IndianJAnaesth522132-8608667 235446 PDF

132
Indian Journal of Anaesthesia, April 2008

Anaesthetic Implications of Substance Abuse in Adolescent
A Rudra
1
, Anjan Bhattacharya
2
, S Chatterjee
3
, S Sengupta
4
, T Das
5
Summary
Despite ongoing preventive and rehabilative efforts at the local and international level, substance abuse by adolescents
has crossed social, economic, and geographic borders and - throughout the world remains one of the major problems facing
society today. The diverse clinical manifestation of drug abuse combined with physiologic changes may significantly have
impact on the anaesthetic management. Moreover, it is always difficult to predict the exact anaesthetic implications in chemically
dependent patients. Therefore, a complete understanding of the pathophysiology and anaesthetic implications of drug abuse in
adolescent is essential to tailor a safe anaesthetic plan for these high-risk groups of patients.
Key words Substance abuse; Adolescent; Anaesthesia; Anaesthetic implication
Introduction
Illicit drugs have been of increasing social and
medical concern. Abuse of illicit drugs is unfortunately
not limited to adults. Although the rates of use of various
substances vary from year to year and decade to de-
cade, children, adolescents, and young adults continue
to use tobacco, alcohol, and other drugs at terrifying high
rates. Alcohol continues to be the drug of choice for
intoxication, marijuana and hallucinogen use is slightly
less than in previous decades; stimulant use continues
its popularity in the form of methylenedioxyme-
thamphetamine (MDMA; "Ecstasy") and other "club
drugs". Smoking rates may go down while smokeless
tobacco use goes up; and inhalants continued to go
abused, particularly by young adolescents
1
. A survey of
school children in Great Britain showed that 15.8% of
boys have been offered the drug Ecstacy and that 5.7%
have taken it
2
. A survey among school children revealed
that, frequently used drugs are marijuana (59%), am-
phetamines (19%), cocaine (18%), and LSD (18%)
3
.
Substance abuse has crossed social, economical,
and geographic borders, and it remains one of the major
problems facing society today. Because, drug abuse may
result in increased morbidity and mortality during intra-
and postoperative period, therefore, a thorough under-
standing of the consequences of drug abuse is essential
for practicing anaesthesiologists.
Anaesthesia and postoperative analgesia in patients
dependent on psychoactive substances poses special
problems. Often these patients suffer from severe medi-
cal and psychotic illness. In addition, drug-specific adap-
tations such as tolerance, physical dependence, and with-
drawal may diminish the effectiveness of anaesthetic and
analgesic drugs. Therefore, problems resulting from sub-
stance intoxication, or recent ingestion of or exposure to
a substance may arise in evaluation of patients for ana-
esthesia. When patients present for anaesthesia and sur-
gery there is a mandate to detect manifest mental prob-
lems, as well as covert substance use patterns that may
impact response to anaesthetic agents and the surgical
procedures
4
.
Substance abuse
Substance abuse may be defined as self-adminis-
tration of drug(s) that deviate(s) from accepted medical
or social use which if sustained can lead to physical and
psychological dependence
5
.
Adolescence
Between 10 and 20 years of age, children undergo
rapid changes in body size, shape, physiology, and psy-
chologic and social functioning. Adolescence precedes
across three distinct periods -early (10-13 years), middle
(14-16 years), late (17-20 years)
6
.
Alcohol
Alcohol use among adolescents has increased dur-
ing the past decade and poses a threat to the normal
functioning of the teenager as well as to the lives of those
potentially jeopardized by drunken drivers. The initiation
of alcohol use at an early age is associated with an in-
1.Hon. Consultant Anaesthesiologist, Apollo Gleneagles Hospital, Kolkata. 2.Consultant Paediatrician, Apollo Gleneagles Hospital, Kolkata.
3.Assistant Professor of Anaesthesiology, Medical College & Hospital, Kolkata. 4,5. Consultant Anaesthesiologist, Apollo Gleneagles Hospi-
tal, Kolkata. Correspondence to: A. Rudra, 1, Shibnarayan Das Lane, Kolkata - 700006.
Email :sumanc_24@yahoo.co.in Accepted for publication on: 22.2.08
I ndian J ournal of Anaesthesia 2008; 52(2):132-139 Review Article
[Downloadedfreefromhttp://www.ijaweb.orgonSunday,October19,2014,IP:189.219.134.161]||ClickheretodownloadfreeAndroidapplicationforthisjournal
133
creased risk for alcohol-related problems. Adoption stud-
ies indicate that male children of alcoholic parents are
more likely to become alcoholic even when raised by
nonalcoholic adoptive parents
5,7
.
