ppt giving perioperative implications of anti psychiatric medications. more useful for practicing anaesthesiologists and anaesthesiology trainees

1. ANAESTHETIC IMPLICATIONS OF
PSYCHOTROPIC MEDICATIONS
BY
DR VENKATA SAIBABU B. DA DNB FLTA
CONSULTANT ANAESTHESIOLOGIST
APOLLO HOSPITALS
VISHAKAPATNAM.

2. AIM OF THE TALK
• Basic PSYCHOPHARMACOLOGY in relation to ANAESTHESIA.
• Side effects of drugs relevant to ANAESTHESIA.
• Pharmacodynamics and pharmacokinetics in relation to ANAESTHESIA.
• Drug interatctions with ANAESTHETIC medications.
• Peri operative implications of PSYCHOTROPIC medications.

3. WHAT ARE PSYCHOTROPICS ???
LEGAL PSYCHOTROPICS
• ANTI ANXIETY AGENTS
• ANTI DEPRESSANTS
• ANTI PSYCHOTICS
• MOOD STABILIZERS
• STIMULANTS
ILLEGAL PSYCHOTROPICS
• COCAINE
• HEROIN
• LSD
• MARIJUANA
• AMPHETAMINES
ANY DRUG CAPABLE OF AFFECTING THE MIND, EMOTION AND BEHAVIOUR
OTHER PSYCHOTROPICS – ALCOHOL,NICOTINE, CAFFEINE,HERBAL MEDICINES.

4. BASIC MECHANISM OF ACTION OF ANTIDEPRESSANTS
THEY GENERALLY POTENTIATE THE ACTIONS OF NOREPINEPHRINE AND
SEROTONIN IN BRAIN EITHER DIRECTLY OR INDIRECTLY.
THE DRUGS INCLUDED ARE
1.TCAs 4. MAOIs
2.SSRIs 5. ATYPICAL ANTIDEPRESSANTS
3.SNRIs 6. HERBAL MEDICATIONS.
INHIBITION OF REUPTAKE
OF SEROTONIN,
NOREPINEPHRINE AT
PRESYNAPTIC TERIMINUS
INCREASED LEVELS OF
SEROTONIN AND
NOREPINEPHRINE AT
SYNAPTIC CLEFT

5. TRICYCLIC ANTIDEPRESSANTS (TCAs)
Inhibition of reuptake
of NE & 5HT
UNOPPOSED
CATECHOLAMINE
ACTION ON BRAIN
EXAGGERATED
RESPONSE TO
INDIRECT ACTING
VASOPRESSORS
ANTI CHOLINERGIC
SEDATION,DRYMOUTH,
CONSTIPATION
URINAY
RETENTION,BLURRY
VISION, DELIRIUM
ANTI MUSCARINIC
DIRECT
MYOCARDIAL
DEPRESSION,
ARRHYTHMIAS
PROLONGED QT
INTERVAL ,
WIDENED ECG
INTERVALS
ANTI ALPHA
ADRENOCEPTOR
POSTURAL
HYPOTENSION
SEDATION
EXAMPLES ARE AMITRYPTYLINE, NORTRYPTYLINE, IMIPRAMINE, DESIPRAMINE, DOTHIEPIN

6. PERIOPERATIVE CONCERNS OF TCAs
CAUTION IN PATIENTS
WITH PREXISTING
CARDIAC CONTIONS AND
ARRHYTHMIAS.
PREOPERATIVE ECG
AVOID MEPERIDINE,FENTANYL,
METHADONE,
ONDANSETRON,TRAMADOL,METACL
OPRAMIDE AS THEY PRECIPITATE
SEROTONIN SYNDROME
AVOID EPHEDRINE AND
METARAMINOL BECAUSE OF
THE EXAGGERATED RESPONSE
TO INDIRECT VASOPRESSORS
AVOID KETAMINE,
PANCURONIUM,
AND LAs
CONTAINING
EPINEPHRINE
BECAUSE OF
SYMPATHOMIMETIC
ACTION INCREASED MAC AND
ANAESTHETIC
REQUIREMENTS BECAUSE OF
ENHANCED BRAIN
CATECHOLAMINES
AVOID ATROPINE AND
SCOPALAMINE AS THEY
PRECIPITATE POST OPERATIVE
SEDATION AND DELIRIUM
ABRUPT
CESSATION MAY
CAUSE
CHOLINERGIC
REBOUND
WITHDRAWL
SYMPTOMS
PSYCHIATRIC PATIENT
ON TCAs COMING FOR
SURGERY

