Psychiatric Disease and Substance Abuse – Flashcards

*Delirium* -Rapid Onset (hours to days) of widespread disorganized thought. -Confusion, inattention, memory impairment, disorientation, clouding of consciousness. -Frequently associated with underlying organic cause. -Often *reversible* *Dementia* -Gradual onset. -Memory impairment associated with: -Aphasia (inability to communicate) -Apraxia (inability to carry out motor activity) -Agnosia (failure to recognize objects, stimuli) -Disturbances in executive function (inability to plan, organize, sequence) -Typically *irreversible*

*Dementia* may be associated with increased incidence of Postoperative Cognitive Decline-inform the family! -Closely monitor hemodynamics. -Provide MAC required and NO More. -Avoid polypharm, especially long acting medications or mind-altering agents (midazolam, ketamine, etc.) Increased risk of *Delirium* after anesthesia, especially in elderly-tell families! -Re-orient patients after anesthesia. -Provide a clean anesthetic Be carefull with ketamine in pts >50-60 years old. Sevo emergence delirium. Iso and Nitrous is "nice anesthetic"-Zanghi

1. Generalized anxiety disorder/episodic, situation-dependent anxiety. 2. Panic Attacks. 3. Post-traumatic stress syndrome.

Believed to be due to *alterations in (GABA) NT system*. Overwhelming subjective sense of unease, dread or foreboding. Nervousness, insomnia, hypochondriasis, somatic complaints. Reactions are out of proportion to situation or in reaction to situation that should not provoke response in "normal" population. Treatment: *Buspirone* (a partial 5-HT2a receptor antagonist), *benzos, gabapentin, pregabalin, and divalproex*. Supplemental cognitive-behavioral therapy, relaxation techniques, hypnosis and psychotherapy.

Exaggerated feeling of apprehension, uncertainty, fear. Patient becomes increasingly "scattered", less able to concentrate. Usually peaks in 10 minutes, resolves in less than 1 hour. S/Sx: tachycardia, palpitations, sweating, trembling, SOB, choking sensation, chest pain, chills or hot flashes, nausea, abdominal pain, dizziness, de-realizartion, depersonalization, fear of losing control, fear of dying, paresthesias (pins and needles).

*Reaction to life-threatening event outside of range of normal human experience* Sx: fear of reoccurance, recurrent intrusive thoughts, depression, sleep disturbance, nightmares, persistant increased arousal. Treatment: Psychotherapy (cognitive-behavioral therapy, group psychotherapy or combination), meds (anti-depressants, atypical anti-psychotics, benzos)

Communicate with patients, when possible (safe) allow personalization of anesthesia. Medicate as appropriate for home medication regimen. Anxiety can manifest as increased pain/nausea in PACU. Keep panic attacks on differential for PACU events. Maintain personal and patient safety, especially with PTSD pts during wake-up (have help available, chemical agents drawn up and ready). Zanghi like to do a gas anesthetic with precedex running in background...do precedex wake-up.

Anorexia nervosa, bulimia nevosa, binge-eating disorder. Disturbances in normal eating behavior. Excessive concerns about body weight. Typically adolescent to young adults. Women > men.

Decreased food intake, excessive physical activity, possible bulimic symptoms. *Weight loss >24% of noraml body weight*. S/Sx: decrease in cardiac muscle mass, depressed myocardial contractility, cardiomyopathy, ventricular dysrhythmias, hyponatremia, hypochloremia and hypokalemia, possible metabolic alkalosis, orthostatic hypotension, osteoporosis, *delayed gastric emptying*, impaired cognitive function, fatty liver, anemia, neutropenia, thrombocytopenia and amenorrhea. PE: emaciated (abnormally thin or weak), dry skin, cold/cyanotic extremities, bradycardia. Treatment: SSRIs, psychotherapy.

Binge eating, purging (vomiting or laxatives) and dietary restriction. Vomiting with or without laxatives and diuretics. S/Sx: dry skin, dehydration, hypertrophy of salivary glands, bradycardia, metabolic alkalosis, dental complications. Treatment: Cognitive behavioral therapy, TCA and SSRIs.

