PSYCHOTROPIC DRUGS AND ANAESTHESIA

Dr. S. Parthasarathy Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), MD., DA., DNB, MD (Acu),

Dip. Diab. DCA, Dip. Software Dip. Diab. DCA, Dip. Software statistics statistics

PhD (physio)PhD (physio)Mahatma Gandhi Medical college and Mahatma Gandhi Medical college and research institute , puducherry , India research institute , puducherry , India

MAHAMAHAM 2004MAHAMAHAM 2004

FIRE TRAGEDY 16-07-04FIRE TRAGEDY 16-07-04

PSYCHIATRIC COUNSELLINGPSYCHIATRIC COUNSELLING

OPD STATISTICSOPD STATISTICSgovt hospitals – tamilnadu

2800 OUT OF 30000/MONTH GETTING ANTIPSYCHIATRIC DRUGS.

PRIVATE CLINIC ( GP)

20 % OF PATIENTS ARE RECEIVING SOME FORM OF ANTIPSYCHIATRIC DRUGS

CLASSIFICATION OF CLASSIFICATION OF PSYCHOTROPIC DRUGSPSYCHOTROPIC DRUGS

ANTIPSYCHOTICS

PHENOTHIAZINE, HALO,THIO (ATYPICAL -CLOZ, RIZ,OLANZIPINE.)

SCHIZOPHRENIA.MANIA.

ANTIDEPRESSANTS

TRICYCLICS,SSRI, MAOI,

DEPRESSION,NEURO PAIN.

MOOD STABILIZERS.

LITHIUM.,CARBAMAZIPINE

MANIA

ANXIOLYTICS BENZODIAZ.BUSPIRONE

ANXIETY

HYPNOTICS ZOPICLONE,BENZODIAZ.

INSOMNIA

ANTIPSYCHOTICSANTIPSYCHOTICSSED AC OH EP SEI WT CH SX QT

CP +++ ++ +++ + + + ++ + +

TH + + + +++ + + + +++ +

HL + + + +++ - + - - -

CL +++ +++ +++ - +++ +++ - - -

RI + - ++ + - + - - -

OL ++ + ++ + + +++ + - -

TABLE IN ANOTHER ANGLETABLE IN ANOTHER ANGLE• SED.—CPZ, CLOZ, OLANZIPINE.• ORTH. HYPO.-- CPZ, CLOZ,OLON,RIS.• WT.GAIN.--CLOZ,OLANZ.• ANTI.CH-- CPZ, CLOZ,OLAN,RIS.• SEIZURE—CLOZ.• EPS.—HPL. THIOTHEXENE.• ECG.-- CPZ, THIO.,ZIS.• DYS. SEX. --CPZ, THIO• CHOLE .– CPZ.

ANAESTHETIC IMPLICATIONSANAESTHETIC IMPLICATIONS• ALPHA 1 BLOCKADE—• PRONE FOR EXAGGERATED

HYPOTENSION• RESPONSE TO A VASOPRESSOR

INADEQUATE.• TOLERATE HAEMORHAGE POORLY.• INTRA OP WHEEZE-TEBUTALINE INJ. MAY

PRECIPITATE EXAGGERATED HYPOTENSION

ANAES. IMPLICATION.-CONT.ANAES. IMPLICATION.-CONT.

• SEDATION MAY CAUSE PROLONGED RECOVERY.

• OPIOIDS MAY CAUSE EXCESS VENTILATORY DEPRESSION.

• PATIENTS MAY BEHAVE POIKILOTHERMIC . TEMP. MAINT.

• ANTICHOLINERGIC PREMED –AVOID

ANAES. IMPLICATION.-CONTANAES. IMPLICATION.-CONT

• CHOLESTASIS –HALOGENATED HYDROCARBONS? (PREOP. EVAL.)

• CLOZAPINE INDUCED AGRANULOCYTOSIS (PREOP. EVAL.)

• SUFANTINYL PROLONGS QT. (PREOP. EVAL.)

• LOOK FOR EXTRAPYRAMIDAL SIGNS- FACE TRUNK, EXTREMITIES. PREOP EXPLANATION. (AVOID DROPERIDOL)

• LARYNGEAL DYSKINESIA AND SPASM.

