In compliance with the Health Insurance Portability and Accountability Act HIPPA all patient data has been deidentified and every attempt has been made to ensure patient privacy and data security ID: 798477
Download The PPT/PDF document "Case Studies are descriptive studies tha..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
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.
Slide2Anesthetic Management of a Vascular Surgery Patient at Risk For Alcohol Withdrawal SyndromeElizabeth Pritchard BSN, RN, SRNA
Slide3Patient Summary and BackgroundPatient:71-year-old malePresented with severe pain and gangreneScheduled surgery:Femoral-popliteal bypass graft & trans-metatarsal amputation
Comorbidities
:
Peripheral Arterial Disease
Hypertension
Alcohol Use Disorder
Slide4Peripheral Arterial DiseaseRisks20% of populationNon-white raceMale genderIncreased ageSmoking Patients with diabetics, hypertension, and CRI
Indications for surgery
Intermittent claudication
Ischemic rest pain
Gangrene
Management
Medical Optimization
~10% myocardial injury
Slide5Aortoilliac occlusive disease (AIOD)Atherosclerotic narrowing of AortaCan result in hypoperfusion
Critical limb ischemia
Arterial blood flow compromised
1-2% of PAD patients
Increased risk for limb loss
25%- amputation
25%- fatal cardiovascular event
Risk for stroke & MI
Slide6Alcohol UseMetabolized by zero-order kinetics
ACUTE
CNS depression
Disinhibition of inhibitory pathways
Cardiorespiratory Depression
Slide7Alcohol Use DisordersIncreased risk for aspirationLiver synthesis dysfunctionDecreased circulating plasma cholinesteraseMAC level alterationsHeart Failure Decreased Lung Volumes
Peripheral nerve and neuropsychiatric diseases
Nutritional deficiencies
Wernicke’s Encephalopathy
Folic Acid deficiency
Neuropathies and weakness
HTN
Slide8Alcohol Withdrawal Syndrome (AWS)Up to 50% of patients with AUD will experience AWS Symptoms begin as soon as six hours after decreasing intake
More severe withdrawal due to “kindling” which lowers threshold
Disruption in GABA and NMDA pathways
Seizures can be seen between 6 and 48 hours, hallucinations between 12 and
Delirium tremens (DT) can occur 48-96 hours and can cause tachycardia, hypertension, fever, diaphoresis and delirium
Mortality risk is up to 15%
Preoperative magnesium
Slide9Treatment & Prevention Long acting benzodiazepine the night before surgery
Short acting benzodiazepine the morning of surgery
Short acting benzodiazepine for premedication
Clonidine .5mcg/kg/hour
Haloperidol (up to 3.5 mg daily)
Ketamine .5mg/kg
Thiamine 200 mg IV up to 5 days
Stress dose steroids?
Slide10Case Study:Patient presentation 71 year-old white malePMH: Hypertension DiabetesPeripheral arterial diseaseAlcohol use disorderPSH:Right to left femoral bypass in 2010 with 4th and 5
th
transmetatarsal
amputation
Aortobifemoral
graft 2010
Discharged to SNF on lisinopril and aspirin.
Lost to follow up and presented in September of 2018 with dry gangrene, pain and contraction of his right lower extremity
Slide11Preoperative evaluation and examExtremely thin BMI: 19.1Sitting on the edge of the bed in significant pain and contractedPleasant and answered questionsDenies taking medications or any recent medical careEndorsed 25 beers daily Airway exam concerning for limited ROM
EKG: NSR
VSS: 99.1, HR 89, BP 92/56
Pain: 7/10- 10/10
Open draining black wound
Doppler US showed limited arterial blood flow distal to the knee
Morphine ER BID, Vancomycin and Zosyn
Lisinopril held for low BP
Slide12Intraoperative courseExtremely irritable and non-cooperative10/10 pain and photophobia 36 hours since his last drinkBP: 82-95/49-55Midazolam 2mg was given prior to OR
Propofol, fentanyl, rocuronium
Hypotension was treated with phenylephrine and ephedrine
16g IV and radial Artline were placed
Ketamine 50mg was given as an infusion
Additional 3mg midazolam in divided doses
Additional rocuronium
Slide13Slide14Postoperative course and outcomeEmergence:HypertensiveObstructed airwayPACU:Ekg, CMP with Magnesium (1.6 mEq/L)Hypotension to 72/40Albumin %5 500 ml
Phenylephrine restarted
Transferred to STCU and placed on CIWA protocol and received lorazepam per protocol overnight
POD 1:
Resting comfortably and weaned off phenylephrine
Pleasant and cooperative
Oxycodone 5mg PRN
Discharged to SNF for 3 weeks of physical therapy
Slide15Discussion & Lessons learnedStandardized protocols for screening and treatmentOptimizing patient vs emergent surgeryOverlapping disease processesCAD and increased oxygen demandAUD and AWS have high rates of undetected Anesthetic medications can mask signs and symptoms of AWS
Regional anesthesia in patients at risk for AWS?