Binge eating with short periods of restriction and *no purging*. Morbidly obese patient, especially with weight cycling. Associated with depression, anxiety and personality disorders. Medical effects: hypertension, DM, hypercholesterolemia, degenerative joint disease. Treatment: antidepressants.

ECG to evaluate cardiac function. Labs: electrolyte abnormalities and dehydration. Consider RSI for delayed gastric emptying despite meeting NPO guidelines. Possible dysrhythmias intraoperatively, may require potassium supplementation. Place V5 in correct place. Note QT interval before induction.

Disturbances in Mood, Behavior and Affect. 1. Depressive Disorders. 2. Bipolar Disorders. 3. Depression in conjunction with medical illness or substance abuse.

*2-4% of the population.* Combination of severity and duration. Familiar, females > males. Suicidality (15% of patients with major depression). Pathology unknown-NT imbalance.

*5+ symptoms, greater than 2 weeks* -Depressed mood. -Decreased interest or pleasure in activities. -Changes in body weight and appetite. -Insomnia or hypersomnia. -Restlessness. -Fatigue. -Feeling or worthlessness or guilt. -Inability to concentrate. -Suicidal ideation. Depression doesnt effect anesthesia, but anesthesia effects depression. It is better to ask pts about their depression then pretend its not there. Studies show that acknowledging depression does not make it worse.

*SSRIs* -block reuptake or serotonin at presynaptic membranes (decreased side effects) *Tricyclics* -Inhibit reuptake of NE and serotonin. -Also effect histaminergic and cholinergic systems. *MAOIs* -Inhibit A and B forms of monoamine oxidase, prevent breakdown of catecholamines and serotonin. -Risk of hypertensive crisis if combined with *tyramine- containing foods*. *Atypicals* -Inhibition of reuptake of serotonin, NE and dopamine, -Dopamine receptor blockade. -Presynaptic alpha 2 blockade. -Histamine receptor blockade.

Fluoxetine (Prozac) Paraxetine (Paxil) Sertraline (Zoloft) Fluvoxamine (Luvox) Citalopram (Celexa)

Amitriptyline (Elavil) Imipramine (Tofranil) Protriptyline (Vivactil) Doxepin (Sinequan)

Phenelzine (Nardil) Tranylcypromine (Parnate)

Bupropion (Wellbutrin) Trazadone (Desyrel) Nefazodone (Serzone)

*Treat mild to moderate depression*. SE: insomnia, agitation, HA, nausea, diarrhea, dry mouth, *sexual dysfunction* Discontinuation Syndrome -1-3 days after cessation. -Dizziness, irritability, mood swings, HA, N/V, dystonia, tremor, lethargy, malaise, fatique. Tx: restart SSRI, taper

*Overdose or interaction of serotonergic drugs* Range from Mild Symptoms to Life-threatening toxicity. -Akathisia -Tremor -Altered mental status -Clonus (inducible) -Clonus (sustained) -Muscular hypertonicity -Hyperthermia

SSRIs. Atypical cyclic antidepressants. MAOIs Anticonvulsant drugs: valproate *Analgesics: meperidine, fentanyl, tramadol (especially), pentazocine.* *Antiemetic drugs: ondansetron, granisetron, metoclopramide* Methylene Blue: Has MAOI activity Antimigrain drugs: sumatriptan Bariatric medications: sibutramine Antibiotics: linezolid, ritonavir OTC cough medicine: dextromethorphan Drugs of abuse: ecstasy, LSD, 5-methoxy-diisopropyltyptamine ("foxy methoxy"), syrian rue. Dietary supplements: St. Johns wort, ginseng. Other: Lithium

*2nd line depression, treatment of chronic pain* -almost all chronic painers are on a TCA SE: sedation, anticholinergic effects, cardiovascular (orthostatic hypotension and cardiac dysrhythmias)

*Increased anesthetic requirements* (increased availability of NTs) Increased post-synaptic NE can produce exaggerated bp response to indirect-acting vasopressors (ephedrine) -Critical in first 14-21 days. Interaction between TCAs and sympathetic-stimulating drugs (pancuronium, ketamine, meperidine, epinephrine containing LAs).

