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Post by Kim Hall on Jan 30, 2019 13:22:18 GMT -5
I have taken care of many patients with a history of drug abuse. I too agree that methadone should be continued preferably given in preoperatively. I also utilize a multimodal approach and give preoperative medications when appropriate. I really like Precedex for these patients and wish is was more readily accessible in our ORs.
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Post by Jackie Howell on Jan 30, 2019 14:19:34 GMT -5
1. During school and my career I've had many experiences with patients and substance abuse. I find a thorough interview, physical assessment and cardiac studies will guide the anesthesia plan. Anticipating large swings in hemodynamics is usually what I've encountered most commonly with cocaine/meth abuse.
2. There is no single drug of choice for the patient with substance abuse, it depends on the substance that's being used and how long this abuse has been going on for. Utilization of regional blocks, gabapentin, Neurontin, NSAIDS, lidocaine gtt, ketamine are popular amongst providers.
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Post by Marley Ferraro on Jan 30, 2019 15:46:19 GMT -5
Great article! I learned some new information about certain substances and how they affect our anesthetics. Like a few others said, I have taken care of patients with a current or prior history of substance abuse. If they are upfront about it, I try to explain how the anesthetic plan may change. If a patient is fearful about intra-operative opioid use I will educate them and try to make a plan that is appropriate for the situation. I've had the conversation many times with patients who smoke marijuana or vape that they are at risk of the same complications as cigarette smokers (laryngospasm and bronchospasm).
If I have a patient with prior substance abuse, I try to use multimodal therapies similar to the ERAS protocols (ketamine, ofirmev or PO Tylenol, pre-op gabapentin, toradol or other NSAIDs if appropriate for the case/patient, and/or precedex). For patients on chronic opioid therapy I will try multimodal but it seems that they still require a higher than average dose of opioid. The situation is really patient and procedure specific.
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Post by Mary Clothier on Jan 31, 2019 19:17:35 GMT -5
Caring for substance abuse patients during the Anesthetic experience poses many challenges, both Physiologically as well as Psychologically. IV access for pts with IVDA history is particularly challenging pre-op. The hemodynamic challenges intra-op varies with substance(s) and can require some creative tailoring of the anesthetic to meet the autonomic nervous system variability. Post op may be the challenging of all, trying to meet the pain needs of the illicit drug using patient, wants vs needs for pain medication while maintaining a non judgemental caring approach!
Very tough decision on pain medication, the object would be multimodal and non narcotic choices if possible! Regional also ideal to avoid narcotic, however must be careful with our cocaine abusers as they can have cocaine induced thrombocytopenia. Of course methadone always a great choice, keeping them on the road to recovery with many on methadone as part of their treatment.
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Post by darolyn on Jan 31, 2019 22:21:38 GMT -5
My concern has been with patients that have lied about their last time of use as well as those who have just used while on their way to hospital for their elective surgery. In the case of the latter, the attending cancelled the case after the tox screen came back positive for cocaine. In the case of the patient who was not forthcoming about last use, once it became apparent, more vigilant anesthetic plan became apparent. I wanted to make sure be administer anesthesia with the goal of a safe wake up and a comfortable pacu experience. I do like methadone, ketamine and non opioid combo such as gabapentin acetaminophen and celbrex barring any contraindications.
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Post by Chuck Eder on Jan 31, 2019 23:38:17 GMT -5
Dealing with patients that have current substance abuse issues or are in recovery can be challenging to care for. As stated multiple times previously, regional if possible is a preferred way to go. Incorporating Tylenol, gabapentin, ketamine, and Precedex can also be beneficial. If the patient is in a recovery program with daily methadone, that should be continued. These methods and meds can be used in an attempt to give a successful anesthetic for this patient population.
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