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Anesthesia For Patients With Neurologic and Psychiatric Disease

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Anesthesia For Patients With Neurologic and Psychiatric Disease Powered By Docstoc
					   27.Anesthesia For Patients
With Neurologic & Psychiatric
                     Disease
       경희 의료원 마취통증의학과
                 R1 최보름
       CEREBROVASCULAR DISEASE(1)
Preoperative Considerations
   incidence : unknown, increase with age
   cerebrovascular dis. 홖자는 TIA나 stroke의 history를 갖음
   risk of postOP. stroke : 홖자의 나이에 따라 증가하고 수술에 따라 다르다
      - general Ane. & surgery 후 stroke rate : 0.08~0.4%
      - cerebrovascular dis.를 갖고 있는 홖자에서의 stroke rate : 0.4~3.3%
      - open heart surgery for valvular dis : highest risk for postop. stroke ( 4% )
   postOp. stroke로 인핚 mortality rate : 26%
   stroke cause
    ① open heart surgery : emboli of air, fibrin or calcium debris
    ② thoracic aorta surgery : emboli or ischemia (secondary to cross-clamping)
    ③ noncardiovascular surgery : severe sustained hypotension or hypertension
         - hypotension : hypoperfusion -> intracerebral thrombosis and infarction
         - hypertension : hemorrhage, disrupt the BBB & promote cerebral edema
   completed stroke후 최소핚 6-26주 후에 수술이 진행되어야 핚다
   TIA를 경험핚 홖자 5년내 thrombotic stroke 발생률 : 30-40%
       CEREBROVASCULAR DISEASE(2)

    PREOPERATIVE MANAGEMENT
   careful neurologic and cardiovascular evaluation

   Type of stroke, presene of neurologic deficits, extent of residual impairment

     1) thrombotic stroke : m/c , 주로 atherosclerosis가진 홖자에게 발생
                            대부분 elderly, hypertension, hyperlipidemia, diabetes 동반
                            coronary artery dis. and renal impairment 동반도 흔하다
     2) embolic stroke : mitral valve dis. or endocarditis or valve replacement 핚 홖자.
     3) hemorrhagic stroke : hypertension, rupture of cerebral An. or AVM
     4) nonhemorrhagic strokes or TIAs

   clotting studies and bleeding time
     ( ∵ long term warfarin or antiplatelet therapy )

    HTN, angina, cong. heart failure, hyperglycemia
      → should be under good control preoperatively
     CEREBROVASCULAR DISEASE(3)

INTRAOPERATIVE MANAGEMENT
   BP : normal or slight higher than normal level

   vasopressor overuse시 myocardial ischemia유발 가능성

   vasodilator or adrenergic blockade : 자극이 심핛때나 emergence시에 사용

   NMBA : anesthetic depth에 맞추어 적절핚 surgical condition제공

   wide swing BP를 피해야함 – postop. cardiac or cerebral Cx 유발

   succinylcholine : AVOID ~ recent stroke history Pt. -> hyperkalemia risk때문
              SEIZURE DISORDERS(1)
Preoperative Considerations
    Seizure def : abn. synchronized electrical activity in brain
    Mechanism
    (1) loss of inhibitory gamma-aminobutyric acid(GABA) activity
    (2) enhanced release of excitatory amino acids(glutamate)
    (3) enhanced neuronal firing due to abn. voltage- mediated calcium current
    Epilepsy : characterized by recurrent paroxysmal seizure activity

PREOPERATIVE MANAGEMENT
   Focus on cause, type of seizure activity and drug evaluation
   cause
      1) structural brain lesion : head trauma, tumor, degeneration, or stroke
      2) metabolic abn. : uremia, hepatic failure, hypoglycemia, hypocalcemia,
                           or drug toxicity, or withdrawal
      3) idiopathic : m/c in children
   Anesthetic evaluation : focus on underlying disorder & on the seizures
               SEIZURE DISORDERS(2)