Alcohol is rapidly absorbed in the stomach and is
transported to the liver and metabolized and leading to a
fatty liver followed by fibrosis, the hallmark of cirrhosis,
even in those who are well nourished. Furthermore,
chronic alcohol consumption may result in malnutrition,
altered drug metabolism, coagulopathy, pancreatitis, and
cardiomyopathy. Acute alcohol intoxication increases
gastric fluid acidity and volume, with simultaneous de-
crease in the ability to protect the airway. If heavy alco-
hol ingestion is not associated with food intake, pro-
nounced hypoglycaemia may occur.
Anaesthetic implications
Physiologic dependence on alcohol is manifested
as a withdrawal syndrome when the drug is abruptly
discontinued. Acute withdrawal manifestations include
generalized tremor, tachycardia, cardiac arrhythmias,
hypertension, nausea, vomiting, and confusion with agi-
tation and hallucinations
8
. The withdrawal symptoms may
be suppressed by the administration of benzodiazepines,
alpha 2 adrenergic agonists. Acute alcohol intoxication may
pose a significant risk of pulmonary aspiration.
Regional anaesthesia can be safely administered
to adolescent with a history or alcohol abuse. However,
regional anaesthesia may be influenced by occasional
patients who are treated with disulfiram and in whom
polyneuropathy develops. Alcohol-containing solutions,
as used for skin cleansing, probably should be avoided in
disulfiram - treated patients. Furthermore, acute, unex-
plained hypotension could reflect inadequate stores of
norepinephrine due to disulfiram-induced inhibition of
dopamine -hydroxylase
9
. Therefore, intravascular fluid
volume must be optimized before induction of regional
anaesthesia to avoid adverse consequences of sympa-
thetic blockade. This hypotension may respond to ephe-
drine, but direct - acting sympathomimetics such as phe-
nylephrine may produce more predictable responses in
the presence of norepinephrine depletion. Neuropathy
also should be considered as a medicolegal contraindi-
cation to regional anaesthesia.
If general anaesthesia is necessary, associated
hepatic dysfunction, hypoalbuminemia, and cardiac fail-
ure may require appropriate dose adjustments of intra-
venous induction drugs. Chronic use of alcohol is usu-
ally associated with resistance to the actions of central
nervous system (CNS) depressants. The use of exces-
sive concentrations of potent inhaled anaesthetics can
lead to cardiovascular depression. The risk of aspiration
increase is due to increased gastric fluid volume and
acidity, as well as impaired laryngeal reflexes.
Tobacco
Cigarettes
Human and animal studies confirmed that the ef-
fect of nicotine, the primary active ingredient in tobacco
produces as syndrome of dependence. Nicotine is ab-
sorbed by multiple sites in the body, e.g., lungs, skin, gas-
trointestinal tract, and buccal and nasal nucosa
6
.
The average smokers start at age 12 years, and
most are regular smokers by age to 14 years. Most
alarming is the compelling evidence of the addictive na-
ture of cigarette smoking with greater than 90% of ado-
lescent smokers becoming adult smokers
6
.
Cigarette smoking affects pulmonary function pri-
marily. The irritant effect of smoke decreases ciliary
motility, increases sputum production, and impairs gas
exchange
10
. Smoking is associated with an increase in
the rate of development of atherosclerosis. Smokers have
an increased prevalence of peripheral vascular disease,
coronary artery disease, and an increased risk of acute
myocardial infarction.
In smokers, 4 to 6 weeks of abstinence from to-
bacco smoke is required to decrease postoperative res-
piratory morbidity to the level of a nonsmoker
9
. How-
ever, any period of abstinence is recommended, and as
little as a few days can improve mucociliary function
10
.
In tobacco-abusing patients who undergo as little 48
hours of abstinence, levels of carboxyhaemoglobin may
return toward those levels seen in non-smokers. Ciga-
rette smoke may affect hepatic enzyme function and
alter the metabolism of induction drugs used for general
anaesthesia.
Regional anaesthesia seem suitable for tobacco-
abusing adolescents. Intraoperative complications, such
as bronchospasm, as well as postoperative respiratory
dysfunction, can be avoided with the administration of
neuraxial anaesthetic technique and avoidance of air-
way manipulation.
A Rudra et al. Anaesthesia for the substance abusing adolescent
134
Smokeless tobacco
Smokeless tobacco, comes in the forms of snuff,
quid (khaini), guraku and chewing tobacco. Smokeless
tobacco contains more nicotine than smoking tobacco
11
.