7. SSRIs AND SNRIs
SSRIs include
FLUOXETINE,SERTRALINE,PAROXETINE,FLUVOXAMINE,CITALOPRAM,ESCITALOPRAM
• SSRIs INHIBIT SEROTONIN REUPTAKE AND CYP-450 ENZYMES WITH MINIMAL ANTI CHOLINERGIC AND
SEDATIVE PROPERTIES
SNRIs INCLUDE DESVENLAFAXINE, DULOXETINE, MILNACIPRAN , LEVOMILNACIPRAN
• INHIBIT BOTH NOREPINEPHRINE AND SEROTONIN REUPTAKE AND CAUSE HYPERTENSION AS
PREDOMINANT SIDE EFFECT

8. PERIOPERATIVE CONCERNS OF SSRIs & SNRIs
PATIENT ON SSRI AND SNRI COMING FOR SURGERY
• ABNORMAL BLEEDING DUE TO
ALTERATION OF PLATELET SEROTONIN
LEVELS.
• POSSIBLE MECHNISMS FOR THIS IS
1. BLOCKADE OF PLATELET CALCIUM
2. NIRIC OXIDE SYNTHASE
INHIBITION
3. DECREASED PLATELET FACTORS
4. REDUCED PLATELET ACTIVATION
LEVELS OF
1.ANTI ARRHYTHMIC DRUGS
2.BENZODIAZEPINES
3.NEUROMUSCULAR BLOCKING
DRUGS
WILL BE PROLONGED BECAUSE OF
INHIBITION OF CYP 450 ENZYMES
SERTRALINE AND CITALOPRAM HAS LOWEST RISK OF BLEEDING WHEN COMBINED WITH WARFARIN

12. MONO AMINE OXIDASE INHIBITORS(MAOIs)
MAOIs
INHIBIT OXIDATIVE
DEAMINATION OF
AMINES
INCREASE THE LEVELS OF
SERATONIN,NOREPINEPHRINE,
DOPAMAINE
MAOIs
IRREVERSIBLE NON SELECTIVE TYPE A
& TYPE B INHIBITORS
SELECTIVE REVERSIBLE
TYPE A INHIBITORS
PHNELIZINE,
TRANYLCYPROMINE,ISOCA
RBOXAZID
MOCLOBEMIDE
MAOIs ARE USED TO TREAT RESISTANT DEPRESSION

13. PERIOPERATIVE CONCERNs OF MAOIs
PATIENT ON MAOIs COMING
FOR SURGERY
HYPERTENSIVECRISIS.
AVOID TYRAMINE CONTAINING FOODS
LIKE CHEESE, FAVA BEANS, WINE ,
AVACADO
AVOID
PHENYLPROPONOLAMINE,
DEXTROMETHORPHAN,
PSEUDOEPHEDRINE.
RISK OF SYMPATHETIC
STIMULATION.
AVOID KETAMINE, MEPIRIDINE,
EPHEDRINE.
MAINTAIN GREATER DEPTH OF
ANAESTHESIA
NEEDS TO BE
CONTINUED
PERIOPERATIVELY
HYPOTENSION.
PHENYLEPHRINE IS
PREFERRED .
STRICT
MONITORING OF
BLOOD PRESSURE
RISK OF SEROTONIN
SYNDROME
PHENELIZINE- PLASMA
CHOLINESTERASE LEVELS. ACTION OF
SUCCYNYLCHOLINE AND
MIVACURIUM IS PROLONGED
MAC BECAUSE
OF INCREASED
CATECHOLAMINES

14. ATYPICAL
ANTIDEPRESSANTS SNRIs,NDRIs
SARIs
(serotonin antagonist and
receptor inhibitors)
CRIBs
(combined reuptake inhibitors
and receptor blockers)
BUPROPRION,TRAZADONE,
NEFZADONE,VENLAFAXINE
PERI OPERATIVE CONCERNS
ARE SIMILAR TO TCAs AND
MAOIs
NEFZADONE CAN CAUSE QT
PROLONGATION AND
INHIBITION OF CYP 450 3A4
ENZYME

15. HERBAL MEDICATIONS
St JOHNS WART
HYPERECIUM PERFORATUM
KAVA
PIPER METHYSTICUM
GINKGO
GINKGO BILOBA
VALERIAN
VALERIANA OFFICINALIS
GINSENG
PANAX GINSENG(ASIAN)
PANAX QUINQUEFOLIUS(AMERICAN)