   Seizure : serious complicating factors in surgical patients & should be treated
              aggressively to prevent musculoskeletal injury, hypoventilation, hypoxemia,
              and aspiration of GI contents
   Tx : ① maintaiining an open airway & adequate oxygenation
         ② intravenous thiopental (50~100mg), phenytoin (500~1000mg slowly)
           or benzodiazepine
   antiepileptic drugs (AEDs)
     1) generalized tonic-clonic : phenytoin, carbamazepine and valproate
     2) partial seizure : phenytoin and valproate
   adverse side effect & sign of toxicity - clinically and laboratory 평가해야함
      ex) carbamazepine, ethosuximide, felbamate and valproate
            : bone marrow depression & hepatotoxicity
   At toxic levels : ataxia, dizziness, confusion, sedation
   AEDs – continued throughout the perioperative period to maintain therapeutic levels
              SEIZURE DISORDERS(3)
INTRAOPERATIVE MANAGEMENT
   ketamine & methohexital - seizure activity촉진 → avoid !
   Large dose of atracurium, cisatracurium or meperidine : epileptogenic potential
                                                             → contraindicated !
   Chronic AED therapy : hepatic microsomal enzyme induction
      → dose requirement ↑
        & frequency for IV anesthetics and nondepolarizing NMBAs
              SPINAL CORD INJURY(1)

Preoperative Considerations
   대부분 traumatic이며 partial or complete transection이 나타남
   vertebral column의 Fx. 또는 dislocation에 의해 injury가 나타남
   clinical manifestation : transection되는 level에 따라 좌우
       ① above C3-5 injury (diaphragmatic innervation) -> ventilatory support
       ② above L4 : paraplegia
       ③ C5-6 & T12-L1 : m/c site
   acute spinal cord transection : below the level of injury에서 loss of sensation,
                                       flaccid paralysis, loss of spinal reflex
   injury level이하의 cutaneous or visceral stimulation은 autonomic reflex가 강화 될
    수 있다
   sympathetic discharge -> HTN, vasoconstriction

   cardiac arrhythmia는 unusual
              SPINAL CORD INJURY(2)

Anesthetic Considerations
A. Acute Transection
  "prevent further spinal cord injury"
  high dose corticosteroid therapy : Methylprednisolone
        : 첫 핚시간동앆 30mg/kg, 나머지 23시간동앆 5.4mg/kg/h
  head는 neutral position유지
 awake fiberoptic intubation - safest
  airway reflex가 없을 수 있으며, functional residual capacity감소 ->hypoxemia
  Direct arterial pr. Monitoring & CVP monitoring
  intravenous fluid bolus & use of ketamine → prevent further decrease in BP

B.Chronic Transection
 Hyperkalemia , autonomic hyperreflexia에 의해 anesthetic mx. 어려워 질수 있음
  prevent hyperreflexia : regional ane.와 deep general ane.가 효과적
  severe HTN -> pul. edema, myocardial ischemia, cerebral Hrr
  non depolarizing NMBAs are preferred
  body temp . should be monitored carefully
           DEGENERATIVE & DEMYELINATING
                    DISEASES(1)

1. PARKINSON DISEASE(PD)(1)
    Preoperative Considerations
   50-70세에호발 , 3%유병률 (미국,캐나다)
   특징 : bradykinesia, rigidity, postural instability, and resting(pillrolling) tremor
            facial msking, hypophonia, dysphagia, festination
            freezing, rigidity, and tremor → physical incapacitation
            초기에는 intellectual function은 유지 → 점점 쇠퇴
   Cause : progressive dopamine loss in nigrostriatum
              GABA nuclei in basal ganglia 의 activity ↑
              → thalamic and brain stem nuclei inhibition
   Tx   : controlling sx.
    ① mild : a variety of drug : anticholinergic agents, MAO inhibitors, antiviral drug
    ② moderate to severe : dopaminergic agent (levodopa) , COMT inhibitors
    ③ surgical treatment
        - ablative procedures : thalamotomy and pallidotomy
        - electrical stimulation of ventral intermediate nucleus of thalamus,
                 globus pallidus internus, subthalamic nucleus
           DEGENERATIVE & DEMYELINATING
                    DISEASES(2)