In Central, Southern, and South -East Asia, the
abuse of smokeless tobacco popularly involves the chew-
ing of betal quid or "paan-supari"
12
. The mixture is held
adjacent to the buccal mucosa and slowly chewed over
a long period of time
13
. The abuse of smokeless tobacco
can lead to oral submucosal fibrosis (OSMF). OSMF
typically affects the buccal mucosa, lips, retromolar ar-
eas, soft palate and occasionally the pharynx and oe-
sophagus. Finally, results in progressive inability to open
the mouth, pain, burning sensation and dysphagia
14,15
.
Chewing of tobacco result in lesions, primarily in the
mandibular mucobuccal fold. With chronic use, these
lesions may become malignant.
Anaesthesiologist should have a high degree of
suspicion and carefully examine the airway of patient
who abuse betal quid or "paan-supari". Mallampati clas-
sification and Cormack's grading should be incorporated
with routine preoperative assessments to decide whether
these patients would need awake fibreoptic guided intu-
bation. It is worthwhile to categorize all these patients
as having "anticipated difficult airways". Mahajan et al
16
have reported a case of "unanticipated difficult airway"
in a patient with betal quid abuse, suggesting that indi-
rect laryngoscopy be included in the routine preopera-
tive assessment of these patients.
Opioids
Opiate abuse by adolescents decreased consider-
ably during the 1980s, but the magnitude and variety of
its medical sequelae warrant continued attention. Although
it has been one of the least frequently reported drugs of
use since 1991, heroin produces euphoria and analgesia.
Heroin is hydrolyzed to morphine, which undergoes he-
patic conjugation with glucoronic acid before excretion,
through kidney, usually within 24 hours of admission.
Addiction to opioids is possible, in less than 14 days
if the drug is administered daily in ever increasing
doses
4,7
. Opoids are abused orally, subcutaneously, or
intravenously for their euphoric and analgesic effects.
Numerous medical complications such as cellulitis, su-
perficial skin abscess, septic thrombophlebitis, hepatitis,
autoimmune deficiency syndrome (AIDS), endocarditis,
and malnutrition have been observed in opioid addicted
patients
5
.
Clinical manifestations of opioid overdose include
slow respiratory rate (RR) with increased tidal volume
(VT) however, the increase in VT may not always be
present. The pupils are characteristically miotic. Acute
opioid withdrawal syndrome is manifested by symptoms
of increased sympathetic nervous system activity. Cen-
tral nervous system manifestations range from dyspho-
ria to various forms of bizarre behavior and unconscious-
ness. The ability to protect airway may be compromised
and the risk of aspiration greatly increased.
Opioid addicts should have opioids maintained dur-
ing the perioperative period. Preoperative medication
may also include opioids
16
. Opioid agonist-antagonists
are not recommended as these drugs could precipitate
acute withdrawal reactions.
The symptoms of withdrawal from opioids may be
treated with clonidine, or diphenhydramine
17
. Clonidine
attenuates opioid withdrawal symptoms by replacing
opioid-mediated inhibition with alpha-2 agonist-mediated
inhibition of the central nervous system
18
.
Regional anaesthesia may be safely administered
to opioid-addicted patients. However, increased tendency
for hypotension should be anticipated following the in-
duction of spinal or epidural anaesthesia. However, re-
gional anaesthesia may be relatively contraindicated in
AIDS patients with central nervous system HIV infec-
tion and progressive demyelination.
General anaesthesia may be indicated in the pa-
tient with haemodynamic instability, coagulopathy, or
sepsis. Reduced intravascular fluid volume, malnutrition
or liver disease may require appropriate dose adjustments
of anaesthetic drugs. Chronic opioid use leads to cross-
tolerance to central nervous system depressants that may
manifest as decreased analgesic responses to inhaled
anaesthetics such as nitrous oxide. Conversely, acute opioid
administration decreases anaesthetic requirements
(MAC). Opioid overdose may cause respiratory depres-
sion and loss of the airway. There is a tendency for
perioperative hypotension to occur, which may reflect in-
adequate intravascular fluid volume secondary to chronic
infections, fever, malnutrition, adrenocortical insufficiency,
or inadequate opioid concentrations in the brain
19
.
135
Postoperatively, the opioid -abusing patient often
seems to experience an exaggerated degree of pain. De-
creased pain tolerance is secondary to decreased pro-
duction of endogenous opioid peptides. Alternative meth-
ods of postoperative pain relief in these patients include
continuous regional analgesia with local anaesthetics,
neuraxial opioids, and transcutaneous electrical nerve
stimulation.