16. HERBAL MEDICATIONS
St JOHNS WORT
PHARMACOLOGICAL
ACTIVITY IS BECAUSE OF
HYPERICIN AND
HYPERFORIN
ACTS BY INHIBITING REUPTAKE OF
SEROTONIN,NOREPINEPHRINE,
DOPAMINE
INDUCTION OF CYTOCHROME P450 ENZYMES;
EFFECTS LEVELS OF CYCLOSPORINE,WARFARIN,STEROIDS, BZDs, CCBs
DECREASED SERUM DIGOXIN LEVELS
DELAYED EMERGENCE
RECOMMONDED TO STOP 5 DAYS PRIOR TO SURGERY

17. HERBAL MEDICATIONS
VALERIAN
causes sedation
By GABA receptor
modulation
Increased sedative effects of anaesthetics
BZD like acute withdrawl
Increase anaesthetic requirements with
long term use
KAVA
Sedative and anxiolytic
because of
KAVALACTONES
Antiepileptic,neuroprotective,
local anaesthetic properties
Abuse potential
Increased gamma glutamyl
transpeptidase levels leads to
hepatotoxicity
Kava dermopathy
Recommonded
to stop 24 hrs
prior to surgery

18. HERBAL MEDICATIONS
GINGKO
Inhibit platelet
activating
factor
Pharmacological
effects are due to
flavanoids and
terpenoids
Increased risk of bleeding
Should be discontinued 36
hrs prior to surgery
GINSENG
Pharmacological
effects are due to
steroidal saponins
Inhibit platelet
aggregation
Hypoglycemia
Increased risk of
bleeding
Decrease the
anticoagulant
effect of warfarain
should be
discontinued 7
days prior to
surgery

19. ANTI PSYCHOTIC DRUGS (APDs)
TYPICAL APDs
• PREDOMINANTLY ACT BY
BLOCKING DOPAMINE (D2)
RECEPTORS
• HAVE EXTRA PYRAMIDAL SIDE
EFFECTS.
CHLORPROMAZINE
HALOPERIDOL
TRIFLUPERAZINE
ATYPICAL APDs
• PREDOMINANTLY BLOCKS
SEROTONIN(5HT2) RECEPTORS.
• ALSO BLOCK DOPAMINE, HISTAMINE,
MUSCARANIC AND ALPHA
ADRENERGIC RECEPTORS
• NO EXTRA PYRAMIDAL SIDE EFFECTS
CLOZAPINE,OLANZAPINE,RIS
PERIDONE,AMISUPIRIDE,
QUETIAPINE, ARIPIPRAZOLE
• PRIMARILY USED FOR TREATMENT OF SCHIZOPHRENIA AND BIPOLAR DISORDERS
• EFFECTIVE ONLY FOR TREATING ONLY POSITIVE SYMPTOMS OF SCHIZOPHRENIA

20. ANTI PSYCHOTIC DRUGS (APDs)
APDs
Block repolarising
potassium currents
Prolongs QT and
PR interval
Sudden cardiac
death
Neurolept malignant
syndrome
Mental state
changes
dysautonomia
Fever,rigidity
Idiosyncratic life
threatening
emergency
Orthostatic
hypotension
Anti cholinergic
side effects
Lowers seizure
threshold

21. ANTI PSYCHOTIC DRUGS (APDs)
PERI
OPERATIVE
CONCERNS
CONTINUED PERIOPERATIVELY
POTENTIATE
HYPOTENSIVE AND
SEDATIVE EFFECTS
OF GENERAL
ANAESTHETICS
TEMPARATURE REGULATION IS
IMPAIRED BECAUSE OF DOPAMINE
RECEPTOR BLOCKADE
HIGHER INCIDENCE
OF POSTOPERATIVE
ILEUS
• INCREASED RATES OF INFECTION BECAUSE OF IMMUNE SUPPRESSION
• WATER INTOXICATION DUE TO HYPERSECRETION OF ADH

