Test 4: Drugs of Abuse pt 3

Question 1

How does acute use of substances affect anesthesia requirements?

Answer 1

Acute use decreases analgesia and anesthesia requirements

Question 2

How does chronic use of substances affect anesthesia requirements?

Answer 2

Chronic use increases the analgesia and anesthesia requirements.
-Consider pathophysiologic and major organ damage
-Patients can be CYP Induced and very tolerant.

Question 3

What are the effects associated with Cutting Agents?

Answer 3

-Ex: baking soda/talcum powder (snorting).
-Stretches out amount of product.
-Can result in V/Q mismatches (impurities injected into vasculature = blockage)
-Pulmonary HTN due to blockage from injection
-No regulation for what people use to mix in

Question 4

What are the effects associated with different routes of administration?

Answer 4

-IV: Track marks, difficult IV access
-Nasal: nosebleeds, deviated septum, septal erosions
-Smoking: same as cigarettes. Burning of the cilia

Question 5

What is important to know regarding tolerance to opioids and anesthetic drugs in a patient with substance use disorder?

Answer 5

-There is a genetic mutation that causes some people to be unable to metabolize morphine.
-Under anesthesia, abuser will need more and more medications. Especially muscle relaxants.

Question 6

How does nutrition differ with substance abuse?

Answer 6

-Malnutrition usually comes with the lifestyle of addiction.
-Opioid users are typically well nourished
-Amphetamines usually have a fast metabolism so are malnourished.

Question 7

What are complications associated with IV drug abuse?

Answer 7

Local infections/access
Osteomyelitis
Abscesses
Endocarditis
Venous thrombosis
Pulmonary Hypertension
HIV, Hepatitis, etc.

Question 8

What are complications associated with Inhalational drug abuse?

Answer 8

Cilia depletion
↑ Secretions
Reactive airways (inc risk of bronchospasm)
Septal erosion

Question 9

What should you assess for evidence of injection use?

Answer 9

Evidence of drug injections:
-Track marks, scarring, thrombotic veins phlebitis
-Tattoos – may be used to mask sites
-Ablation of venous return leading to unilateral edema of the non-dominant hand. Thrombosis impacting lymph drainage from arm that gets injected.
-SQ skin abscesses

Question 10

What pupil changes occur with Substance use?

Answer 10

-Opioids: pupils constrict (not affected by tolerance)
-Amphetamines: Pupils dilate (activation of SNS)
-PCP/Ketamine: Nystagmus

Question 11

What is Bruxism?

Answer 11

The involuntary grinding and clenching of teeth.
-Sign of amphetamine use

Question 12

What is lymphadenopathy?

Answer 12

-Secondary to non-specific activation of the immune system.
-Result of repeated injections of impurities

Question 13

What is nasal perforation a sign of?

Answer 13

Cocaine use

Question 14

What are the general goals of management of a patient with substance use disorder?

Answer 14

Pain Control
Management of Anxiety
Psychological States
Hemodynamic Control

Question 15

What are the general recommendations of management of a patient with substance use disorder?

Answer 15

-Ketamine infusions
-Alternate routes of LA’s
-Regional anesthesia

Question 16

What are non-opioid medications you can use for treatment of a patient with substance use disorder?

Answer 16

Gabapentin
Lidocaine
Pregabalin
Ketamine – if Ketamine is not the drug being abused
Acetaminophen
Dexmedetomidine

Question 17

What should you do if you suspect the patient is under the influence of an illicit drug?

Answer 17

Elective surgery should be delayed or canceled in patients suspected of being under the influence of an illicit drug until further patient evaluation can be performed.

Question 18

What drugs should you avoid in a situation of acute abuse with elevated heart rates?

Answer 18

Avoid:
-Ketamine
-Pancuronium
-Atropine
-Epinephrine

These drugs increase SNS and can lead to tachycardia. Avoid if elevated HR is present.

Ketamine is not appropriate in the absence of catechols. Will act as a direct myocardial depressant.

Question 19

What is the anesthetic management for a patient who uses Cannabinoids?