Volatile substances (solvent abuse)
Young adolescents are attracted to these sub-
stances because of their rapid action, easy availability,
and low cost. "Huffing"i.e. directly inhaling, or inhaling
deeply from a paper bag containing a chemical soaked
cloth is the common method used by teens.
There are enormous variety of solvents and fuels
that are used, including almost any household cleaning
agent or propellant, paint thinner, glue and lighter fluid.
Children and teenagers are more likely to abuse solvent
than other CNS-depressant substances. Solvent produce
euphoria and other effects similar to subanaesthetic con-
centrations of volatile anaesthetics, as well as CNS de-
pression similar to alcohol intoxication
20
. Physical de-
pendence is rare but psychological dependence and tol-
erance can develop
21
.
Glue sniffing can cause a unique distal and proxi-
mal tubular acidosis
22
. Toluene, causes relaxation and
pleasant hallucination for up to 2 hours. Toluene sniffing
may lead to autonomic cardiac dysfunction, ventricular
fibrillation, and myocardial infarction
23,24
. Gasoline, con-
tains a complex mixture of organic solvents. Euphoria is
followed by violent excitement. Volatile nitrites, such as
amyl nitrite, butyl nitrite, and related compounds mar-
keted as room deodorizers, are used as euphoriants, en-
hancers of musical appreciation, and aphrodisiacs among
older adolescents and young adults. They may result in
profound hypotension and cutaneous flushing followed
by vasoconstriction and tachycardia; methemoglobinemia,
and increased bronchial irritation. Chronic use of gaso-
line may cause pulmonary hypertension, restrictive lung
defects or reduced diffusion capacity, peripheral neur-
opathy, acute rhabdomyosis, haematuria, and possibly
cerebral and cerebellar atrophy. Increased airway re-
sistance, pulmonary hypertension, acute respiratory dis-
tress syndrome (ARDS) and liver toxicity have all been
reported in patients with documented exposure to sol-
vents
25
.
Diagnosis of inhalant abuse is particularly difficult,
relying almost entirely on a through history and high in-
dex of suspicion. No laboratory tests confirm solvent
inhalation
26
. However, complete blood counts, coagula-
tion studies, and hepatic and renal studies may identify
the complications
27
.
Optimal anaesthetic management of solvent-abus-
ing adolescent requires a high level of suspicion and early
diagnosis. Altered perception of sensory stimuli, loss of
coordination, headache, nausea, vomiting, and respira-
tory compromise may result from vapour sniffing. Care-
ful physical examination, including determination of pos-
sible sensory and motor deficits, is indicated before in-
duction of anaesthesia.
Chronic inhalant abuse can cause cardio-vascular
and respiratory depression and the interaction with halo-
genated hydrocarbons may induce life-threatening
dysrhythmias
5
.
Hallucinogens
Adolescents for their hallucinogenic properties have
used several naturally occurring and synthetic sub-
stances. Psychedelic agents are ingested orally to in-
duce hallucinations, illusions, and distorted thought pro-
cess. The hallucinogenic substances lysergic acid diethy-
lamine (LSD), phencyclidine (PCP) and 3, 4-
methylenedioxymethamphetamie (MDMA; Ecstasy) are
the most commonly reported hallucinogens in high school.
Although there is a high incidence of psychological de-
pendence, there appears to be no evidence of physical
dependence or withdrawal symptoms when hallucino-
gens are discontinued
5
.
Ingestion of these drugs activates the sympathetic
nervous system as evidenced by increased body tem-
perature, tachycardia, hypertension, and dilated pupils.
Psychological characteristics of intoxication include anxi-
ety, panic attacks, hallucinations, and fear of "going
crazy". Chronic hallucinogen use is uncommon.
The mechanisms of action of both PCP and LSD
are quite complex and include agonist, partial agonist,
and antagonist effects at various serotonin, dopaminer-
gic, and adrenergic receptors
28
. Anaesthesia during acute
exposure with excitatory drugs is dangerous and should
136
be avoided until acute effects have disappeared. Exag-
gerated response to sympathomimetic drugs should be
anticipated in these patients (PCP is a structural ana-
logue of ketamine). Hallucinogens may prolong the an-
algesic and ventilatory depressants effects of opioids.
Prolongation in the effects of suxamethonium is pos-
sible due to inhibition of plasma cholinesterase activity
by PCP and LSD
29
.
General anaesthesia and surgery have been re-
ported to precipitate panic responses in these patients.
In the event that such responses occur, diazepam is likely
to be useful
5
. Postoperative hallucinations in patients
undergoing general anaesthesia have been reported as
well
30
.