22. LITHIUM
INORGANIC ION MAINLY USED FOR PROPHYLAXIS OF BIPOLAR DISORDER
MECHANISM OF ACTION
MIMICS SODIUM ION AT
MEMBRANES AND RESULTS IN
REDUCTION OF RELEASE OF
NEUROTRANSMITTERS
INHIBITING NMDA RECEPTOR
GSK3 INHIBITION AND
IONOSITOL DEPLETION
BY INHIBITING IMPase
NARROW THERAPEUTIC INDEX. SERUM LEVELS SHOULD BE MAINTAINED BETWEEN 0.6-1 mmol/l
SERUM LEVELS > 1.5 mmol/l ,TOXICITY OCCURS
CONFUSION, MUSCLE WEEKNESS,
TREMORS,SLURRED SPEECH
SA NODE DYSFUNCTION,AV BLOCK,
VENTRICULAR IRRITABILITY
HYPOTHYROIDISM
AS IT IS RENALLY EXCRETED, DEHYDRATION, DIURETICS, RENAL FAILURE INCREASE LITHIUM TOXICITY

23. LITHIUM
PERIOPERATIVE
CONCERNS
AVOID NSAIDS.
THEY INCREASE
LITHIUM LEVELS
BY 10-25%
AVOID THIAZIDE
DIURETICS. THEY
REDUCE RENAL
CLEARANCE OF LITHIUM
HAS TO BE STOPPED
72 HRS PRIOR TO
SURGERY
PROLONGS THE
ACTION OF BOTH
DEPOLARISING AND
NONDEPOLARISING
MUSCLE RELAXANTS
REDUCTION OF MAC
BECAUSE OF DECREASED
CATECHOLAMINE RELEASE

24. OTHER MOOD STABILISERS
CARBAMAZEPINE
Sodium channel blocker.
Treats MANIAC episodes
Induces cytochrome P450
system.
NMBs drugs should be given
more frequently.
Coagulopathy.
SODIUM VALPROATE
Enhances inhibitory effect
GABA
Highly protein bound.
Enhances the action of
other protein boiund drugs.
Thrombocytopenia
LAMOTRIGINE
Used to treat bipolar
depression.
Inhibits sodium and calcium
channels.

25. SEROTONIN SYNDROME
CLINICAL MANIFESTATION OF EXCESS SEROTONIN IN CNS RESULTING FROM
THERAPEUTIC USE OR OVERDOSAGE OF SEROTONERGIC DRUGS

29. MALIGNANT
HYPERTHERMIA
PRECIPITATED BY
SUCCINYLCHOLINE AND
OTHER INHALATIONAL
AGENTS.
AUTOSOMAL DOMINANT
INHERITENCE.
HYPERCAPNIA,
TACHYPNOEA,
SYMPATHETIC NERVOUS
SYSTEM OVERACTIVATION
SEROTONIN
SYNDROME
PRECIPITATED BY
SEROTONERGIC DRUGS
(MAOIs,SSRIs,TCAs)
MYOCLONUS,
MYDRIASIS,
HYPERREFLEXIA,
HYPERACTIVE BOWEL
SOUNDS,
AGITATION
NEUROLEPT
MALIGNANT
SYNDROME
PRECIPITATED BY
ANTIPSYCHOTICS.
ABRUPT CESSATION OF
DOPAMINERGIC DRUGS
CHOREA,
OPISTHOTONUS,
TRISMUS,
BLEPHAROSPASM,
OCCULOGYRIC CRISIS

30. ALCOHOL
ACUTE INTOXICATION
• Respiratory depresssion,
coma
• Risk of aspiration.
Intubation for airway
protection and furthur
management
CHRONIC ALCOHOL MISUSE
• Examination should concentrate on
• CVS-(hypertension, arrhythmias, and signs
of cardiac failure)
• CNS- (disturbance of vision, co-ordination or
cognitive function, or evidence of autonomic
or peripheral neuropathies).
• Specific signs of liver disease should also be
sought
Before surgery, administration of parenteral B vitamins may be indicated to prevent
Wernicke –Korsakoff syndrome.
Vitamin K, clotting factors, fresh frozen plasma, or platelets may also be necessary to
correct coagulopathy.

32. PERIOPERATIVE CONCERNS OF ALCOHOL
REGIONAL ANAESTHESIA
• Any pre existing neurlogical deficit or
neuropathy should be documented.
• Sudden severe hypotension can
occur in patients who are on
treatment with Disulfuram
• Hypotension can be treated with
phenylephrine (preferable) and
Ephedrine.
• Neuropathy sometimes considered
as medicolegal contraindication
GENERAL ANAESTHESIA
• Rapid sequence induction
• Increase requirements of anaesthetic
agents because of cytochrome P450
enzyme induction
• The effective doses of propofol,
thiopental, and opioids such as alfentanil
are increased.
• The distribution and metabolism of
anaesthetic drugs is altered by
hypoalbuminaemia and hepatic
impairment.
• Alcohol use is an independent risk factor
for post operative delirium.

