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Antipyschiatric drugs and ect anaesthesia
- 1. PSYCHOTROPIC DRUGS AND ANAESTHESIA Dr.S. ParthasarathyDr. S. Parthasarathy MD., DA., DNB, MD (Acu),MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statisticsDip. Diab. DCA, Dip. Software statistics PhD (physio)PhD (physio) Mahatma Gandhi Medical college andMahatma Gandhi Medical college and research institute , puducherry , Indiaresearch institute , puducherry , India
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- 3. FIRE TRAGEDY 16-07-04FIRETRAGEDY 16-07-04
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- 5. OPD STATISTICSOPD STATISTICS govthospitals – tamilnadu 2800 OUT OF 30000/MONTH GETTING ANTIPSYCHIATRIC DRUGS. PRIVATE CLINIC ( GP) 20 % OF PATIENTS ARE RECEIVING SOME FORM OF ANTIPSYCHIATRIC DRUGS
- 6. CLASSIFICATION OFCLASSIFICATION OF PSYCHOTROPICDRUGSPSYCHOTROPIC DRUGS ANTIPSYCHOT ICS PHENOTHIAZINE, HALO,THIO (ATYPICAL -CLOZ, RIZ,OLANZIPINE.) SCHIZOPHRENIA. MANIA. ANTIDEPRESS ANTS TRICYCLICS, SSRI, MAOI, DEPRESSION, NEURO PAIN. MOOD STABILIZERS. LITHIUM.,CAR BAMAZIPINE MANIA ANXIOLYTICS BENZODIAZ. BUSPIRONE ANXIETY HYPNOTICS ZOPICLONE, BENZODIAZ. INSOMNIA
- 7. ANTIPSYCHOTICSANTIPSYCHOTICS SED AC OHEP SEI WT CH SX QT CP +++ ++ +++ + + + ++ + + TH + + + +++ + + + +++ + HL + + + +++ - + - - - CL +++ +++ +++ - +++ +++ - - - RI + - ++ + - + - - - OL ++ + ++ + + +++ + - -
- 8. TABLE IN ANOTHERANGLETABLE 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.
- 9. 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
- 10. 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
- 11. 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.
- 12. 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
- 13. NEUROLEPTIC MALIGNANT SYNDROME.NEUROLEPTICMALIGNANT 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.
- 14. • A PSYCHIATRISTASKS 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?
- 15. PATIENT 3 : ITIS EASY . I SUBTRACTED 274 FROM TUESDAY.!
- 16. ANTIDEPRESSANTSANTIDEPRESSANTS • THE CARDINALDIFFERENCE 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
- 17. ANTIDEPRESSANTSANTIDEPRESSANTS • ANTIDEPRESSANTS CANBE 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)
- 18. SIDE EFFECTS OF(TCAD) ANTIDEPRESSANTSSIDE EFFECTS OF (TCAD) ANTIDEPRESSANTS PHARMACOLOGY SIDE EFFECTS MUSCARINIC BLOCK DRYMOUTH,TACHYCARD BLURRED 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
- 19. TCAD ANTIDEPRESSANTS—TCAD ANTIDEPRESSANTS— ANAESTHETICIMPLICATIONSANAESTHETIC 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
- 20. TCAD ANTIDEPRESSANTS—TCAD ANTIDEPRESSANTS— ANAESTHETICIMPLICATIONSANAESTHETIC 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.
- 21. TCAD ANTIDEPRESSANTS—TCAD ANTIDEPRESSANTS— ANAESTHETICIMPLICATIONSANAESTHETIC 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
- 22. 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.
- 23. OTHERSOTHERS • VENLAFAXINE –AKIN TO SSRIS AND INTRAOP HYPERTENSION IS A POSSSIBILITY. • BUPROPION NO EFFECT ON SEXUAL FUNCTION BUT BEWARE OF SEIZURES.
- 24. MAO INHIBITORSMAO INHIBITORS.. MAO- MONOAMINE OXIDASE- OXIDATIVEMAO - MONOAMINE OXIDASE- OXIDATIVE DEAMINATION OF BIOGENIC AMINES.DEAMINATION OF BIOGENIC AMINES. MAO-A (5HT,NE& E) MIXED MAO-B PHENYL ETHYLA MINE IRREVE RSIBLE CLORGY LINE PHENEL ZINE, TRANYL CYPRA MINE DEPRE NYL REVERS IBLE MOCLO BEMIDE ---- ---
- 25. 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.
- 26. 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.
- 27. MEPERIDINE & MAOIMEPERIDINE & 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.)
- 28. 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.
- 29. SEROTONIN SYNDROMESEROTONIN 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.
- 30. A LIGHT BREAKALIGHT 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 :
- 31. • I CANTSTOP MYSELF FROM REMOVING AN APPENDIX WHEN I SEE ONE.
- 32. LITHIUM AND ANAESTHESIALITHIUMAND ANAESTHESIA SIDE 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,HYPERPAR THYROID,HYPERGLYCEMIA DRUGS ↑ LITHIUM LEVEL NSAIDS, METROGYL, ACE INH., COX 2 INH.
- 33. 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.
- 34. ANAESTHETIC IMPLICATIONSANAESTHETIC 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.
- 35. ANAESTHETIC IMPLICATIONSANAESTHETIC IMPLICATIONS LITHIUMLITHIUM IWOULD 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.
- 36. ESSENCEESSENCE • NOT NECESSARYTO 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.
- 37. ANAESTHESIA FOR ECT.ANAESTHESIAFOR 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.
- 38. EFFECTS OF ECTEFFECTSOF ECT PARASYMPATHETIC: (TONIC PHASE) BRADYCARDIA,HYPOTENSION. SYMPATHETIC : (CLONIC PHASE) TACHCARDIA, HYPERTENSION, ARRYTHMIAS AND TRANSIENT LARGE UPRIGHT WAVES. ↑ ICT,IOT,IGT AND CBF.
- 39. AIMS OF ANAESTHESIAAIMSOF ANAESTHESIA • NO HYPOXEMIA. • NO MUSCULO SKELETAL INJURIES. • MAINTAINANCE OF HAEMODYNAMICS. • QUICK RECOVERY.
- 40. 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.
- 41. 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.)
- 42. 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.
- 43. 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.
- 44. 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
- 45. TO CONCLUDE INA 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 ---------
- 46. THEY THINK THEYARE SEXY !