Less frequently perscribed now (*3rd line agent*) Inhibit NE and serotonin breakdown. -*Hypertensive crisis* when combined with tyramine containing foods (aged meats, cheese, pickled and fermented foods and drinks). SE: sedation, blurred vision, orthostatic hypotension, excessive effects of sympathomimetic drugs. (traditionally avoid meperidine), serotonin syndrome.

Past recommended d/c MAOIs for 14 days prior to anesthesia. Expect *exaggerated efffects on CNS and respiratory depression*. *Avoid* sympathomimetics (pancuronium, ketamine, meperidine, and epi in local) Possible decrease in serum cholinesterase activity (use less sux). *Increased anesthetic requirements* Cautious use of neuraxial anesthesia due to hypotension. Avoid light anesthesia, topical cocaine, ephedrine (use phenylephrine at lower doses for hypotension).

Periods of elation (manic episodes) with or without alternating periods of depression. Affects 1% of population, *autosomal dominance with variable penetrance* Onset usually in adolescence or early adulthood. *Males > females* Diagnosis: -Inflated self-esteem; grandiosity -Decreased need for sleep -Talkativeness -Distractibility -Increase in goal directed activity -Psychomotor agitation -Excessive involvement in risky pleusurable activity -Delusional thoughts Treatment: -Acute mania: hospitalization -First line: *Lithium* -Second line: *carbamazepine, valproate, olanzapine*

*Actions on second messenger systems (phosphatidylinositol turnover), transmembrane ion pumps, inhibits adenylate cyclase.* *Narrow therapeutic range* with significant toxicity. *SE*: cognitive dysfunction, weight gain, tremor, hypothyroidism, *diabetes insipidus*, cardiac problems (sinus bradycardia, sinus node dysfunction, AV block, T-wave changes, and ventricular irritability), leukocytosis. *Toxicity*: skeletal muscle weakness, ataxia, sedation, widening of the QRS complex, AV heart block, hypotension, seizure.

Check serum levels for lithium or look for signs/symptoms of toxicity. Sodium IVF prevent lithium accumulation. Avoid Thiazide diuretics. Cautious use of drugs that alter renal excretion (toradol) Monitor EKG. *Decreased MAC* Cautious NMB (prolongation of both depolarizing and nondepolarizing).

Affects about 1% of population. Symptoms include: -Delusions -Hallucinations -Disorganized speech -Disorganized or catatonic behavior -Flat affect Symptoms must cause social or occupational dysfunction. Neurotransmitter Systems Implicated in Schizophrenia: -Dopamine, Ach, Glutamte, Serotonin, GABA, NE, Neuropeptides (cholecystokinen) *Schizophrenie probably involves multiple NT system abnormaltiea* Treatment: -Central neurotransmitter imbalance-Dopamine. -Dopamine blockade-D2 and D4. -Older "typical anti-psychotics" associated with many more side effects due to inability to effect specific receptor subtypes. -Newer "atypical anti-psychotics" less side effect profile.

*Traditional Drugs* Phenothiaiznes: -Chlorpromazine (Thorazine) -EPSE common -Perphenazine (Trilofon) -Fluphenazine (Prolixin) -Trifluoperazine (Stelazine) Butyrophones: -Haloperidol (Haldol) -EPSE common -Retinal pigmentation Thioxanthenes: -Thiothixene (Navane) -EPSE common *Atypical Drugs* - EPSEs uncommon or rare. -Risperidone (Risperdal) -Clozapinie (Clozaril) -EPSE rare -Agranulocytes -Quetiapine (seroquel) -catatracts -Qlanzapine (seroquel) -Neutropenia -Ziprasiodne (Geodon) -Prolonged QT interval

-Tardive dyskinesia (choreoathetois movements) -Akathisia (restlessness) -Acute dystonia (contraction of skeletal muscle of the neck, mouth and tongue). -Parkinsonism. -*Anti-cholinergics can lessen side-effect.* -*Acute dystonic reaction may respond to 25-50 mg iv of benadryl*