In regional anaesthesia, ephedrine should be used
carefully (which has both direct and indirect actions) for
the treatment of sympathectomy - induced hypotension.
Cocaine
Cocaine use for non-medical purposes is a public
health problem with important economic and social con-
sequences. Cocaine is an alkaloid (benzoylmet
hylecgonine) that is prepared from the leaves of
Erythroxylon coca plant
31
. Cocaine can be abused via
every possible route, including oral, nasal, intravenous,
and rectal. The hydrochloride form can be chemically
altered to the base form, which is then concentrated by
extraction in ether or baking soda
31
. The residue from
this method is a form of cocaine base commonly called
"crack" (based on the cracking sounds it makes when
heated)
31
. The metabolism of cocaine occurs primarily
through plasma and hepatic cholinesterase, and patients
with pseudocholinesterase deficiency are at increased
risk for cocaine toxicity. Less than 5% of ingested co-
caine is excreted unchanged in the urine
32
.
Cocaine produces prolonged adrenergic stimulation
by blocking the presynaptic uptake of sympathomimetic
neurotransmitters including norepinephrine, serotonin, and
dopamine
33,34
. The euphoric effects of cocaine "cocaine
high" also result from prolongation of dopamine's activity
in the limbic system and the cerebral cortex.
Preoperative assessment presents a special chal-
lenge, as self-reporting of drug abuse is notoriously unre-
liable. The nasal mucosa should be carefully observed for
ulceration signs. All extremities should be examined for
sclerosis of peripheral veins and needle marks from intra-
venous injections. Auscultation over the lungs is important
to exclude cocaine-induced asthma and a careful cardio-
vascular and neurologic examination is necessary
31
.
Preoperative laboratory tests include complete
blood cell count, with a platelet count, to rule out throm-
bocytopenia; ECG to identify signs of rhythm disturbance
or myocardial ischaemia; chest radiography to rule out
any pulmonary or cardiac involvement; and abdominal
radiography to detect pseudo-obstruction
35
.
General or regional anaesthesia in the cocaine
abuse adolescent may be associated with serious com-
plications. Any event or drug likely to increase already
enhanced sympathetic nervous system activity must be
carefully considered before its selection to avoid myo-
cardial ischaemia and cardiac dysrhythmias. However,
beta-blockade also cause cocaine - induced coronary
vasoconstriction. Esmolol may provide effective control
of tachycardia and hypertension. The short elimination
half-life of esmolol may offer some advantages if drug
administration is deemed necessary. Of concern is that
(1) ketamine should be used with extreme caution in
these patients because it can markedly potentiate the
cardiovascular toxicity of cocaine; (2) because both co-
caine and suxamethonium undergo metabolism by plasma
cholinesterase, the use of suxamethonium may result in
prolonged paralysis; however, they may produce car-
diac arrhythmias; (3) an increased anaesthetic require-
ment for volatile anaesthetics may be present in the
acutely intoxicated patient; and (4) the temperature rise
and sympathomimetic effects associated with cocaine
can mimic malignant hyperthermia (MH), and it may be
difficult to differentiate between the two.
When regional anaesthesia is used, combative
behavior; altered pain perception, cocaine - induced
thrombocytopenia; and ephedrine - resistant hypotension
may be encountered. Low doses of phenylephrine ti-
trated to the effect usually restore blood pressure to nor-
mal values. Pronounced abnormalities in endorphin lev-
els and changes in both mu and kappa opioid receptor
densities resulting from cocaine addiction which may
result in perception of pain despite adequate spinal - epi-
dural anaesthesia sensory levels
36
.
137
Marijuana
Marijuana is the most commonly used illegal drug.
The hemp plant Cannabis sativa, from which marijuana
grows throughout the world, flourishes in most temper-
ate and tropical regions
35
. Marijuana is commonly in-
gested by smoking, which increase the bioavailability of
the primary psychoactive constituent, tetrahydrocannab-
inol (THC)
37,38
. Inhalation of marijuana smoke produces
euphoria, with signs of increased sympathetic nervous
system activity and decreased parasympathetic nervous
system activity. The most consistent cardiac change is
an increased resting heart rate, although orthostatic hy-
potension may occur. Chronic marijuana abuse leads to
increased tar deposits in the individual's lungs, impaired
pulmonary defense mechanisms, and decreased pulmo-
nary function. As such an increased incidence of sinusi-
tis and bronchitis is likely. Smoke from cannabis ciga-
rettes is known to suppress both hormonal and cell-me-
diated immune responses
39
. In predisposed persons, mari-
juana may evoke seizures
5
.