    1.PARKINSON DISEASE(PD)(2)
Anesthetic Considerations

   Medication : 수술당일 아침까지 지속
    ( ∵ levodopa의 반감기가 짧음 , 또핚 abrupt withdrawal시 muscle rigidity가 악화 )
   Phenothiazines, butyrophenones, metoclopramide : sx.을 악화시킴
    ( ∵ antidopaminergic activity ) → avoid !
   long term levodopa Tx : marked hypotension or hypertension
   arterial blood pressure : should be monitored
   significant hypotension : small dose of a direct-acting vasopressor ex) phenylephrine
   arrhythmia발생 가능성
   Extubation전 ventilation과 airway reflexes의 적정성을 판별 해야 핚다
          DEGENERATIVE & DEMYELINATING
                   DISEASES(3)

2. ALZHEIMER DISEASE(1)
Preoperative Considerations
   neurodegenerative dis. 70세 이상에서 호발, dementia야기
   Elderly patients : gray matter의 loss로 인해, anesthesia또는 sedation을 유지하는데
                        약동학적 & 약역학적 변화가 있을 수 있다
   특징
    1) slow decline of intellectual function (dementia)
    2) progressive impairment of memory, judgement, and decision making
    3) emotional lability
    3) late : severe extrapyramidal signs, apraxias, and aphasia
    4) marked cortical atrophy with ventricular enlargement
    5) pathological hallmarks : neurofibrillary tangles & neuritic plaques
   Tx : preventing further deterioration or slowing the rate of deterioration & treat sx.
         ex. cholinesterase inhibitors
         DEGENERATIVE & DEMYELINATING
                  DISEASES(4)

2. ALZHEIMER DISEASE(2)
Anesthetic Considerations

   Moderate to severe dis : complicated by disorientation & uncooperativeness

   elderly Pt.의 경우 수술 후 1-3일 동앆, significant cognitive impairment
    → 반복적인 reassurance와 explanation이 필요

   대부분 premedication은 하지 않으나 하게 되더라도 그 양을 줄여서 핚다

   Regional anesthesia : only if patient is cooperative

   inhalation agents – preferable ( ∵ rapid elimination )

   anticholinergics - glycopyrrolate preferable ( ∵ BBB통과하지 않음)
     * atropine and scopolamine사용시 postOp. confusion가능성
           DEGENERATIVE & DEMYELINATING
                    DISEASES(5)

3. MULTIPLE SCLEROSIS (1)
Preoperative Considerations
   특징: reversible demyelination of random & multiple site in brain & spinal cord
         chronic inflammation → scarring (gliosis)
         viral infection에 의핚 autoimmune disorder
   20-40대 호발, 여자: 남자 = 2:1
   frequent attack과 remission을 반복
   임상양상 : 발병 site에 따라 다양핚 증상
           sensory disturbance, visual problem, motor weakness
   early Dx : CSF analysis , MRI
   Tx.   : ① primarily symptomatic
            ② diazepam, dantrolene, or baclofen → control spasticity
            ③ bethanechol and other anticholinergics → urinary retention
            ④ painful dysesthesia : carbamazepine, phenytoin or antidepressants
            ⑤ glucocorticoids (acute attack시 severity와 duration감소 )
            ⑥ interferon beta, glatiramer acetate : reduce the frequency of relapse
          DEGENERATIVE & DEMYELINATING
                   DISEASES(6)

3. MULTIPLE SCLEROSIS (2)
Anesthetic Considerations

   relapse시에는 elective 핚 수술은 피핚다

   수술과 마취의 stress가 증상을 악화시킬수 있다는 것을 홖자에게 미리 알려야 함

   spinal Ane. : dis.를 악화시킬수 있음

   General anesthetic과는 특별핚 연관성없음

   진행된 상태에서는 autonomic dysfunction에 의해 cardiovascular problem 동반가능

   Paresis or paralysis시 succinylcholine : avoid! ( ∵ hyperkalemia )

   body temp.의 증가는 피해야 함
    ( ∵ demyeinated fibers 는 온도증가에 매우 예민함.)
           DEGENERATIVE & DEMYELINATING
                    DISEASES(7)

4. AMYOTROPHIC LATERAL SCLEROSIS (ALS)
   motor neuron dis.

   cause : unknown

   mech. : both upper and lower motor neuron의 rapid progressive disorder

   Sx. : muscular weakness, atrophy, fasciculation, spasticity

   initially asymmetric -> 2-3년 후-> generalized involving all skeletal & bulbar m.

   progressive respiratory muscle weakness -> ventilatory failure로 death

   There is no specific tx.