ANAES. IMPLICATION.-CONTANAES. IMPLICATION.-CONT• CESSATION OF SMOKING –USUALLY

ADVISED BEFORE SURGERY MAY INCREASE CLOZAPINE LEVELS.

• CLOZAPINE ↓ SEIZURE THRESHOLD• POTENTIAL SEIZUROGENIC DRUGS • TRAMADOL,ENFLURANE,ATRACURIUM AND

KETAMINE CAN BE AVOIDED• SEXUAL DYSFUNCTION -PREOP

EXPLANATION TO AVOID IMPLICATION ON SPINAL ANAESTHESIA

NEUROLEPTIC MALIGNANT SYNDROME.NEUROLEPTIC MALIGNANT SYNDROME.• 0.5-1% 0F ANTIPSYCHOTIC THERAPY.• DEHYDRATION AND INTERCURRENT

ILLNESS ---RISK FACTORS.• 24-72 HOURS AFTER DRUG INGESTION.• HYPERTHERMIA,MUSCLE RIGIDITY,• ANS INSTABILITY,? CONSCIOUS STATUS.• DEATH-CARDIAC FAILURE,RENAL FAILURE

AND ARRTHYMIAS.• TREATMENT-SUPPORTIVE

MEASURES,DANTROLENE AND BROMOCRIPTINE.

• A PSYCHIATRIST ASKS 3 PSYCHIATRIC PATIENTS THE SAME QUESTION 3 TIMES 3 = ?

• PATIENT 1 : 274• PATIENT 2 : TUESDAY• PATIENT 3 : 9• PSYCHIATRIST WAS HAPPY AND

ASKED HOW HE ANSWERED CORRECT?

PATIENT 3 : IT IS EASY .I SUBTRACTED 274

FROM TUESDAY.!

ANTIDEPRESSANTSANTIDEPRESSANTS• THE CARDINAL DIFFERENCE REGARDING

ANTIDEPRESSANTS IS ABOUT THEIR ADDITIONAL USES IN VARIOUS NON PSYCHIATRIC CONDITIONS. THEY INCLUDE:

• DIABETIC NEUROPATHY.• POST HERPETIC NEURALGIA.• MIGRAINE.• CENTRAL PAIN.• TENSION HEADACHE.• FACIAL PAIN

ANTIDEPRESSANTSANTIDEPRESSANTS• ANTIDEPRESSANTS CAN BE CLASSIFIED AS

• TRICYCLICS (TCAD) AND RELATED — E.G. AMITRYPTILLINE, IMIPRAMINE, NORTRYPTILLINE.

• SELECTIVE SEROTONIN UPTAKE INHIBITORS (SSRI) -- E.G. FLUOXETINE, SERTRALINE.

• MAO INHIBITORS. — IRREVERSIBLE AND NONSELECTIVE. (PHENELZINE AND TRANYLCYPRAMINE) –REVERSIBLE MAO A INHIBITION. (MOCLOBEMIDE).

• OTHERS. E.G.VENLAFAXINE(SNRI).BUPROPION(DNRI)

SIDE EFFECTS OF (TCAD) ANTIDEPRESSANTSSIDE EFFECTS OF (TCAD) ANTIDEPRESSANTS

PHARMACOLOGY SIDE EFFECTS

MUSCARINIC BLOCK DRYMOUTH,TACHYCARDBLURRED VISION,SEX. DYS. URINARY RET.

ALPHA BLOCK POSTURALHYPO.DIZZINESS

H 1 REC. BLOCK DROWSINESS,WEIGHT GAIN

MEMBRANE STAB. ↑PR,QRS,QT,SEIZURE AND ARRYTHMIA

OTHERS EDEMA,LEUCOPENIA AND ↑ LIVER ENZYMES

TCAD ANTIDEPRESSANTS—TCAD ANTIDEPRESSANTS—ANAESTHETIC IMPLICATIONS ANAESTHETIC IMPLICATIONS

• ACUTE THERAPY –INDIRECT ACTING SYMPATHOMIMETICS (EPHEDRINE)CAN CAUSE HYPERTENSIVE CRISIS.-USE DIRECT (PHENYLEPHRINE) ⅓ DOSE INCREASED SYNAPTIC NE

• CHRONIC THERAPY- SAME PRINCIPLE -BUT IN SOME PATIENTS DUE TO RECEPTOR DOWNREGULATION NE MAY BE NECESSARY TO COUNTERACT INTRAOP HYPOTENSION

TCAD ANTIDEPRESSANTS—TCAD ANTIDEPRESSANTS—ANAESTHETIC IMPLICATIONSANAESTHETIC IMPLICATIONS

• INVESTIGATIONS INCLUDE ECG,LIVER FUNCTION TEST AND IF POSSIBLE A TCAD BLOOD LEVEL.