Rare, potentially fatal complication of *antipsychotic drug therapy*. *Reflects dopamine depletion* in the CNS. Usually in first few weeks of therapy or following an increase in drug dosage. Clinical manifestations: hyperpyrexia, severe skeletal muscle rigidity, rhabdomyolysis, autonomic hyperactivity (tachycardia, HTN, cardiac dysrhythmias), altered consciousness and acidosis. Skeletal muscle spasm may be so severe that mechanical ventilation becomes necessary. *Renal failure* may occur as a result of *myoglobinuria and dehydration*. Sux *is not* CI in NMS.

*Malignant Hyperthermia* -Onset: within minutes -Cuasative drugs: Sux, volatiles -Outstanding features: muscle rigidity, severe hypercarbia. -Tx: dantrolene, supportive care. *Neuroleptic Malignant Syndrome* -Onset: 24-72 hrs -Cuasative Drugs: Dopamine antagonist antipsychotic drugs -Outstanding feutures: muscle rigidity, stupor or coma, bradykinesia. -TX: Bromocriptine or dantrolene, supportive care. *Serotonin Syndrome* -Onset: up to 12 hours -Causative Drugs: Serotoniergic drugs including SSRIs, MAOIs and atypical antidepressants -Outstanding features: CLonusm hyperreflexia, agitation, possible muscle rigidity. -Tx: cyproheptadine, supportive care, cases with extreme temperature may benefit from dantrolene. *Sympathomimetic Syndrome* -Onset: up to 30 mins -Causative drugs: cocaine, amphetamines -Outstanding features: Agitation, hallucinations, myocardial ischemia, dysrhythmia, *no rigidity* -Tx: vasodilators, alpha and beta blockers, supportive care. *Anticholinergic Poisoning* -Onset: up to 12 hours -Causative drugs: Atropine, belladonne -Outstanding features: Toxidrome of hot, red, dry skin, dilated pupils, delirium, no rigidity. "*hot as a hare, blind as a bat, dry as a bone, red as a beet mad as a hatter*" -Tx: Physostigmine, supportive care. *Cyclic Antidepressant Overdose* -Onset: up to 6 hrs -Causative drugs: cyclic antidpressants -Outstanding Features: hypotension, stupor or coma, wide-complex dysrhythmias, no rigidity. -Tx: serum alkalinization, magnesium. *Parkinsonism Hyperthermia Syndrome (PHS)* *Baclofen Withdrawal* -Enhances the effect of GABA and is usually given IT to reduce muscle spasticity in pts with spinal cord injuries, cerebral palsy or dystonia. -Usually given as an infusion. -D/c of infusion can cause NMS or MH type picture.

Contraindications: -Recent MI (< 3 months) -Recent Stroke (<1 month) -Intracranial mass or increased ICP -Pheochromocytoma -Relative-angine, HF, pulmonary disease, bone fractures, severe osteoporosis, pregnancy, glaucoma, retinal detachment. Anesthetic Management: -Manage hemodynamic effect of shock. *PSNS followed by SNS*. -Do not mess up shock (dont alter seizure threshold by giving drugs that alter seizure threshold-low dose propofol is okay). Brevitol is the best thing to give. -Usually dont intubate. -Give low dose sux so they dont hurt themselves during seizures. -Also use tnq to section off limb so sux cant get to that area so you can monitor seizure (foot flapping around). -People give atropine or glyco to battle early PSNS. -*Hyperventilation lowers seizure threshold and it is favored* Physiologic Effects: -PSNS: -Bradycardia -Hypotension -SNS -Tachycardia -HTN -Dysrhythmias -Increased CBF -Increased ICP -Increased intraocular pressure -Increased intragastric pressure

Substance Abuse: *self-administration of drugs outside of normal medical or societal use* Dependence: 3 of 9 symptoms for at least 1 month or occurring repeatedly: -Use in higher dosages or for longer periods than intended. -Unsuccessful attempts to reduce use. -Increased time spent obtaining drug. -Frequent intoxication of withdrawal symptoms. -Effects social and work activities. -Continues use despite social or physical problems due to drug. -Evidence of drug tolerance -Withdrawal symptoms -Drug use to avoid withdrawal symptoms. *Physical Dependence*: Drug must be present for normal physiologic function and prevention of withdrawal. *Tolerance*: increased dosages are necessary to produce the same effect. In General: long term tolerance increases anesthetic requirements and acute abuse decreases anesthetic requirement.

