# 012 Caution: Perioperative Surgery Medications

Fast Facts and Concepts #012 PDF Authors: Kathryn Denson MD, John Petronovich, Bambi Wessel Objectives: List 4 classes of medication that may precipitate delirium in elderly susceptible patients. Identify the mechanism of action of those 4 medication classes which my precipitate delirium. 3. Identify one neurotransmitter whose perturbation may lead to delirium.
1. 2.

Context: Geriatric patient in a post surgery hospital setting Action: Patient needs medications for pain, medical management, etc. but the medications required can cause delirium. Patient has a history of dementia. Incidence/Prevalence: Adults 65 yr old are prescribed the highest proportion of medications in relation to their percentage of the U.S. population. Currently, approximately 13% of the U.S. population is 65 yr old; this age group purchases 33% of all prescription drugs (Holmes). Underlying Science: The cause of delirium is typically multifactorial. The development of delirium involves the complex interrelationship between a vulnerable patient and exposure to precipitating factors or insults. Extensive evidence supports the role of cholinergic deficiency. Dopaminergic excess also appears to contribute to delirium. Perturbations of other neurotransmitters, such as norepinephrine, serotonin, gamma aminobutyric acid, glutamate, and melatonin may also have a role in the pathophysiology of delirium, but the evidence is less well developed. Assessment: FACE High-Risk Medication List (Froedtert Acute Care for the Elderly)

The Froedtert ACE List is a reference list of medications to avoid in elderly patients based on a compilation of the Beers Criteria 1, The Medical Letter2, Chutka et al3 and Froedtert geriatric specialists' expert opinions Medication / Class

Potentia l adverse effect

Notes & Alternative (s)*

Class: Benzodiazepines, anxiolytics:

Prolonge d sedation, cognitive impairme nt,

Lorazepam, oxazepam (l owest dose, shortest duration of therapy

alprazolam (Xanax),Diazepam (Valium),Flurazepam (Dalmane), Chlordiazepo xide(Librium), Meprobamate (Equanil)

depende nce, increased fall risk, addiction risk

possible) *Lorazepam doses > 3mg = excessive sedation*

Class: AntiSSRIs (other Antidepressants: Amitriptyline(Elavil), Chlordiazepoxide/amitript cholinergi than yline(Limbitrol), Doxepin (Sinequan) c effects, fluoxetine). orthostati c hypotensi on, sedation, e.g sertraline, paroxetine cardiac arrhythm ias Class: Non-steroidal anti-inflammatory(NSAIDs): Ibuprofen (Motrin) Indomethacin(Indocin), Naproxen (Aleve, Anaprox, Naprosyn), Piroxicam (Feldene), Oxaprozin(Daypro) Serious GI toxicity. If used, titrate to lowest effective dose and monitor for GI toxicity Possible renal toxicity

Acetaminop hen (<4gm/day) , tramadol, nonacetylated salicylates (Trilisate), morphine3

[Ketorolac: I f used, titrate to lowest effective dose and monitor for GI toxicity (15mg QID x 5 days maximum)] Acetaminop hen (<4gm/day) , tramadol, non-

Class: Analgesics (misc):

1. Propoxyp hene: Convulsio ns, CNS

toxicity, limited effective ness 1. Propoxyphene, including combos(Darvon, Darvocet) 2. Pentazoci ne: Psychotr opic effects, hallucinat ions, seizure risk 3. Meperidin e: Confusio n, convulsio ns, tremors, myoclonu s

acetylated salicylates (eg. Trilisate ), morphine3

2. Pentazocine (Talwin)

3. Meperidine (Demerol) Class: Antihistamines Diphenhydramine(Benadryl) Chlorpheniramine ( Chlor-Trimeton) Hydroxyzine (Vistaril, Atarax) Anticholinergi c, highly sedating, delirium, cognitive decrease Loratadine ( Claritin) Cetirizine (Z yrtec)

Class: Muscle Relaxants:

Anticholinergic symptoms, Carisoprodol (Soma) Cyclobenzaprine (Flexeril) Methocarbamol (Robaxin) Met limited axalone(Skelaxin) effect Sedation, decrease d attention Benzodiazep ines (lorazepam, oxazepam)

Class : Barbiturates

(eg Phenobarbital [Luminal], secobarbital[Seconal], pentobarbital [Ne mbutal]

(risk of falls), respirato ry depressio n, addiction risk, hallucinat ions Extrapyra midal effects, lower potency, sedating

May be appropriate as an anticonvulsa nt3

Class: Antiemetics Trimethobenzamide(Tigan) Promethazine (Phenerga n)

Prochlorpera zine (Compazine) 5HT3antagonists: ondansetron (Zofran)

ACGME Competencies: Medical Knowledge, Patient Care