Sally Wenger SRNA York College of Pennsylvania WellSpan Health Case Studies are descriptive studies that are prepared for illustrating novel unusual or atypical features identified in patients in anesthesia practice and they potentially generate new research questions ID: 774953
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Slide1
Scopolamine & Delayed Emergence from Anesthesia: A Case Report
Sally Wenger, SRNAYork College of Pennsylvania/ WellSpan Health
Slide2Case Studies are descriptive studies that are prepared for illustrating novel, unusual, or atypical features identified in patients in anesthesia practice and they potentially generate new research questions.
In compliance with the Health Insurance Portability and Accountability Act (HIPPA) all patient data has been de-identified and every attempt has been made to ensure patient privacy and data security.
Slide3Objectives
Discuss case and anesthetic course
Discuss implications of Central Anticholinergic Syndrome
Discuss scopolamine and implications for nurse anesthetists
Review
physostigmine
pharmacology and uses in anesthesia
Slide4Patient Demographics
63 y/o male
ASA 3
Allergies: penicillin, adhesive, codeine
102 kg, BMI 30.7 kg/m2
Thoracic and lumbar decompression with fusion and instrumentation T12 – pelvis
Slide5Pre-operative Assessment
PMH: HTN, asthma, degenerative disc disease, GERD, PONV
Home medications
Amiodarone Albuterol Gabapentin
Amlodipine
Singulair
Oxycodone
Metoprolol Escitalopram Ambien
PSH: lumbar fusion (October ’18), shoulder replacement, ERCP, cholecystectomy
Slide6Pre-operative Assessment
ECG: normal sinus rhythm
CXR: within normal limits, no acute processes
Labwork
within normal limits
Starting H&H 11.8/ 36.2
Slide7Surgical Course
0708 : patient in room
0715: induction
0810: incision
1536: procedure stop
Slide8Surgical Course
Slide9Surgical Course
0708 : patient in room 0715: induction 0810: incision 1536: procedure stop 1740: out of OR1800: CT scan1830: handoff to PACU
1515: sedation off
Slide10Central Anticholinergic Syndrome
What is it: A manifestation of central and peripheral competitive antagonism of acetylcholine at the muscarinic receptor M1 receptors: CNSM2 receptors: heart, CNSM3 receptors: glandular organsM4 receptors: heart, CNSM5 receptors: CNS
Dawson & Buckley, 2016;
Nagelhout
&
Plaus
, 2014;
Renner ,
Oertel
, &
Kirch
, 2005
Slide11Peripheral
Dry mouth/ skin Dysphagia Dilated pupilsBlurred vision Reduced gastrointestinal motility Absent bowel sounds Urinary retention Sinus tachycardia Blood pressure swingsFeverCentral Depressed type Coma Decreased consciousness Hyperactive type Agitation Delirium Seizures
Dawson & Buckley,
2016
Slide12Scopolamine
Non-selective, competitive antagonist of peripheral and central muscarinic receptorsTertiary amine Administration via transdermal routePriming dose 140 mcg with 1.5 mg drug reservoir Contraindicated in pregnant women, patients with glaucoma, plaster allergy
Gan
& Habib, 2016;
Knuf
, Spaulding, & Stevens, 2019;
Renner et al.,
2005
Slide13Dawson & Buckley, 2016
Slide14Differential Diagnoses
Respiratory: hypoxia, hypercarbiaNeuropsychiatric: cerebral hypoxia, intracerebral hemorrhage, acute psychosis Metabolic: glucose, electrolytesIllicit drug useAcute withdrawal from alcohol and opiates
Schneck
&
Rupreht
, 1989
Slide15CAS Treatment
Current recommended treatment is a centrally acting acetylcholinesterase inhibitorSelective M1 receptor agonist?
Dawson & Buckley, 2016
Pharmacological Blog, 2013
Slide16Physostigmine
Derived from calabar bean – native of tropical AfricaCited to be used in trial by ordeal – early 1800s
Nickalls & Nickalls, 1988;Rygnestad, 1992
First clinical use in 1863
Main alkaloid physostigmine isolated in 1864
First systemic use in
1864
Slide17Pharmacology
Volume of distribution: 1.35 L/kgDistribution half-life: 2.3 minElimination half-life: 22 min Clearance: 4.3 L/min Duration of action: 30-60 minMetabolized by cholinesterase-mediated hydrolysis
Dawson & Buckley, 2016;
Hartvig
,
Wiklund
, &
Lindström
, 1986
Slide18Dawson & Buckley, 2016
Slide19Dosing
Dawson & Buckley, 2016; Quang et al. 2015
Slide20Afterthoughts
Slide21Scopolamine and PONV
Effective in reducing rates of PONV during initial 24 hoursMonotherapy vs. combo-therapy Zofran + scopolamineDecadron + scopolamine Most frequently reported side effects include dry mouth and vision disturbances
Apfel
et al., 2010;
Gan
et al., 2009;
Lee et al., 2010;
Pergolizzi
et al., 2015
Zhang et al., 2016
Slide22Handoff of Care
Critical points MDA to CRNACRNA to SRNA MDA to MDAWhat was missedChart review at handoff and at end of case
Agarwala
, Firth, Albrecht, Warren, &
Musch
, 2015
Slide23Good things
Write up in bi-weekly anesthesia newsletter
Pharmacy and
physostigmine
Patient was clear headed and cognitively intact in post-op period, no stroke-like symptoms
Slide24References
Agarwala
, A. V., Firth, P. G., Albrecht, M. A., Warren, L., &
Musch
, G. (2015). An electronic
checklist
improves transfer and retention of critical information at intraoperative handoff of care.