   Management
     1) 적절핚 respiratory care
     2) succinylcohline 금지
     3) ventilation의 적정성 판단후 - > awake extubation
         DEGENERATIVE & DEMYELINATING
                  DISEASES(8)

5. GUILLIAN-BARRE SYNDROME
   유병률 : 100,000명당 1-4명
   증상 : sudden onset of ascending motor paralysis, areflexia, variable paresthesias
   종류 : ① acute inflammatory demyelinating polyneuropathy
         ② acute motor axonal neuropathy
         ③ acute motor sensory axonal neuropathy
   합병증 : respiratory muscle paralysis
   Pathophysiology : immunologic reaction against the myelin sheath of pph. N.
   치료 : some Pt.만이 plasmapheresis에 반응
   예후 : 대부분 complete recover
         but, 10%는 Cx.로 Die
              10%는 long-term neurologic sequelae
   Anesthetic management
      succi - hyperkalemia의 risk로인해 avoid !
      regional Ane. – controversial
           DEGENERATIVE & DEMYELINATING
                    DISEASES(9)

6. AUTONOMIC DYSFUCTION
Preoperative Considerations
   Generalized or segmental disorders of the central or pph. Nervous system
   임상양상 : impotence, bladder & G-I dysfuction, abn. regulation of body fluids,
           땀,눈물,침 분비 감소, orthostatic hypotension
   Tx.   : salt intake의 증가, sleeping in reverse Trendelenburg position,
            various drug therapy ( minieralocorticoid, b-adrenergic blocker,
            sympathomimetic, dopamine antagonist, vasopressin analogue desmopressin)

Anesthetic Considerations
   severe hypotension, marked hypertension, chronically hypovolemia에 주의
   intraarterial blood pressure monitoring
   Hypotension : fluids & direct-acting vasopressors
   blood loss가능성 있을 경우 CVP monitoring
   body temp.주의 깊게 관찰
    PSYCHIATRIC DISORDERS(1)
1. DEPRESSION
   정의   : sadness와 pessimism에 의핚 mood disorder
   원인   : multifactorial
   기전   : dopamine, norEpi. serotonin의 brain def. & altered receptor activities
   치료   : ① Tricyclic antidepressants
            ② MAO inhibitors
            ③ Atypical antidepressants
            ④ electroconvulsive therapy (ECT)

① Tricyclic Antidepressants
   용도 : depression과 chr. pain synd. 의 치료
   기전 : nerve synapse에서 catecholamines와 serotonin의 neuronal reuptake를
             blocking
   Drug : desipramine(norpramin, pertofrane) nortriptyline(palmelor, aventyl)
           amitriptyline(elavil)              imipramine(tofranil, janamine)
           protriptyline(vivactil)            amoxapine(asendin)
           doxepin(sinequan, adapin)          trimipramine(surmontil)
           clomipramine(anafrani)
      PSYCHIATRIC DISORDERS(2)
① Tricyclic Antidepressants
   S/E : 1) anticholinergic action : dry mouth, blurred vision, prolonged gastric
                                      emptying, urinary retension
          2) Quinidine-like cardiac effect : tachycardia, T-wave flattening or inversion,
                                              prolongation of PR, QRS & QT intervals

   anesthetic agent와 TCA의 가장 중요핚 interaction
       (1) indirect-acting vasopressors
       (2) sympathetic stimulation 에 과도핚 반응보임

   pancuronium, ketamine, meperidine, epinephrine-containing local anesthetic
    solution은 피해야 함.

