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Assessment 2 > Psychiatric Disorders (2) > Flashcards

Psychiatric Disorders (2) Flashcards

1
Q

What percent of the U.S. population takes a prescription medication for their mental health?

A

15.8%

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2
Q

Of prescriptions, what is the most prescribed drug?

A

Lyrica

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3
Q

Discontinuation syndrome signs and symptoms:

A

~ Nausea
~ Abdominal pain and diarrhea
~ Sleep disturbances (insomnia, vivid dreams and nightmares)
~ Somatic symptoms (sweating, lethargy and headaches)
~ Affective symptoms (low mood, anxiety and irritability

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4
Q

Discontinuation syndrome when do signs and symptoms begin?

A

Symptoms begin abruptly within a few days of stopping the antidepressant

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5
Q

Continuation of medications:

A

With the exception of MAOIs (where debate exists) continue all antidepressants throughout the perioperative period

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6
Q

MAOI continuation during surgery

A

Continuation of MAOIs carries risks, but with careful anesthetic technique, these risks can be minimized and must be balanced against the risks of relapse and discontinuation syndrome

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7
Q

Psychiatric disease - Mood disorders include and involve:

A

Depression, Bipolar disorder, Schizophrenia
~ Imbalance of NTs (Norepinephrine [NE], Serotonin [5-HT], Dopamine [DA])
~ Treatments - potential drug interactions, anesthesia considerations

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8
Q

Depression dx:

A

Most common psychiatric disorder
~ Lifetime prevalence of between 10 and 20%
~ Diagnosis requires presence of at least 5 of the following symptoms for a period of 2 weeks
- depressed mood
- markedly diminished interest or pleasure in almost all activities
- fluctuations in body weight and appetite
- insomnia or hypersomnia
- restlessness
- fatigue
- feelings of worthlessness or guilt
- decreased ability to concentrate
- suicidal ideations

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9
Q

***What causes depression?

A

Imbalance in endogenous amines (5-HT or NE) in the CNS

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10
Q

***Depression: Classification of antidepressants base on MOA structure

A

~ MAOIs inhibit amine (NE or 5-HT) metabolism
~ TCAs (and heterocyclics) non selectively inhibit both NE and 5-HT
~ Selective Serotonin Reuptake Inhibitors (SSRIs) selectively inhibit 5-HT reuptake
~ Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) selectively inhibit reuptake of both 5-HT and NE

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11
Q

Depression treatment:

A

~ Initial (primary) therapy - antidepressant drugs (70-80* of patients respond to antidepressant pharmacologic therapy)
~ Psychotherapy
~ Electroconvulsive therapy (ECT) - (50% who do not respond to antidepressants do respond favorably to ECT

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12
Q

MAOIs and Tyramine

A

When taken together, MAOIs and Tyramine can cause a sudden increase in blood pressure, called the tyramine pressor response, which can be dangerous and even life-threatening

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13
Q

Tyramine containing foods:

A

Meat - wine - cheese

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14
Q

***What is the most common adverse side effect of MAOIs?

A

*** Orthostatic hypotension

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15
Q

Tricyclic Antidepressants (TCAs) side effects:

A

~ Anticholinergic: dry mouth, blurred vision, urinary retention, consitpation
~ A-blockade: postural hypotension
~ Sedation (blockade of histominergic and a-adrenoceptors)

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16
Q

MAOIs and TCAs have largely been replaced by what drugs?

A

SSRIs (due to side effects - sedation, anticholinergic and a-adrenoceptor)

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17
Q

Low dose TCAs (amitryptyline and imipramine are currently used in the treatment of what?

A

Chronic pain: Structural similarities to local anesthetics (Na+ channel blocking properties)

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18
Q

***What are the most commonly prescribed type of antidepressants?

A

***SSRIs

19
Q

How do SSRIs work?

A

Block reuptake of serotonin at presynaptic membranes but have relatively little effect on adrenergic, cholinergic or histaminergic systems, therefor they are associated wit few side effects

20
Q

Most prescribed SSRIs

A

Citalopram (Celexa)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Escitalopram (Lexapro)
Fluvoxamine (Luvox)

21
Q

Use extreme caution when giving what medications to patients who are on serotonergic drugs (SSRIs, SNRIs, MAOIs, TCAs)

A

~ Penylpiperidiens - Opioids (Fentanyl, Meperidine, Dextromethorphan)
~ Anti-emetics
~The potential to cause serotonin syndrome exists.

22
Q

Serotonin Syndrome Anesthetic Concerns:

A

~ May occur with therapeutic drug use, overdose, or interaction between serotonergic drugs.
~ In contrast to neuroleptic malignant syndrome, serotonin syndrome develops within 24 hours
~ Potentially life threatening

23
Q

Mnemonic used for Serotonin Syndrome symptoms

A

HARM
H - Hyperthermia
A - Autonomic instability (delirium)
R - Rigidity
M - Myoclonus

24
Q

St John’s Wort, what is it?