Anesthesia & Analgesia
,
120
(1), 96-104.
doi
: 10.1213/ANE.0000000000000506
Apfel
, C. C., Zhang, K., George, E., Shi, S.,
Jalota
, L.,
Hornuss
, C., ... &
Kranke
, P. (2010). Transdermal scopolamine for the prevention of postoperative nausea and vomiting: a systematic review and meta-analysis.
Clinical therapeutics
,
32
(12), 1987-2002.
Dawson, A. H., & Buckley, N. A. (2016). Pharmacological management of anticholinergic delirium‐theory, evidence and practice.
British journal of clinical pharmacology
,
81
(3), 516-524.
Gan
, T. J., & Habib, A. S. (2016).
Postoperative nausea and vomiting
. Cambridge, New York:
Cambridge University
Press.
Gan
, T. J., Sinha, A. C.,
Kovac
, A. L., Jones, R. K., Cohen, S. A.,
Battikha
, J. P., ... &
Pergolizzi
, J. V. (2009). A randomized, double-blind, multicenter trial comparing transdermal scopolamine plus ondansetron to ondansetron alone for the prevention of postoperative nausea and vomiting in the outpatient setting.
Anesthesia & Analgesia
,
108
(5), 1498-1504.
Hartvig
, P.,
Wiklund
, L., &
Lindström
, B. (1986). Pharmacokinetics of
physostigmine
after intravenous, intramuscular and subcutaneous administration in surgical patients.
Acta
anaesthesiologica
scandinavica
,
30
(2), 177-182
.
Knuf
, K. M., Spaulding, F. M., & Stevens, G. J. (2019). Scopolamine Toxicity in an Elderly Patient. Military Medicine.
doi:10.1093/
milmed
/usz086
Lee, H. K., Lee, J. H., Chon, S. S.,
Ahn
, E. K., Kim, J. H., & Jang, Y. H. (2010). The effect of transdermal scopolamine plus intravenous dexamethasone for the prevention of postoperative nausea and vomiting in patients with epidural PCA after major orthopedic surgery.
Korean journal of anesthesiology
,
58
(1), 50.
Moore
, P. W.,
Rasimas
, J. J., & Donovan, J. W. (2015).
Physostigmine
is the antidote for anticholinergic syndrome.
J Med
Toxicol
,
11
(1), 159-60
.
Nagelhout
, J. L., &
Plaus
, K. L. (2014).
Nurse anesthesia.
St. Louis, Missouri: Elsevier.
Nickalls
, R. W. D., &
Nickalls
, E. A. (1988). The first use of
physostigmine
in the treatment of atropine poisoning: A translation of
Kleinwachter's
paper entitled ‘Observations on the effect of
Calabar
bean extract as an antidote to atropine poisoning’.
Anaesthesia
,
43
(9), 776-777
.
Pergolizzi
, J. V.,
Raffa
, R. B.,
Zamponga
, G.,
Annabi
, H. M.,
Pallaria
, T. J., & Taylor, R. (2015). Revisiting transdermal scopolamine for postoperative nausea and vomiting.
Research and Reports in Transdermal Drug Delivery, 4,
35-44.
Pharmacological Blog. (2013).
Cholinergic agonists.
Retrieved from
http://n-pharmacology.blogspot.com/2013/06/chapter-4-cholinergic-agonists-overview.html
Renner
, U. D.,
Oertel
, R., &
Kirch
, W. (2005). Pharmacokinetics and pharmacodynamics in clinical use of scopolamine.
Therapeutic drug monitoring
,
27
(5), 655-665
.
Rygnestad
, T. (1992). Development of
physostigmine
from a poisonous plant to an antidote. One of the most important drugs in the development of modern medicine?
Tidsskrift
for den Norske
Igeforening
, 112
(10), 1300-1303.
Schneck
, H. J., &
Rupreht
, J. (1989). Central anticholinergic syndrome (CAS) in anesthesia and intensive care.
Acta
Anaesthesiologica
Belgica
,
40
(3), 219-228
.
Walker, A.,
Delle
Donne, A., Douglas, E., Spicer, K., &
Pluim
, T. (2014). Novel use of
dexmedetomidine
for the treatment of anticholinergic
toxidrome
.
Journal of Medical Toxicology
,
10
(4), 406-410
.
Quang
, C. Y., Blair, S. G., Watson, R., Brevard, S. B., Simmons, J. D., & Tan, M. C. (2017). Postoperative Central Anticholinergic Syndrome: Is it Really that Rare?.
The American surgeon
,
83
(3), E104
.
Zhang, L. L., Liu, H. Q., Yu, X. H., Zhang, Y., Tian, J. S., Song, X. R., ... & Liu, A. J. (2016). The combination of scopolamine and psychostimulants for the prevention of severe motion sickness.
CNS neuroscience & therapeutics
,
22
(8), 715-722.