Answer 19

-Patient is tolerant to inhalation agents, opioids, and muscle relaxants.
-No other effects beyond tolerance.
-Inherent issues with smoking (bronchospasm, inc secretions). Presence of airway inflammation and mucosal injury.
-Underlying mental health issues?
-Acute use + elective case = cancelectomy
-Acute use + emergency = lower MAC of anesthetics (acute use is additive to agents)
-Regular user with positive test doesn’t really change anything.

Question 20

What are the issues/risks associated with Heroin?

Answer 20

-Peptic Ulcer Disease
-Pneumonia
-Thrombophlebitis
-Endocarditis
-Opioid withdrawal = ↑SNS for 6 hours

Question 21

What are anesthetic recommendations for a patient who uses Heroin?

Answer 21

-Regional Anesthesia
-Multi-modal pain management (gabapentin, Mg)
-Ketamine infusions
-↑ or ↓ MAC depending on patient
-Avoid opioid agonist-antagonists

Make sure patient’s baseline opioid requirement is handled. If they’re completely off their opioids, that forces them into withdrawal. Receptors are hyperstimulated. More likely to have an intense response to noxious stimuli.
-Opioid user will get opioids + extra than opioid naive person
-Will have greater response to incision than normal

Question 22

What are the issues/risks associated with Methamphetamines?

Answer 22

Upper: Increases SNS.
-MH
-Rhabdo
-DIC
-Hepatorenal failure
-Strokes
-Seizures
-Catecholamine depletion (will need a direct acting agent - don’t use Ephedrine. Can use Neo or Vaso)

Question 23

What are the anesthetic recommendations for a patient who uses Methamphetamines?

Answer 23

-Avoid neuraxial anesthesia. Catechols are depleted and they cannot handle the sympathectomy (pt will be unable to rebound)
-Can ↑ or ↓ MAC depending on patient
-Teeth are airway hazard - monitor for sharp or loose teeth
-Use VL probably

Question 24

What are the issues/risks associated with Cocaine use?

Answer 24

-Catecholamine depletion
-Increased SNS activity
-Respiratory depression
-Seizures, vasoconstriction, MI, arrhythmias

Question 25

What are the anesthetic recommendations for a patient who uses cocaine?

Answer 25

-Avoid long acting Beta Blockers (Use Esmolol or Phentolamine)
-Avoid Ketamine (pt is catechol depleted)
-Avoid Succinylcholine (Cocaine is partially metabolized by pseudocholinesterase, so will prolong block with succ)
-Treat HTN with Benzos
-Treat with Nitroprusside, NTG,
-Use Precedex or Clonidine

Question 26

Why can you not use long-acting beta blockers with a patient who uses cocaine?

Answer 26

Avoid Metoprolol or Labetalol: Puts them into HF.
-Alphas are constricted (high SVR), and with BB use, Heart can’t pump against inc SVR, so puts them into HF.
-Use Esmolol (short acting) or Phentolamine (Alpha Blocker)

Question 27

What is the anesthetic management of a patient who uses MDMA?

Answer 27

-↑ SNS activity: Beware of sympathomimetics
-Monitor F&E for H20 intoxication (Pulmonary & Cerebral edema)
-Delay case: Until acute effects have resided. Can precipitate panic attacks postop

Question 28

What is Medicated-Assisted Treatment (MAT) of the patient with a substance use disorder?

Answer 28

-Naltrexone (MUR antagonist)
-Buprenorphine (partial MOR agonist): Reduces withdrawal symptoms, but not as much of a high as the opioid itself.
-Risk of relapse after surgery (Especially opioid abusers)
-Involve pain specialists early
-Consult addiction specialists/involve patient’s current provider

Question 29

Should you continue Naltrexone/Buprenorphine periop?

Answer 29

-Naltrexone: stop it before to allow MORs to be available for therapy during surgery
-Buprenorphine: continue, can use full opioid agonists to stave off noxious stimuli of surgery.
-Discharge from hospital with equianalgesic dose of buprenorphine or full MOR as necessary with appropriate outpatient monitoring

Question 30

What is the most addictive class of drugs?

Answer 30

Amphetamines (Meth and Cocaine)
-Greatest potential for anesthetic issues