Missed aspects of recommendations
Preoperative optimization on floor
Slide16Questions?What type of screening or assessment do you perform preoperatively on patients that endorse alcohol use both related to withdrawal potential and cardiovascular complications. What communication methods or tools would provide a more comprehensive plan of care for these vulnerable patients?
Slide17ReferencesDevereaux
, P. J., Yang, H., Yusuf, S.,
Guyatt
, G., Leslie, K., Villar, J. C., . . .
POISE Study Group. (2008). Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): A
randomised
controlled trial.
Lancet, 371
(9627), 1839-1847. doi:10.1016/S0140-6736(08)60601-7
Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation.
2014;130(24):2215–2245
Kork
, F., Neumann, T., & Spies, C. (2010). Perioperative management of patients with alcohol, tobacco and drug dependency.
Current Opinion in Anaesthesiology
, 23
(3), 384-390. doi:10.1097/ACO.0b013e3283391f79
Littleton, J. (1998). Neurochemical mechanisms underlying alcohol withdrawal.
Alcohol Health and Research World, 22
(1), 13.
Mostafaie
, K.,
Bedenis
, R., & Harrington, D. (2015). Beta-adrenergic blockers for perioperative cardiac risk reduction in people undergoing vascular surgery.
The Cochrane Database of Systematic Reviews, 1
, CD006342. doi:10.1002/14651858.CD006342.pub2
Olin, J. W. &
Sealove
, B. A. (2010). Peripheral artery disease: Current insight into the disease and its diagnosis and management.
Mayo Clinic Proceedings, 85
(7), 678-692. doi:10.4065/mcp.2010.0133
Puz
, C. A., & Stokes, S. J. (2005). Alcohol withdrawal syndrome: Assessment and treatment with the use of the clinical institute withdrawal assessment for alcohol-revised.
Critical Care Nursing Clinics of North America, 17
(3), 297-304. doi:10.1016/j.ccell.2005.04.001
Schuckit
, M. A. (2014). Recognition and management of withdrawal delirium (delirium tremens).
The New England Journal of Medicine, 371
(22), 2109-2113. doi:10.1056/NEJMra1407298
Substance Abuse and Mental Health Services Administration (SAMHSA). 2015 National Survey on Drug Use and Health (NSDUH). Table 5.6A—Substance Use Disorder in Past Year among Persons Aged 18 or Older, by Demographic Characteristics: Numbers in Thousands, 2014 and 2015. Available at:
https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.htm#tab5-6a
. Accessed 12/18/18.
Substance Abuse and Mental Health Services Administration (SAMHSA). 2015 National Survey on Drug Use and Health (NSDUH). Table 5.6B—Substance Use Disorder in Past Year among Persons Aged 18 or Older, by Demographic Characteristics: Percentages, 2014 and 2015. Available at:
https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.htm#tab5-6b
. Accessed 12/18/18.
Tetrault
, J. M., & O'Connor, P. G. (2008). Substance abuse and withdrawal in the critical care setting.
Critical care clinics
,
24
(4), 767-788.
doi
:
10.1016/j.ccc.2008.05.005
Long J B Suresh S 2017 Clinical
anesthesiaValentine
, E. &
Ochroch
, E.A. (2017). Anesthesia for Vascular and Endovascular Surgery. In P. G. (Valentine, &
Ochroch
, 2017), B. F. Cullen, R. K.
Stoelting
, M. K.
Cahalan
, M. C. Stock, R. Ortega,...N. F. Holt (Ed.),
Clinical anesthesia
(8th ed., pp. 1113-1139). Philadelphia, PA: Wolters Kluwer. 20180404213833538859010