Test 4: Drugs of Abuse pt 3 Flashcards
How does acute use of substances affect anesthesia requirements?
Acute use decreases analgesia and anesthesia requirements
How does chronic use of substances affect anesthesia requirements?
Chronic use increases the analgesia and anesthesia requirements.
-Consider pathophysiologic and major organ damage
-Patients can be CYP Induced and very tolerant.
What are the effects associated with Cutting Agents?
-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
What are the effects associated with different routes of administration?
-IV: Track marks, difficult IV access
-Nasal: nosebleeds, deviated septum, septal erosions
-Smoking: same as cigarettes. Burning of the cilia
What is important to know regarding tolerance to opioids and anesthetic drugs in a patient with substance use disorder?
-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.
How does nutrition differ with substance abuse?
-Malnutrition usually comes with the lifestyle of addiction.
-Opioid users are typically well nourished
-Amphetamines usually have a fast metabolism so are malnourished.
What are complications associated with IV drug abuse?
Local infections/access
Osteomyelitis
Abscesses
Endocarditis
Venous thrombosis
Pulmonary Hypertension
HIV, Hepatitis, etc.
What are complications associated with Inhalational drug abuse?
Cilia depletion
↑ Secretions
Reactive airways (inc risk of bronchospasm)
Septal erosion
What should you assess for evidence of injection use?
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
What pupil changes occur with Substance use?
-Opioids: pupils constrict (not affected by tolerance)
-Amphetamines: Pupils dilate (activation of SNS)
-PCP/Ketamine: Nystagmus
What is Bruxism?
The involuntary grinding and clenching of teeth.
-Sign of amphetamine use
What is lymphadenopathy?
-Secondary to non-specific activation of the immune system.
-Result of repeated injections of impurities
What is nasal perforation a sign of?
Cocaine use
What are the general goals of management of a patient with substance use disorder?
Pain Control
Management of Anxiety
Psychological States
Hemodynamic Control
What are the general recommendations of management of a patient with substance use disorder?
-Ketamine infusions
-Alternate routes of LA’s
-Regional anesthesia
What are non-opioid medications you can use for treatment of a patient with substance use disorder?
Gabapentin
Lidocaine
Pregabalin
Ketamine – if Ketamine is not the drug being abused
Acetaminophen
Dexmedetomidine
What should you do if you suspect the patient is under the influence of an illicit drug?
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.
What drugs should you avoid in a situation of acute abuse with elevated heart rates?
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.
What is the anesthetic management for a patient who uses Cannabinoids?
-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.
What are the issues/risks associated with Heroin?
-Peptic Ulcer Disease
-Pneumonia
-Thrombophlebitis
-Endocarditis
-Opioid withdrawal = ↑SNS for 6 hours
What are anesthetic recommendations for a patient who uses Heroin?
-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
What are the issues/risks associated with Methamphetamines?
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)
What are the anesthetic recommendations for a patient who uses Methamphetamines?
-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
What are the issues/risks associated with Cocaine use?
-Catecholamine depletion
-Increased SNS activity
-Respiratory depression
-Seizures, vasoconstriction, MI, arrhythmias