Anaesthesia during acute exposure with excitatory
drugs is dangerous and should be avoided until the acute
effects have disappeared. Severe tachycardia should be
controlled preoperatively with labetalol or esmolol
35
.
Marijuana may enhance the sedative-hypnotic effects
of drugs that depress the CNS. Studies have shown cross-
tolerance of marijuana with barbiturates, opioids, benzo-
diazepines, and phenothiazines
40
.
Additive effects of marijuana and potent inhaled
anaesthetic can result in pronounced myocardial depres-
sion in general anaesthesia
41
. Drugs that increase heart
rate such as atropine, ketamine, pancuronium and ephe-
drine should be avoided. Barbiturate and ketamine sleep
times are prolonged in THC - treated animals, and opioid
induced depression of ventilation may be potentiated
42
.
Possible intraoperative complications include bron-
chospasm secondary to airway irritability by the mari-
juana smoke, although marijuana is a bronchodilator.
Adverse psychiatric and autonomic reactions to cannabis
may interfere with postoperative recovery.
Amphetamines
Stimulants, particularly amphetamines, are among
the most frequently reported illicit drugs other than mari-
juana. Methylamphetamine, commonly known as "ice",
is accounted for more than 25% of its use as a stimu-
lant. Methylamphetamine is particularly popular among
adolescents and young adults because of its potency and
ease of absorption. It can be used by snorting, smoking,
ingesting by mouth, or absorption across mucous mem-
brane such as vaginal mucosa. Amphetamines are abused
individually or in conjunction with other CNS stimulants
such as opioids or cocaine. Amphetamines stimulate the
release of catecholamines from presynaptic vesicles,
resulting in euphoria, increased cortical alertness, de-
creased fatigue, and appetite suppression.
The symptoms of acute amphetamine intoxication
include, hypertension, arrhythmias, tachycardia, dilated
pupils, hyperreflexia, proteinuria, and confusion. Chronic
abuse of amphetamines results in depletion of body stores
of catecholamines, which may be manifested as anxiety,
somnolence, or psychotic state. Agitation and delusional
behaviours can be treated with haloperidol or droperidol.
Phenothiazines are contraindicated and may cause a rapid
drop in blood pressure or seizure activity. Other support-
ive treatment consists of cooling blanket for hyperthermia
and treatment of the hypertension and arrhythmias, which
may respond to sedation with lorazepam or diazepam.
Avoidance of halothane is recommended in gen-
eral anaesthesia as, it may sensitize the myocardium to
endogenous catecholamines. Acute intake of amphet-
amine increases the minimum alveolar concentration of
potent inhaled anaesthetics
43
. However, chronic intake
decreases the dose for general anaesthetic
44
.
Sympathectomy caused by neuraxial blocks in re-
gional anaesthesia may precipitate severe hypotension.
The response to treatment of hypotension with vasopres-
sors is unpredictable in amphetamine abusing adolescents.
Conclusion
Environmental, social and perhaps genetic factors
lead to behavioral disorders from abuse of psychotropic
(mind altering) substances. Knowledge of a patient's
substance abuse preoperatively may prevent adverse
drug interactions, predict tolerance to anaesthetic agents,
and facilitate the recognition of drug withdrawal.
Anaesthetic requirements for substance abusers
vary depending on whether the drug exposure is acute
or chronic. Elective procedures should be postponed for
acutely intoxicated patients and those with signs of with-
drawal. Regional anaesthetics should be considered when
138
possible. For general anaesthesia, a technique primarily
relying on a volatile inhalational agent may be prefer-
able so that anaesthetic depth can be readily adjusted
according to individual need.
References
1. Johnston LD, O'Malley PM, Bachman JG. Monitoring the
future: National report on adolescent drug use. Washington
DC : NIH Publication, Department of Health and Human Ser-
vices; 2004.
2. Milroy CM. Ten years of "ecstasy". J R Soc Med 1999; 92 :
68-71.
3. Christophersen AS. Amphetamine designer drugs - an over-
view and epidemiology. Toxicol Lett 2000; 112-113: 127-31.
4. Kaye AD, Hoover JM, Ertner RA, Sutker PB. Behavioral and
psychiatric disorders. In:Anesthesia and uncommon diseases.
Fleisher LA (editor), 5th edition , Saunders (Elsevier) 2006;
pp. 469-91.
5. Stoelting RK, Dierdorf SF. Psychiatric diseases and substance
abuse. In : Stoelting RK, Dierdorf SF (editors) : Anesthesia and
co-existing disease (4th edition) . Churchill Livingstone : New
York 2002; pp. 639-54.
