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 Scopolamine & Delayed Emergence from Anesthesia: A Case Report  Scopolamine & Delayed Emergence from Anesthesia: A Case Report

Scopolamine & Delayed Emergence from Anesthesia: A Case Report - PowerPoint Presentation

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Scopolamine & Delayed Emergence from Anesthesia: A Case Report - PPT Presentation

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

amp 2016 scopolamine dawson amp 2016 scopolamine dawson physostigmine anesthesia buckley anticholinergic patient postoperative central transdermal 2015 receptors nausea

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Slide1

Scopolamine & Delayed Emergence from Anesthesia: A Case Report

Sally Wenger, SRNAYork College of Pennsylvania/ WellSpan Health

Slide2

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.

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.

Slide3

Objectives

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

Slide4

Patient 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

Slide5

Pre-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

Slide6

Pre-operative Assessment

ECG: normal sinus rhythm

CXR: within normal limits, no acute processes

Labwork

within normal limits

Starting H&H 11.8/ 36.2

Slide7

Surgical Course

0708 : patient in room

0715: induction

0810: incision

1536: procedure stop

Slide8

Surgical Course

Slide9

Surgical Course

0708 : patient in room 0715: induction 0810: incision 1536: procedure stop 1740: out of OR1800: CT scan1830: handoff to PACU

1515: sedation off

Slide10

Central 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

Slide11

Peripheral

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

Slide12

Scopolamine

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

Slide13

Dawson & Buckley, 2016

Slide14

Differential Diagnoses

Respiratory: hypoxia, hypercarbiaNeuropsychiatric: cerebral hypoxia, intracerebral hemorrhage, acute psychosis Metabolic: glucose, electrolytesIllicit drug useAcute withdrawal from alcohol and opiates

Schneck

&

Rupreht

, 1989

Slide15

CAS Treatment

Current recommended treatment is a centrally acting acetylcholinesterase inhibitorSelective M1 receptor agonist?

Dawson & Buckley, 2016

Pharmacological Blog, 2013

Slide16

Physostigmine

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

Slide17

Pharmacology

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

Slide18

Dawson & Buckley, 2016

Slide19

Dosing

Dawson & Buckley, 2016; Quang et al. 2015

Slide20

Afterthoughts

Slide21

Scopolamine 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

Slide22

Handoff 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

Slide23

Good 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

Slide24

References

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.