syndrome CAS Dr S Parthasarathy MD DA DNB MD Acu Dip Diab DCA Dip Software statisticsPh D physiology Mahatma gandhi medical college and research institute ID: 909821
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Slide1
Central anticholinergic syndrome (CAS)
Dr. S.
Parthasarathy
MD., DA., DNB, MD (
Acu
), Dip.
Diab
. DCA, Dip. Software
statistics,Ph
D (physiology)
Mahatma
gandhi
medical college and research institute,
puducherry
, India
Slide2Central anticholinergic syndrome (CAS) is a clinical entity
which shows central and peripheral effects produced by over dosage
or abnormal reaction to clinical dosage of
anticholinergic
drugs
Slide3Symptoms Central
Peripheral
Lowest age reported is 4
Slide4Central - Young patients
Slide5Central old patients
Slide6Central Agitation Amnesia
Ataxia
Asynergia
Confusion,excitement
Hallucinations
Delirium
Somnolence
Slide7Central NauseaEmotional instability
Hyperpyrexia,
Hyperalgesia
Convulsions
Muscle
incoordination
Slide8Peripheral Dry mouth Dry skin Arrhythmias
Mydriasis
Blurred vision
Micturition
and bowel dysfunction
Thirst
Slide9Almost no symptom is spared
Slide10Basic mechanism Cholinergic synapses necessary for memory and
anticholinergics
??
Acetylcholine and
anaesthetics
GABA modifies Cholinergic synapses
EEG behavioral dissociation
Slide11Incidence After GA, 9.4 %After RA with sedation 3.3 %
Reported from 4 year child onwards
From Immediate
postop
to first week
Slide12Old age- more incidence The decreased cholinergic reserve in older persons
Other drugs
Slide13Drugs and CAS Antidepressants Anticholinergics
Antipsychotics
Antispamodics
Halo,enflurane
Morphine,
pethidine
Ketamine
Antiparkinson
drugs
Slide14What is this ??An elderly patient is scheduled for enucleation
of a blind, painful eye. Scopolamine, 0.4 mg IM, premedication.
preoperative holding area, the patient becomes agitated and disoriented.
The only other medication the patient has received is 1%atropine eye drops
.
Slide15Differential diagnosis Metabolic encephalopathy ABG, renal parameters ,electrolytes
Neurologic damage
CT scan
Slide16How to conclude as CAS Method of exclusion
Profile
Physostigmine
challenge
0.04 mg / kg IV or IM
5 – 15 minutes symptoms improve
Slide17Physostigmine A cholinesterase inhibitor
Rapidly
hydrolysed
Raised BP and tachycardia !!
No problem with
neostigmine
Analgesia
Usually one dose is enough
Slide18Other drugs Galantamine hydrobromide
4 amino pyridine
Tacrine
But nonspecific
Slide19Delayed recovery naloxone and flumazenil
,
Usually the patients recover to go back to sleep
In CAS , recovery after
physostigmine
is usually complete
Slide20How to avoid ??Atropine Phenergan
Physostigmine
just before recovery
Slide21Acta Anaesthesiol Belg. 1976;27(2):45-60
treated 200 cases in which the CAS was diagnosed with
physostigmine
salicylate
(0.04 mg/kg).
successfully treated 2 cases of apparently central
anticholinergic
hyperpyrexia in the same way.
suggest that
physostigmine
be included in the armamentarium of every
anesthetist
Slide22Thank you all