6. Needlman RD. Growth and Development. In : Nelson text-
book of pediatrics, 17th edition. Behrman RE, Kliegman RM,
Jenson HB (editors). Saunders (Elsevier) : Philadelphia, Penn-
sylvania 2004; pp. 27-63.
7. High School & Youth Trends. National Institute of Drug Abuse
(NIDA). National Institute of Health - U.S. Department of
Health and Human Services, 2006.
8. Beattie MC, Longabaugh R, Elliott G, Stout RL, Fava J, Noel
NE. Effect of the social environment on alcohol involvement
and subjective well-being prior to alcoholism treatment. J Stud
Alcohol 1993; 54 : 283-96.
9. Diaz JH, Hill GE. Hypotension with anesthesia in disulfiram-
treated patient. Anesthesiology 1979; 51: 355-8.
10. Rudra A, Das Sudipta. Postoperative pulmonary complica-
tions (Review Article). Indian J Anaesth 2006; 50 : 89-95.
11. http://www.nlm.nih.gov/medlineplus/smokelesstobacco.html/
(accessed14th July 2007)
12. Shan B, Lewis MAO, Bedi R. Oral submucous fibrosis in an
11 year old Bangladeshi girl living in the United Kingdom. Br
Dent J 2001; 191 : 130-2.
13. Merchant AT, Haider SM, Firkee FF. Increased severity of oral
submucous fibrosis in young Pakistani men. Br J Oral Maxillo-
facial Surg 1997; 35 : 284-7.
14. Epie N. The chewing of betal quid and oral submucosal fibrosis
and anesthesia. Anesth Analg 2005; 100 : 1210-3.
15. Mahajan R, Jain K, Batra YK. Submucous fibrosis secondary
to chewing of quids : another cause of unanticipated difficult
intubation. Can J Anaesth 2002; 49 : 309-11.
16. Giuffrida JG, Bizzari DV, Saure AC, et al. Anesthetic manage-
ment of drug abusers. Anesth Analg 1970; 49 : 273-82.
17. Gold MS, Pottash AL, Extein I, Kleber HD. Clonidine in acute
opiate withdrawal. N Engl J Med 1980; 302 : 1421-2.
18. Gold MS, Pottash AL, Sweeney DR, Kleber HD. Opiate with-
drawal using clonidine. A safe, effective, and rapid nonopiate
treatment. JAMA 1980; 243 : 343-6.
19. Marck LC. Hypotension during anesthesia in narcotic addicts.
NY State J Med 1966; 66 : 2685-97.
20. Jage J, Heid F. Substance use disorders and anaesthesia. In :
Recent advances in anaesthesia and intensive care : Cashman
JN, Grounds RM (editors). Cambridge University Press, No.
23, 2005, pp. 195-216.
21. Wood PR, Soni N. Anaesthesia and substance abuse. Anaes-
thesia 1989; 44 : 672-80.
22. Carlisle EJ, Donnelly SM, Vasuvattakul S, et al. Glue-sniffing
and distal renal tubular acidosis : sticking to the facts. J Am Soc
Nephrol 1991; 1 : 1019-27.
23. Murata K. Araki S, Yokoyama K, Yamashita K, Okajima F,
Nakaaki K. Changes in autonomic function as determined by
ECG R-R interval variability in sandal, shoe and leather work-
ers exposed to n-hexane, xylene and toluene. Neurotoxicology
1994; 15 : 867-75.
24. Cunnigham SR, Dalzell GW, McGirr P, Kahn MM. Myocar-
dial infarction and primary ventricular fubrillation after glue
sniffing. Br. Med J 1987; 294 : 739-40.
25. Reyes de la Rocha S, Brown MA, Fortenberry JD. Pulmonary
function abnormalities in intentional spray paint inhalation.
Chest 1987; 92 : 100-4.
26. Brouette T, Anton R. Clinical review of inhalants. Am J Addict
2001; 10 : 79-94.
27. Anderson CE, Loomis GA. Recognition and prevention of in-
halant abuse. Am Fam Physician 2003; 68: 869-74.
28. Abraham H, Aldridge A, Gogia P. The psychopharmacology of
hallucinogens. Neuropsychopharma, 1996; 14: 285-98.
29. Beattie C, Mark L, Umbricht - Schneiter A. Evaluation of the
patient with alcoholism and other drug dependencies. In: Rogers
MC, Tinker JH, Covino BG, Longnecker DE (eds) : Principles
and Practice of Anesthesiology, 1st ed. St. Louis : Mosby,
1993 ; pp. 537-59.
30. Morris G, Magee P. Anaesthesia and past use of LSD. Can J
Anaesth 1995; 42 : 177.
