistant to benzodiazepines and other therapy (Clonadine po or intrathecal shows promise)
what is the most abused opiate?
• Heroin remains the most abused opiate, but don’t forget prescription drugs
Heroin:
- where does it come from? what else comes from that?
- how does it look? how is it taken?
- what is duration of action
- what is metabolism; what does that say about withdrawl?
- whithdrawl begins in how many hours post intake of heroin?
- technique (shooting up) of taking heroin leads to what?
- are there contraindications to any anesthetic?
- what are NOT DOING with these patients?
Heroin
1• Derived from the milk of the poppy (same as morphine and codeine)
2• Pure heroin is a white powder. In the past was an IV drug due to lower potency; Current purity/potency allows smoking
3• DOA is typically 3-5 hours therefore taken a few times a day
4• Metabolism is fairly quick so withdrawal symptoms, variability of receptors and therefore unpredictable responses
5• Withdrawal begins around 6-12 hours. Treated with long acting opiates
6• Nonsterile administration therefore potential bloodborne infections, endocarditis, sepsis, hepatitis
7• No specific contraindications to general or regional
8• Not the time to treat addiction
Cocaine as a Drug of Abuse PART 1
- how is it absorbed?
- what is cocaine? how is it made into crack?
- what is the action on the brain? what are s/e?
- what is the cardiac action? what are s/e?
- what does chronic use lead to with regards to heart?
- what are other issues (localized) from sniffing or injecting it?
Cocaine as a Drug of Abuse
1• Absorbed through mucous membranes or or veins (IV–Nonsterile administration)
2• Alkaloid form heated with baking soda and water yields crack-can be heated and inhaled
3• CNS stimulant
–– Euphoria-paranoia
–– Insomnia, restlessness, hallucinations
4• Sympathomimetic effects
–– Tachycardia, HTN, hyperthermia, dysrythmias
–– CV Collapse with high levels
5• Chronic use has lead to cardiomyopathy possibly due to MI, neuronal affect, direct myocardial depression
6• Chronic complications associated with route
–– sinus and septal issues,
–– IV issues
Cocaine as a Drug of Abuse PART 2:
- what are pulmonary issues (especially to crack)?
- issues with pregnancy?
- how is it metabolized?
- excreted where? how much unchanged (%)? how long are metabolites in urine?WOW!
- What are side effects of using it as a local anesthetic?
- what NTs does it block to cause cardiac effect? what ones are blocked to cause CNS effect?
1• Pulmonary issues-asthma, cough, pneumonitis, pulmonary edema, pulmonary hemorrhage 2• OB-preterm labor, abruption,precipitate delivery, meconium stained still born, SIDS, low birth weight 3• Metabolized by plasma esterase (watch for deficient patients) 4• 5% unchanged in urine. Metabolites (some active) present for up to 60 hours 5• As a LA class can cause negative ino/chronotropic effects (increase HR, BP) 6• Effect on NE uptake predominates ( Also inhibits dopamine, serotonin and tryptophan uptake resulting in CNS effect)
Anesthetic Priorities in Cocaine Abuse:
- should you reley on self reporting?
- what about CV effects: what pre op? what should be handy?
- what beta blocker may cause issues? what are they? what should you use instead?
- what should you look for on the monitor?
- what about crack smokers?
- remember CNS effects; what might be needed pre and post op?
- what should you watch for as far as our medications?
Anesthetic Priorities in Cocaine Abuse
1• Self report is unreliable
2• Managing CV effects (preop EKG, alpha and beta blockers)
3• Beware of inderal due to unopposed Beta block (labetalol may be better)
4• Monitoring for MI, dysrythmias and other CV complications
5• Manage pulmonary effects
6• Pre and post op sedation, management of CNS effects
7• Watch for drug interactions
- what is the increase in risk of MI one hour post cocaine abuse?
- what about cocaine causes cardiac risks?
1• Stats vary, may be up to 23 fold increased risk of MI within an hour after abuse
2• Multiple mechanisms including increased myocardial O2 demand, accelerated atherosclerosis and thrombus formation, coronary spasm, vasoconstriction and abnormal increased platelet aggregation
Marijuana as a Drug of Abuse
- how common of an illegal drug?
- what does it come from? what amount of the drug is in the leaves and flower? what is the drug?
- what is plasma clearance (t-1/2 time) and how long do effects last?
- how long does it last in urine?
- route?
- what are effects of THC? Can it make you stupid?
- what are other effects?
- what happens with chronic use (especially with smoking)?
- what anesthesia drugs are potentiated by THC?
Marijuana as a Drug of Abuse
1• MOST common of the illegal drugs used
2• From the Cannabis Sativa: Approximately 5% of the dried leaves and flower contains the main psychoactive component-tetrahydrocannabinol (THC)
3• Plasma t-1/2 20-30 hours but effects last 2-3 hours.
4• Present in urine for days to months depending on extent of use
5• Most often smoked but can be taken PO (brownies)
6• Effects are dose dependent and mainly CNS:
—-– Altered mood, altered perceptions
—-– impaired coordination and learning (effects linger after high) wears off
7• Other effects can include;
—-– CV: Tachycardia, peripheral vasodilation
—-– resp: Bronchodilation acutely, irritated bronchial mucosa
—-– opthalmic: Decreased IOP, conjunctival vascular congestion (both from vasodilation)
——GI: dry mouth (and increased appetite)
8• Chronic use concerns
—-– Obstructive and restrictive disease
—-– Decreased diffusion capacity (of lungs)
9• Beware of potentiation of CNS depressant anesthetics and adjuncts