Alcoholism affects 10 million Americans and is responsible for 200,000 deaths annually. $30 billion in direct medical costs annually. *GABA receptor involvement* *CNS Effects:* -Psychiatric disorders (depression, antisocial behavior) -Nutritional disorders (Wernicke-Korsakoff syndrome) -Withdrawal syndrome -Cerebellar degeneration -Cerebral atrophy *CV Effects:* -Cardiomyopathy -Cardiac dysrhythmias -HTN *GI and hepatobiliary effects* -esophagitis -gastritis -pancreatitis -hepatic cirrhosis -portal HTN *Skin and musculoskeletal effects* -Spider angiomata -myopathy -osteoporosis *Endocrine and metabolic effects* -decreased serum T concentration (impotence). -Decreased gluconeogenesis (hypoglycemia) -Ketoacidosis -Hypoalbuminemia -Hypomagnesemia *Hematologic Effects* -Thrombocytopenia* -Leukopenia

*Disulfiram*: flushing, vertigo, diaphoresis, N/V due to accumulation of acetaldehyde from inhibition of aldehyde dehydrogenase. AA and abstinence. Must have a high level of suspicion.

Vestibular and cerebellar dysfunction. Autonomic nervous system dysfunction (hypotension, hypothermia, stupor, coma). Respiratory Depression. Tx: Maintain ventilation, watch for *hypoglycemia*, possible other drugs of abuse.

*Alcohol Withdrawal Syndrome*: tremors, perceptual disturbances, autonomic nervous system hyperactivity (tachycardia, HTN, cardiac dysrhythmia), N/V, insomnia, and mild confusion. -6-8 hours after stopping, peak at 24-36 hours -Tx: resume EtOh, benzos, alpha-2-agonists, Beta-blockers. *Delirium Tremens*: hallucinations, combativeness, hyperthermia, tachycardia, HTN, HOTN, seizures. -2-4 days after stopping. -Tx: benzos, beta-blockers, airway protecion cuffed ETT, lidocaine for dyrhythmia. *Wernicke-Korsakoff Syndrome*: loss of cerebellar neurons and memory due to *thiamine deficiency* -Tx: IV thiamine

Disulfiram induced sedation and hepatotoxicity, inhibition of other drugs (benzos), inhibition of dopamine Beta-hydroxylase can cause hypotension due to inadequate NE stores (*avoid indirect acting sympathomimetics*). Polyneuropathy from disulfiram or alcohol can effect regional anesthesia. Avoid EtOH skin cleansers in disulfiram. Acute Intoxication - *decreased MAC* Chronic ingestion - *Increased MAC* Hepatic metabolism - variable effect. -may need more or less Rocc

Blocks the *presynaptic* uptake of NE and dopamine. Increased synaptic produces "cocaine high" SE: coronary vasospasm and vasoconstriction, myocardial inschemia and infarction, systemic HTN and tachycardia (increased myocardial oxygen demands), ventricular dysrhythmias, including V-fib, hyperthermia, seizures, pulmonary and cerebral edema from HTN, thrombocytopenia. *Ischemia and hypotension can last up to 6 weeks after stopping.

Myocardial Ischemia and coronary vasospasm. Avoid further sympathetic stimulation (ketamine, pancuronium). Nitroglycerine for vasospasm. +/- Alpha or beta blockade (phentolamine, clonidine). Acute intoxication may increase MAC. Pre-op EKG.

Opioids are abused orally, subcutaneously, or IV for their euphoric and analgesic effects. Large cross-tolerance to different classes. Tolerance may develop to some of the effects of opioids (analgesia, sedation, emesis, euphoria, hypoventilation) but not to others (meiosis, constipation).