31. Fleming JA, Byck R, Barash PG. Pharmacology and therapeu-
tic applications of cocaine. Anesthesiology 1990; 75 : 518-31.
32. Inaba T, Stewart D J, Kalow W. Metabolism of cocaine in man.
Clin Pharmacol Ther 1978 ; 23 : 547-52.
33. Gold MS, Washton AM, Dackis CA. Cocaine abuse neuro-
chemistry, pharmacology, and treatment. NIDA Res Monogr
1985; 61 : 130-50.
34. Pitts DK, Marwah J. Autonomic actions of cocaine. Can J
Physiol Pharmacol 1989; 67 : 1168-76.
35. Krane EJ, Davis PJ. Drug -abusing child and adolescent. In :
Motoyama EK, Davis PJ (eds.) : Smith's anesthesia for infants
and children, 7th edition. Mosby (Elsevier), 2006; pp.262-5.
139
36. Kreek MJ. Cocaine, dopamine and the endogenous opioid sys-
tem. J Addict Dis 1996; 15 : 73-96.
37. Hall W, Solowij N. Adverse effects of cannabis. Lancet 1998;
352 : 1611-6.
38. Musty R, Reggio P, Consroe P. A review of recent advances in
cannabinoid research and the 1994 International Symposium
on Cannabis and the Cannabinoids. Life Sci 1995; 56 : 1933-40.
39. Maykut MO. Health consequences of acute and chronic mari-
juana use. Prog Neuropsychopharmacol Biol Psychiatry 1985;
9: 209-38.
40. Pertwee RG. Tolerance to and dependence on psychotropic
cannabinoids. In : Pratt JA (ed) : The biological basis of drug
tolerance and dependence. New York. Academic Press; 1991;
pp. 232-63.
41. Stoelting RK, Martz RC, Gartner J, Brown DJ, Forney RB.
Effects of delta 9-tetrahydrocannabinol on halothane MAC in
dogs. Anesthesiology 1973; 38 : 521-4.
42. Johnstone RC, Lief PL, Kulp RA, et al. Combination of delta-
9-tetrahydrocannabinol with oxymorphine or pentobarbital.
Anesthesiology 1975; 42 : 674-9.
43. Michel R, Adams AP. Acute amphetamine abuse. Problems
during general anesthesia for neurosurgery. Anaesthesia 1979;
34 : 1016-9.
44. Johnston RR. Way WL, Miller RD. Alteration of anesthetic
requirement by amphetamine. Anesthesiology 1972; 36 : 357-
63.
ANNOUNCEMENT ANNOUNCEMENT ANNOUNCEMENT ANNOUNCEMENT ANNOUNCEMENT
Facilities for online article submission into the Indian Journal of Anaesthesia.
Author Help : Online Submission of the Manuscripts
Articles can be submitted online at bajajpramila@hotmail.com. For online submission articles should be prepared in
two files (first page file and article file). Images should be submitted separately.
1. First Page File :
Prepare the title page, covering letter, acknowledgement, etc., using a word processor program. All information which
can reveal your identity should be here. Use text/rtf/doc/pdf files. Do not zip the files.
2. Article file :
The main text of the article, beginning from Abstract till References (including tables) should be in this file. Do not
include any information (such as acknowledgement, your names in page headers, etc.) in this file. Use text/rtf/doc/pdf
files. Do not zip the files. Limit the file size to 400 kb. Do not incorporate images in the file. If file size is large, graphs can
be submitted as images separately without incorporating them in the article file to reduce the size of the file.
3. Images :
Submit good quality colour images. Each image should be less than 400 kb in size. Size of the image can be reduced by
decreasing the actual height and width of the images (keep up to 1024 x 760 pixels or 4-5 inches) or by reducing the
quality of image. All image formats (jpeg, tiff, gif, bmp, png, eps. etc) are acceptable; jpeg is most suitable. The image
quality should be good enough to judge the scientific value of the image.
Always retain a good quality, high resolution image for print purpose. This high resolution image should be sent to the
editorial office at the time of sending a revised article.
4. Legends :
Legends for the figures/images should be included at the end of the article file.
Pramila Bajaj
Editor, IJA
E mail:bajajpramila@hotmail.com

IndianJAnaesth522132-8608667 235446 PDF

Diunggah oleh

Informasi Dokumen

Deskripsi Asli:

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

IndianJAnaesth522132-8608667 235446 PDF

Diunggah oleh

Hak Cipta:

Format Tersedia

132

Indian Journal of Anaesthesia, April 2008

Anda mungkin juga menyukai