• GLYCOPYROLLATE (IF NECESSARY) AND LESS OPIOIDS-RATIONAL AS PREMED.

• WELL HYDRATED.• ACID ASPIRATION PROPHYLAXIS.

TCAD ANTIDEPRESSANTS—TCAD ANTIDEPRESSANTS—ANAESTHETIC IMPLICATIONSANAESTHETIC IMPLICATIONS

• PREEXISTING PARESTHESIA AND SEXUAL DYSFUNCTION –EXPLAINED.

• NERVE BLOCK AND EPIDURAL –BE SCIENTIFIC IN EPINEPHRINE USE.

• LIGHT ANAESTHESIA AND PANCURONIUM – MORE INTRAOP HYPERTENSION.

• HALOTHANE MAY BE ARRYTHMOGENIC.• POTENTIAL SEIZURE – AVOID

SEIZUROGENIC DRUGS AND ENVIRONMENT

SSRI- FLUOXETINE,SERTRALINESSRI- FLUOXETINE,SERTRALINE

• SIMILAR TO TCADS BUT • LESS ANTICHOLINERGIC• LESS POSTURAL HYPOTENSION• LESS CARDIAC CONDUCTION PROBLEM.• LESS EFFECT ON SEIZURE THRESHOLD• SEXUAL DYSFUNCTION REMAINS.• SIADH PROBLEM AND POSTOP RATIONAL

USE OF HYPOOSMOLAR SOLUTION WARRANTED.

OTHERS OTHERS

• VENLAFAXINE – AKIN TO SSRIS AND INTRAOP HYPERTENSION IS A POSSSIBILITY.

• BUPROPION NO EFFECT ON SEXUAL FUNCTION BUT BEWARE OF SEIZURES.

MAO INHIBITORSMAO INHIBITORS..MAO - MONOAMINE OXIDASE- OXIDATIVE MAO - MONOAMINE OXIDASE- OXIDATIVE

DEAMINATION OF BIOGENIC AMINES.DEAMINATION OF BIOGENIC AMINES.

MAO-A(5HT,NE& E)

MIXED MAO-BPHENYLETHYLAMINE

IRREVERSIBLE

CLORGYLINE

PHENELZINE,TRANYLCYPRAMINE

DEPRENYL

REVERSIBLE

MOCLOBEMIDE ---- ---

PROBLEMSPROBLEMS

• ORTHOSTATIC HYPOTENSION, ANTICHOLINERGIC, WT.GAIN, IMPOTENCE, PARESTHESIA.

• LESS CARDIAC ARRYTHMIAS AND LESS SEIZURE UNLIKE TCADS.

• ANAESTHETIC AIMS:• NO DRUG INDUCED HYPO.• NO SYMPATHETIC STIMULATION.

PERIOPERATIVE PRECAUTIONSPERIOPERATIVE PRECAUTIONS

• DIETARY PRECAUTIONS.• WELL HYDRATED (↓ SYMPATHOMIMETICS.)• LIVER FUNCTION TEST.• BENZODIAZEPINE PREMED.• NO OPIOID AND NO ACH PREMED.• NO INTRAOP HYPOXIA,HYPERCARBIA AND

HYPOTENSION.• NO MEPERIDINE.

MEPERIDINE & MAO IMEPERIDINE & MAO I

• TYPE 1 RESPONSE : AGITATION,MUSCLE RIGIDITY

HYPERPYREXIA ( INHIBITION OF NEURONAL HT UPTAKE)

• TYPE 2 RESPONSE: VENTILATORY DEPRESSION HYPOTENSION

& COMA(DECELERATED BREAKDOWN OF MEPERIDINE DUE TO N-METHYLASE INHIBITION.)

