Substance abuse and anesthesia Dr S Parthasarathy MD
Substance abuse and anesthesia Dr. S. Parthasarathy MD. , DA. , DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics- Ph. D ( physiology), FICA, IDRA , CUGRA
Definition • Substance abuse may be defined as self- administration of drug(s) that deviate(s) from accepted medical or social use which if sustained can lead to physical and psychological dependence. • Leave out alcohol and smoking – separate topics
Ministry statistics 2018
• All substance abuse – 2. 5 – 2. 8 % • Males – 4 % • Females – 0. 2 – 0. 3 % • India
• According to a UN report, One million heroin addicts are registered in India, and unofficially there as many as five million • 50 % of students have atleast tried once !!
Marijiuana • Marijuana can be smoked as a cigarette (a joint), using a water pipe or using a hollow cigar filled with marijuana (a blunt); it can also be taken orally. • Its users experience an intense feeling of relaxation within minutes and a pleasant euphoria that last several hours. • May be for 30 days • Think of abstinence
The list is quite big !! • • • Gutka Fevicol Molasses Paints and thinners Haans Nail polish Cool lip – sublingual granules of ? Hans g-Hydroxybutyric Acid Bath salts – cathinones
Route • • • Oral Nasal Inhaled Injection Sublingual
Gutkha • guṭkha is a chewing tobacco preparation made of crushed areca nut, tobacco, catechu, paraffin wax, slaked lime and sweet or savory flavourings, commonly used in some parts of India. It contains carcinogens, is considered responsible for oral cancer and other severe negative health effects and hence is subjected in India to the same restrictions and warnings as cigarettes
Cool lip by school students !!
Whitener • The pungent smell of whitener can not only erase print on paper, but also memory from the human brain. • The toluene and trychloroethane help to intoxicate and apparently the addicts experience a kick for five to eight hours,
Only toluene • Symptoms of toluene poisoning include CNS effects (headache, dizziness, ataxia, drowsiness, euphoria, hallucinations, tremor, seizures, and coma), • ventricular arrhythmias, ANS – gone !! • chemical pneumonitis, respiratory depression, nausea, vomiting, • and electrolyte imbalances
Sniffing glue • • • Demyelination Lung damage – Type 1 respiratory failure Arrhythmias Liver damage Seizures
Nail polish • Dangerous acetone levels • Starve • Ketoacidosis
Molasses to ethanol !! • Thirumandangudi • Sugar factory in kumbakonam • Molasses packed to cyclone areas !! • ? Ethanol !!
Lip balm • Lip balm or lip salve is a wax-like substance applied topically to the lips to moisturize and relieve chapped or dry lips, angular cheilitis, stomatitis, or cold sores. • Lip balm often contains beeswax or carnauba wax, camphor, alcohol, lanolin, paraffin, and petrolatum, among other ingredients. • Some varieties contain dyes, flavor, fragrance, phenol, salicylic acid, and sunscreen
Incidence in schools in tamilnadu • Even among girls present • I would put as 5 - 10 % • School droppers – still very high
Anesthetic concerns – marijuana • Cannabinoids • • • Sympathetic stimulation – tachycardia Goes later to myocardial depression Life threating arrhythmias on induction Airway irritability Bronchospasm STT changes in ECG !!
Cocaine abuse • Cocaine is extracted from the leaves of Erythroxylon coca, a plant indigenous to South America • Cocaine interferes with presynaptic uptake of sympathomimetic neurotransmitters (e. g. norepinephrine, serotonin and dopamine
Cocaine and anesthesia Platelet count Hypertension in induction Arrhythmias on induction Ephedrine resistant hypotension – may be Phenylephrine • Changes in pain perception may complicate regional anesthesia – may complain of pain after blockade • •
Cocaine !! • Beta -Blockers, such as propanolol, are contraindicated in these patients because of the potential for unopposed a-adrenergic stimulation • Use labetolol ? ? • Halothane ? • Ketamine ? Etomidate and seizures • Propofol and thio – OK • Scoline and cocaine compete ? ?
Cocaine • Nitroprusside, nitroglycerin, or demedetomidine may be used to control blood pressure. • Hemodynamic instability may occur during acute intoxication when the patient can be hypertensive and hyperthermic, or hypotensive as a result of catecholamine depletion • Thinking about malignant hyperthermia
Cocaine !! • Patients under regional anesthesia may also show combative behavior and altered pain perception, perhaps • due to changes in m- and k-opioid receptor densities and abnormal endorphin levels • recommend a cocaine-free interval of at least 1 week before elective surgical procedures
Place close to us !!
Methamphetamine and Amphetamines • Meth mouth ! – bad smell poor hygiene • Cardiac diseases, pulmonary hypertension nasal septal necrosis • Aortic dissection • Postoperative management • Methamphetamine withdrawal peaks at 24 hours after last use and is characterized by • increased sleeping, eating, and depression symptoms
Opioid abuse • • • IV access HIV Hbs. Ag Anesthesia - analgesia – high doses needed Hypoxemia Gastric emptying and aspiration
Opioids • Reduced intravascular fluid volume, malnutrition or liver disease may require appropriate dose adjustments of anaesthetic drugs. • RA is OK but HIV ? ? • Clonidine for withdrawal symptoms
Opioids • Opioids need to be continued to prevent withdrawal, but other medications, such as acetaminophen, NSAIDs, , gabapentin, and pregabalin, may be included in a multimodal therapy regimen. • Ketamine - decrease hyperalgesia= NMDA antagonist
LSD • Lysergic Acid Diethylamide - legal drug till 1960 s • Toxic effects include hallucinations, dilated pupils, synesthesia, tachycardia, tachypnea, fever, hypertonia, and hyperglycemia. Effects last from 6 to 10 hours
Pan supari ! Smoke • • • Leave alone chemicals !! It is worthwhile to categorize all these patients as having "anticipated difficult airways Preoperative laryngoscopic evaluation !! SMF Opening the mouth !!
Room deodorizers • Volatile nitrites, such as amyl nitrite, butyl nitrite, and related compounds. • Euphoria but • profound hypotension and cutaneous flushing followed by vasoconstriction and tachycardia; methemoglobinemia and increased bronchial irritation
Acute or chronic • Operations on acutely intoxicated patients should be delayed, if possible, because of the potential for hemodynamic instability. 3 - 4 days ? ? • Those caring for a substance user postoperatively should be wary of the potential for hemodynamic compromise, poor wound healing, altered consciousness, and difficulty with pain management.
What more problems do we need as an anesthesiologist ? ? • • • Patients understand ( euphoria) what we explain ? ? IV access , fluid deficits Airway Lungs Heart – especially autonomic !! Pain Cognition Temperature handling Poor wound healing
In PAC ? ? • Is it the time to go to the history of illicit drug expose regularly ? ? • YES • Thank you all
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