33. ALCOHOL WITHDRAWL SYNDROME
The syndrome results from neurological receptor changes after long-term alcohol use.
Ethanol binds to post-synaptic GABAA receptors, enhancing their inhibitory effect.
The resulting chronic excitatory suppression, coupled with a direct inhibition of excitatory
glutamate N-methyl-D-aspartate (NMDA) receptors, leads to an increased brain synthesis of
excitatory neurotransmitters such as norepinephrine, 5hydroxytryptamine, and dopamine.
When the inhibitory effects of ethanol are withdrawn, the brain becomes exposed to
increased levels of excitatory neurotransmitters

34. Alcohol withdrawal syndrome is characterized by
Tremor,
Gastric upset,
Sweating,
Hypertension,
Hyper-reflexia,
Anxiety,
Agitation progressing to delirium, hallucinations,
and seizures.

35. COCAINE
Cocaine produces prolonged adrenergic stimulation by blocking the presynaptic uptake
of sympathomimetic neurotransmitters including norepinephrine, serotonin, and
dopamine
GENERAL ANAESTHESIA
• Ketamine should be used with
extreme caution- enhances cvs
toxicity
• Action of suxamethonium is
prolonged.
• Increased volatile anaesthetic
requirement in acute intoxication
• Hyperthermia and sympathomimetic
effects mimick malignant
hyperthermia
REGIONAL ANAESTHESIA
• Combative Behavior
• Altered pain perception
• Cocaine – induced Thrombocytopenia
• Ephedrine - resistant hypotension
ESMOLOL is the preferred
beta blocker

36. MARIJUANA
PERI OPERATIVE
CONCERNS
primary psychoactive
constituent is
tetrahydrocannabinol (THC)
Causes increased SNS
activity and decreases para
sympathetic nervous system
activity.
Anaesthesia
during acute
exposure is
preferably avoided
Additive effects of
marijuana and inhaled
anaesthetics will result
in severe myocardial
depression
Ketamine,atropine,
ephedrine , pancuronium
should be avoided
Intra operative bronchospasm
can occur due to airway
irritability by marijuana smoke
Enhace the
sedative and
hypnotic effects of
CNS depressants.

38. Real case scenario
• 38 YEAR FEMALE POSTED FOR ROBOTIC HYSTERECTOMY
• Has h/o hypothyroidism on thyronorm 25 mcg
• Has history of Paranoid schizophrenia on aripiprazole 5mg OD For the past 5 years.
• H/o 2 suicide attempts in the past
• h/o admission to psychiatric hospital 2 times
• No other comorbidities

40. REFERENCES
• Anesthetic Considerations for Patients on Psychotropic Drug Therapies
Monica W. Harbell 1,* Catalina Dumitrascu 1, Layne Bettini 1, Soojie Yu 1, Cameron M. Thiele 2 and
Veerandra Koyyalamudi 1 NEUROLOGY INTERNATIONAL
• Anaesthetic Implications of Substance Abuse in Adolescent A Rudra1, Anjan Bhattacharya2, S Chatterjee3,
S Sengupta4, T Das INDIAN JOURNAL OF ANAESTHESIA
• Tom Peck, BSc MBBS FRCA, Adrian Wong, BSc (Hons) MBBS MRCP, Emma Norman, BSc (Hons) MBBS,
Anaesthetic implications of psychoactive drugs, Continuing Education in Anaesthesia Critical Care & Pain,
Volume 10, Issue 6, December 2010, Pages 177–181, BRITISH JOURNAL OF ANAESTHESIA
• MILLERS TEXT BOOK OF ANAESTHESIA 9TH EDITION
• ANAESTHESIA AND PSYCHIATRIC DRUGS –PART 2 MOOD STABILISERS AND ANTIPSYCHOTICS ANAESTHESIA
TUTORIAL OF THE WEEK 175
• ANAESTHESIA & PSYCHIATRIC DRUGS part 1 –ANTIDEPRESSANTS ANAESTHESIA TUTORIAL OF THE WEEK
164 14th DECEMBER 2009

41. THANK YOU