MAO I CONSIDERATIONS (CONTD)MAO I CONSIDERATIONS (CONTD)• NO SCOLINE (PHENELZINE INHIBITS

PSEUDOCHOLINESTERASE.)• NO KETAMINE(SYMPATHETIC

STIMULATION)• ISOFLURANE PREFERRED

(ARRYTHMOGENESIS OF HALO)• NONDEPOLARIZERS NOT AFFECTED.• EPINEPHRINE – BE CAUTIOUS.• EPIDURAL CATH - ↓ OPIOID USE.• ONLY DIRECT ACTING VASOPRESSORS IN

MINIMAL DOSES.

SEROTONIN SYNDROME SEROTONIN SYNDROME

• COMBINATION OF SSRI AND MAOI MAY GIVE RISE TO A SYNDROME OF FLUSHING ,SWEATING ,TREMORS MYOCLONUS AND POSSIBLE RENAL FAILURE.

• DRUG DISCONTINUATION AND SUPPORTIVE MEASURES.

A LIGHT BREAK A LIGHT BREAK

• A SURGEON GOES TO RETURN SOME BOOKS BORROWED FROM LIBRARY.

• LIBRARIAN : SIR, YOU ARE A REGULAR READER. FINE. YOUR BOOKS ARE ALWAYS RETURNED WITH LAST PAGE MISSING ? WHY?

• SURGEON REPLIES :

• I CANT STOP MYSELF FROM REMOVING AN APPENDIX WHEN I SEE ONE.

LITHIUM AND ANAESTHESIALITHIUM AND ANAESTHESIASIDE EFFECTS AND INTERACTIONS.SIDE EFFECTS AND INTERACTIONS. CNS DROWSINESS,HEADACHE,

MEMORY IMPAIRMENT. CVS SA NODE BLOCK, DEFECTS

OF CONDUCTION (RARE) GENITO URINARY

NDI,INTERSTIAL NEPHRITIS AND RENAL IMPAIRMENT

GI NAUSEA,VOMITING,DIAR.

ENDOCRINE HYPOTHYROID,HYPERPARTHYROID,HYPERGLYCEMIA

DRUGS ↑ LITHIUM LEVEL

NSAIDS, METROGYL, ACE INH., COX 2 INH.

LITHIUM TOXICITY.LITHIUM TOXICITY.

• NAUSEA,VOMITING,DIARHOEA, DROWSINESS,DYSARTHRIA,RENAL

FAILURE,COMA AND DEATH.ANAESTHETIC IMPLICATIONS.PREOP---ROUTINE + ECG WITH RHYTHM

STRIP + RENAL PARAMETERS + ELECTROLYTES + CALCIUM + T3,T4,TSH + LITHIUM LEVELS.

ANAESTHETIC IMPLICATIONS ANAESTHETIC IMPLICATIONS LITHIUMLITHIUM

• POTENTIATES SEDATION OF BARBITURATES,OPIOIDS AND BZ.

• INH. ANAESTH. ↓• SCOLINE & NDPS PROLONGED.• INTRA OP—ECG,NMB,URINE OUTPUT

MONITOR.• SOME CENTRES STOP LITHIUM

BEFORE ECT –REPORTS OF WORSENING.

ANAESTHETIC IMPLICATIONS ANAESTHETIC IMPLICATIONS LITHIUMLITHIUM

I WOULD SUGGEST PREOP WITHDRAWAL OF TWO DOSES OF LITHIUM (NOT MANDATORY) TO BRING DOWN SERUM LEVELS TO A SAFER RANGE WITHOUT AFFECTING THE PSYCHIATRIC STATE.

POST OP NSAIDS ↑ LITHIUM LEVEL.

ESSENCEESSENCE• NOT NECESSARY TO STOP ANY

PSYCHOTROPIC DRUG BEFORE ANAESTHESIA.

• KNOWLEDGE OF PSYCHOPHARMACOLOGY- MUST.

• TYPE OF ANAESTH. DOES NOT MATTER.• MANIPULATION OF DRUGS WITH

KNOWLEDGE OF INTERACTIONS IS ESSENCE TO DECREASE MORBIDITY.

• Eg. MORE EPHEDRINE IN PATIENTS WITH CPZ, VERY LESS IN MAOI, CAUTIOUS IN ACUTE &CHRONIC TCADS USAGE.

ANAESTHESIA FOR ECT.ANAESTHESIA FOR ECT.

• APPLICATION OF TRANSCUTANEOUS ELECTRIC CURRENT TO EFFECT A GRANDMAL SEIZURE.- 8-12 TIMES - ALT. DAYS.