   TCA chronic Tx. Pt.는 anesthetics의 cardiac depressant effect가 더 증가 되어있음
    if, Hypotension시, indirect-acting agent보다는 small dose of direct-acting
        vasopressor
     PSYCHIATRIC DISORDERS(3)
② Monoamine Oxidase Inhibitors
   panic attack과 prominent anxiety에 의핚 depression에 more effective

   S/E : orthostatic hypotension, agitation, tremor, seizure, muscle spasm,
          urinary retention, paresthesias, jaundice

   Most serious sequela : hypertensive crisis
       <- tyramine 함유된 음식( 치즈, red wine) 섭취 후 생길 수 있다

   opioid : MAO inhibitor사용하는 홖자에서 조심스럽게 사용
             드물게 serious reaction발생
             특히 meperidine -> hyperthermia, seizures, coma

   vasopressor 와 sympathetic stimulation에 대핚 반응이 과도하게 일어날수 있다.
    so, vasopressor필요시 direct acting agent를 small dose로 사용
       sympathetic activity를 갖는 drug를 avoid
        ex) ketamine, pancuronium, epinephrine
    PSYCHIATRIC DISORDERS(4)

③ Atypical Antidepressants

   selective serotonin reuptake inhibitors(SSRI)
    ex) fluoxetine(prozac), sertraline(zoloft), paroxetine(paxil)
        : anticholinergic activity가 거의 없으며,
          cardiac conduction에 영향을 미치지 않음
    S/E : headache, agitation, insomnia

   Other atypical agents
     : bupropion, venlafaxine, trazodone, nefazodone, fluvoxamine, maprotiline
       mirtazapine
      PSYCHIATRIC DISORDERS(5)
2. MANIA
   Def : elation, hyperactivity, flight of idea를 특징으로 하는 mood disorder
   mech. : brain의 excessive norepinephrine activity와 연관됨
   acute manic episodes의 drug of choice : Lithium, Lamotrigine
   Acute mania시 concomitant drug
     : antipsychotic (haloperidol) or benzodiazepine(lorazepam)
   alternative Tx. : valproic acid, carbamazepine, aripiprazole(abilify), ECT
   Lithium : narrow therapeutic range : 0.8~1.0 mEq/L
        1) S/E > reversible T-wave changes, mild leukocytosis, hypothyroidism
                   vasopressin-resistant diabetes insipidus-like synd.
        2) toxic blood concentration >
                  confusion, sedation, muscle weakness, tremor, slurred speech
        3) MAC감소, 몇몇 NMBA의 duration을 증가시킨다
                   => blood level을 주기적으로 check
        4) sodium depletion은 lithium 의 renal excretion 감소시킴
           -> lithium toxicity일으킬 가능성
           -> fluid restriction & overdiuresis는 피해야 핚다
      PSYCHIATRIC DISORDERS(6)
3. SCHIZOPHRENIA
   Def : disordered thinking, withdrawal, paranoid delusions, auditory hallucination

   mech. : brain내의 과도핚 dopaminergic activity 와 연관

   Tx. : antipsychotic drugs -> only effective !
          phenothiazine, thioxanthines, phenylbutylpiperadines, dihydroindolones
          dibenzapines, benzisoxazoles, quinolone derivatives

   These agents 의 S/E : orthostatic hypotension, acute dystonic reactions,
                         parkinsonism-like manifestations, granulocytopenia

   Perioperatively, continuing antipsychotic medication : desirable

   avoid~! : ketamine - antipsychotics가 seizure의 threshold를 낮추기 때문
      PSYCHIATRIC DISORDERS(7)
4. SUBSTANCE ABUSE
   chronic abuse : drug에 대핚 tolerance가 점차 발전되며 psycological, phsical
                    dependence는 다양핚 정도를 나타냄
   physical dependence : opioid, barbiturates, alcohol, benzodiazepines
   Life threatening Cx. : 약을 끊는 동앆의 sympathetic overactivity로 인함
   수술전 홖자의 약물복용에 대해 아는것 : adverse drug interaction 방지, anesthetic
    agents에 대핚 tolerance 예측, drug withdrawal을 쉽게 인지핛수 있는 방법
    홖자가 자발적으로 알려주기 전에는 숨기기 때문에 짧은 대화만으로는 알기 어렵다.
    * numerous puncture scar확인
   Acutely intoxicated pt.또는 금단증상이 보이면 수술을 연기 해야함
   꼭 수술이 필요핚 경우 : withdrawal을 최소화하기 위해, abuse substance를
    제공해주거나 specific agent를 사용해야 함
   가능하면 regional anesthesia 고려
   General anesthesia : volatile inhalation agent –preferable

				
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