Overdose: Slow RR, large TV, meiotic pupils, dysphoria, unconsciousness, gastric atony, pulmonary edema (heroine overdose). Withdrawal -Uncomfortable but *not usually fatal* -Diaphoresis, mydriasis, HTN, tachycardia, yawning, lacrimation, piloerection, rhinorrhea, tremors, body aches, anorexia, muscle spasms.

*Naloxone*: short acting opioid antagonist with rapid reversal of opioids. *Buprenorphine (subutex)*: mixed mu-opioid agonist/antagonist, treatment of dependence. *Naltrexone*: long acting opioid antagonist used in treatment of dependence. *Suboxone*: buprenorphine and naloxone in combination (naloxone is to prevent IV injection of buprenorphine) *Methadone and levomethadyl*: long acting opioids for treatment of opioid addiction and management of chronic pain.

Continue Methadone and/or opioid baseline doses and then administer additional requirements for postoperative pain control. *Hold naltrexone* If possible hold suboxone and buprenorphine and then substitute with narcotic preoperative to prevent withdrawal symptoms. Use alternative methods of pain control due to exaggerated pain response post-op: ketamine, precedex, lidocaine drip, neuroxial. *Acute intoxication decreases MAC, chronic use increases MAC*

GABA receptor agonist. Respiratory depression *common*. Withdrawal produces anxiety, skeletal muscle tremors, hyperreflexia, diaphoresis, tachycardia, HOTN, CV collapse, hyperthermia, and it can precipitate *seizure activity which can be fatal*. Treatment with *phentobarbitol or phenobarbital (barbiturates)* *Long term users will have elevated hepatic metabolism, increased muscle relaxant requirements and volatile.* Acute intoxication decreases MAC, chronic use *no change in MAC*

GABA agonist Much less respiratory depression when OD alone (combination drugs increases risk). Much less severe withdrawal. Specific reversal agent - Flumazenil - may precipitate seizure activity. Acute intoxication will decrease MAC.

Speed, crank, crystal, ice, meth, etc. Sympathomimetics - increase release of catecholamines centrally as well as peripherally. Increased alertness, appetite suppression, and decreased need for sleep. Prescribed for narcolepsy, ADD, significant depression and hyperactivity in children. Dont hold rx amphetamines.

Physiologic dependence on amphetamines is *profound*, and dosages may be increased to several hundred times the therapeutic dosage. Long term abuse of amphetamines results in depletion of body stores of catecholamines. -manifest as somnolence and anxiety or a psychotic state. Withdrawal: lethargy, depression, suicidality, increased appetite, weight gain. -Manage with benzos -Beta blockers for sympathetic nervous system hyperactivity. -Antidepressants

Medically indicated amphetamines can be continued in perioperative period. Acute intoxication can lead to HTN, tachycardia, hyperthermia and *increased MAC*. Intracranial HTN and cardiac arrest have been seen. Chronic users may exhibit *decreased MAC* and profound hypotension due to catecholamine depletion (use direct acting adrenergic agonists to treat HOTN).

LSD and Phencyclidine Effects last about 8-12 hours Visual, auditory and tactile hallucinations. Sympathetic nervous system stimulation with HTN, hyperthermia, mydriasis and tachcardia. Anesthetic Implications: panic response requiring treatment with benzos, exaggerated response to sympathomimetic drugs.

Inhalation of marijuana smoke produces euphoria. THC active component. *Increased sympathetic nervous system activity.* *Decreased parasympathetic nervous system activity* Anxiety, paranoia, hallucinations potentially psychotic like have been associated with newer "more potent" strains, extracts. Most anesthetic concerns regarding decreased pulmonary function and increased airway reactivity much like tobacco.

Wide mood swings, such as periods of depression, anger, and irritability alternating with periods of euphoria. Desire to work alone. Refusal of lunch relief or breaks. Frequent offers to relieve others. Volunteering for extra cases or call. Pt pain needs in the PACU are disproportionately high given the narcotics recorded as administered. Weight Loss. Frequent bathroom breaks.