• RELATIVE CONTRAINDICATIONS:• ↑ ICT,SEVERE CVS DISEASE, PHEO,RECENT

CEREBRAL BLEEDS,RETINAL DETACHMENT.

EFFECTS OF ECTEFFECTS OF ECT

PARASYMPATHETIC: (TONIC PHASE) BRADYCARDIA,HYPOTENSION.SYMPATHETIC : (CLONIC PHASE) TACHCARDIA, HYPERTENSION,

ARRYTHMIAS AND TRANSIENT LARGE UPRIGHT WAVES.

↑ ICT,IOT,IGT AND CBF.

AIMS OF ANAESTHESIAAIMS OF ANAESTHESIA

• NO HYPOXEMIA.• NO MUSCULO SKELETAL

INJURIES.• MAINTAINANCE OF

HAEMODYNAMICS.• QUICK RECOVERY.

ANAESTHESIA FOR ECT (CONTD)ANAESTHESIA FOR ECT (CONTD)

• ROUTINE INV. + DRUG HISTORY + ECG + INV. FOR PHEO,ICT,THYROID IN SELECTED CASES.

• PSYCHOTROPICS TO CONTINUE.• NO PREMED.• ACID ASPIRATION PRO. IN SOME

CASE• SPECS, HEARING AIDS ,CONTACT

LENS, DENTURES REMOVE.

ANAESTHESIA FOR ECT (CONTD)ANAESTHESIA FOR ECT (CONTD)

• RESUSCITATION EQUIP. CHECK.• NPO 8 HOURS.• INFORMED CONSENT CLOSE RELATIVES

ALSO.• ECT ELECTRODES FIXED.• BP CHECK IN ARM FOR ISOLATION• INJ ATR. 0.3 MG. • DENITROGENATION 3-5 MINUTES• PRETREAT WITH ESMOLOL (HT.)

ANAESTHESIA FOR ECT (CONTD)ANAESTHESIA FOR ECT (CONTD)• NO IV XYLOCARD OR BZ.• METHOHEXITAL(1 mg/kg) { NOT AVAILABLE

ROUTINELY } THIO 2 mg/kg OR PROPOFOL 1 mg/kg.• BP CUFF INFLATED.• (IF EEG MONITORED • NOT NECESSARY.)• 0.3-0.5 mg/kg SUXA.• 100% O2 MASK VENT.• SOFT AIRWAY.• HANDED OVER TO• PSYCHIATRIST.• NO PERSONNEL CONTACT.

ANAESTHESIA FOR ECT (CONTD)ANAESTHESIA FOR ECT (CONTD)

• ECT GIVEN. –FACIAL MUSCLE DIRECT CONTRACT. TONIC 10-15 SEC,CLONIC 40-60 SEC. SEEN IN ISOLATED ARM.

• SEIZURE « 30 SEC LESS THERAPEUTIC.• ROUTINE MONITOR + EEG - ECT ATTACH• MASK VENT TO CONTINUE TILL RECOVERY.• NO INTUBATION EXCEES DOSE NECCES.

AND SYMPATHETIC STIMULATION.

ANAESTHESIA FOR ECT (CONTD)ANAESTHESIA FOR ECT (CONTD)• REMEFENTANIL, ETOMIDATE-ALFENTANIL,

PROPOFOL-ALFENTANIL, SEVOFLURANE TECHNIQUES DESCRIBED.

• ATRA , VEC . - PROLONGED RECOVERY.• MORTALITY 2-4 / 1 LAKH.• DISORIENTATION (12%), HEADACHE (16%) ASPIRATION (1-2%),TEETH & LIP TRAUMA

(10%), CVS PROBLEMS (0.05%). • SAFE & SUCESSFUL ECT DESCRIBED IN

PREGNANCY, PACED PATIENTS, PARKINSONS, RECENT CEREBRAL BLEEDS, AND INFARCTION

TO CONCLUDE IN A LIGHTER VEIN,TO CONCLUDE IN A LIGHTER VEIN,

• MEN WITH BALDNESS IN BACK ARE THINKERS.

• MEN WITH BALDNESS IN FRONT ARE SEXY.

• MEN WITH BALDNESS IN BOTH AREAS

---------

THEY THINK THEY ARE SEXY !