A

An herbal supplement that claims to promote positivity and good overall mood. Can inhibit the reuptake of dopamine, norepinephrine, and serotonin. Therefor there is a potential to have synergistic effects of dangerously elevating these neurotransmitter levels regardless of wether patients are taking other antidepressants. will also increase metabolism and reduce efficacy of orally administered midazlolam IV agents may show increased metabolism. will also diminish effects of warfarin and some NSAIDS

25
Q

St Johns Wort synopsis:

A

~ Inhibits - serotonin, norepinephrine, and dopamine reuptake
~ Can lead to serotonergic syndrome
~ Significantly increases metabolism of many commonly administered drugs such as - alfentanyl, midazlolam, and lidocaine
~ Reduced effect of warfarin and NSAIDs

26
Q

St Johns Wort when to stop prior to surgery?

A

Pharmacokinetic data suggests that St John’s Wort should be stopped for at least 5 days before surgery

27
Q

How effective is St Johns Wort?

A

St Johns Wort has been found to be equivalent to TCAs in the treatment of mild to moderately sever depressive disorders

28
Q

Bipolar disorder, what is it?

A

Characterized by episodes of mania or hypomania separated by periods of depression or of “normal” mood (euthymia)

29
Q

Bipolar disorder: what percent of patients who have depression are likely to be bipolar (missed diagnosis)

A

15%

30
Q

Bipolar disorder: family history is a major risk factor. What % increase is associated with first-degree relatives?

A

19%

31
Q

Bipolar disorder: what is the first-line treatment

A

Lithium

32
Q

Bipolar disorder: possible treatments

A

Lithium
Valproate
Carbamazepine
Olanzapine
Risperidone
Benzodiazepines
SSRIs
Bupropion
Venlafaxine

33
Q

Lithium MOA

A

~ Being smaller than sodium it passes through the fast voltage-sensitive sodium channels easily, but the NA+k+ATPase pump does not readily extract lithium from the cells
~ Accumulated intracellular concentration impairs re-entry of potassium after depolarization and reduces the transmembrane potential and facilitates neuronal depolarization

34
Q

Lithium Therapeutic window:

A

Therapeutic/toxic ratio is narrow (0.8 to 1.2 mEq/L) (small therapeutic window)

35
Q

Lithium toxicity correlated with plasma levels:

A

Mild toxicity
~ Sedation
~ Skeletal muscle weakness
~ ECG changes (T wave and QT interval)
Concentrations greater than 2 mEq/L
~ Hypotension
~ Dysrhythmias - heart block
~ Seizures

36
Q

Schizophrenia, what is it?

A

Major psychotic mental disorder (abnormal reality testing or thought process), thought to be related to an excess of dopaminergic activity in the brain

37
Q

Schizophrenia treatment

A

Two generations of antipsychotic drugs:
~ DA receptor antagonists (first generation - typical) cause extrapyramidal side effects (EPSE) acute dystonia, akathisia, Parkinsonism and tar dive dyskinesia
~ 5-HT-DA antagonists (second generation - atypical) less likely to cause EPSE

38
Q

Schizophrenia anesthesia concerns:

A

~ Continue medication
~ A-adrenergic blockade causing postural hypotension with compensatory tachycardia
~ Expect prolongation of QT intervals - tornadoes and sudden death occurs in 10-15 of 10,000, which is almost twice as often as in normal populations
~ Antipsychotic induce glucose intolerance (impairs action of insulin)
~ Temperature regulation impaired (direct effect on hypothalamic thermoregulation by DA blockade)

39
Q

Neuroleptic malignant syndrome, what is it?

A

Complication of treatment with DA antagonists

40
Q

Neuroleptic malignant syndrome causes what issues?

A

~ Blockade of D2 receptors in the hypothalamus may lead to hyperthermia and other signs of autonomic dysfunction due to reduced tonic inhibition of the sympathetic nervous system.
~ Blockade of DA receptors in the nigrostriatal pathways can result in increased muscle rigidity and tremor via extrapyramidal pathways

41
Q

Neuroleptic malignant syndrome: clinical manifestations

A

~ Hyperthermia - higher than 38 degrees Celsius, even higher than 40 degrees
~ Rigidity - typical: “lead pipe rigidity”
~ Mental status changes - agitated delirium with confusion
~ Autonomic instability - tachycardia, tachypnea, labile or high BP

42
Q

Neuroleptic malignant syndrome: incidence

A

1 in every 5,000; 82% of patients develop symptoms within 1 week of starting antipsychotics

43
Q

Neuroleptic malignant syndrome: comparison to MH

A

~ Shares many clinical similarities with MH, to include treatment with Dantroline
~ MH-susceptible mutations of the ryanodien receptor gene have not been detected in NMS patients and there has been no association between NMS and MH based on halothane-caffeine contracture studies. However, when patients with a history of NMS require anesthesia, they probably should be anesthetized with same precautions as MH-susceptible patients

44
Q

Pre-Op Bottom Line:

A

~ Pay particular attention to the therapeutic regimen used
~ Chronic psychiatric meds must be continued
~ Abrupt withdrawal can lead to exacerbation of illness
~ These patients have an increased risk of developing postoperative cognitive deficits, and postoperative delirium
~ Preoperative mini-mental examination - if the score is lower than allowed, re-evaluate decisions regarding the risk/benefits of suggested techniques and informed consent

Assessment 2 (3 decks)

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