general anesthetic question

[HuyetKiem]

A history of medication with which of the following drugs requires special consideration prior to general anesthetic ?

a. estrogen
b. cortisone
c. meperidine
d. phenacetin
e. diphenhydramine


I need your help on this question. Any input ?

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[dentalman]

This is just a guess, but I believe meperidine decreases respiratory rate, and therefore oxygen saturation, so I would be concerned about that.

 

[ItsGavinC]

I agree that the narcotic could increase risk of CNS depression.

 

[toofache32]

The real question is which drug will cause you to alter your management plans.

I think the answer they're looking for is steroids. If they've taken more than a couple of weeks worth of steroids recently then they require a stress-dose of steroids peri-operatively. Exogenous steroids will cause adrenal suppression if given at normal/high doses for more than a few days. This is also the reason why steroids have to be tapered if they've been given long enough to cause adrenal suppression. This isn't true for short-term or "pulse" dose steroid therapy. Everyone does it a little differently, but a common way is to just give a one-time dose of twice their prior dose of steroids. Patients usually don't remember dosages, so you can just give them maybe 40mg prednisone or 4-8mg of dexamethasone. If you don't supplement the compromised adrenal system with steroids, you risk putting the patient into an adrenal crisis which can be life-threatening. In short, if the adrenals are suppressed, you have to compensate by giving the patient what the adrenals can't give during stress (steroids). Surgery and anesthesia cause significant stress on multiple body systems. You can also google "Cushing's Ulcers" if you want another example.

Estrogen, tylenol and benadryl therapy shouldn't normally change your management. Opioids (meperidine) cause dose-dependant respiratory depression, but general anesthetics are usually in an intubated setting where the patient is on a ventilator anyway, so it doesn't change your management decisions. There are exceptions (mainly in OMFS) where general anesthetics are administered without intubating the patient. Lower doses of opioids have to be used to prevent apnea (and therefore oxygen saturation as mentioned), but this is a primary consideration in every case, and doesn't really "require special consideration" as the question stated.

Chronic opioid usage can cause a patient to require more opioids intraoperatively due to tolerance, but it's not really a pre-op consideration except to make sure you've got enough opioids laying around for the case.

I may be misinterpreting the question, but I would answer cortisone. Just my humble 2 cents.

 

[DcS]

My initial impression was cortisone as well.

 

[OMFS2B]

The real question is which drug will cause you to alter your management plans.

I think the answer they're looking for is steroids. If they've taken more than a couple of weeks worth of steroids recently then they require a stress-dose of steroids peri-operatively. Exogenous steroids will cause adrenal suppression if given at normal/high doses for more than a few days. This is also the reason why steroids have to be tapered if they've been given long enough to cause adrenal suppression. This isn't true for short-term or "pulse" dose steroid therapy. Everyone does it a little differently, but a common way is to just give a one-time dose of twice their prior dose of steroids. Patients usually don't remember dosages, so you can just give them maybe 40mg prednisone or 4-8mg of dexamethasone. If you don't supplement the compromised adrenal system with steroids, you risk putting the patient into an adrenal crisis which can be life-threatening. In short, if the adrenals are suppressed, you have to compensate by giving the patient what the adrenals can't give during stress (steroids). Surgery and anesthesia cause significant stress on multiple body systems. You can also google "Cushing's Ulcers" if you want another example.

Estrogen, tylenol and benadryl therapy shouldn't normally change your management. Opioids (meperidine) cause dose-dependant respiratory depression, but general anesthetics are usually in an intubated setting where the patient is on a ventilator anyway, so it doesn't change your management decisions. There are exceptions (mainly in OMFS) where general anesthetics are administered without intubating the patient. Lower doses of opioids have to be used to prevent apnea (and therefore oxygen saturation as mentioned), but this is a primary consideration in every case, and doesn't really "require special consideration" as the question stated.

Chronic opioid usage can cause a patient to require more opioids intraoperatively due to tolerance, but it's not really a pre-op consideration except to make sure you've got enough opioids laying around for the case.

I may be misinterpreting the question, but I would answer cortisone. Just my humble 2 cents.

I agree, but I did run into a couple of anesthesiologists on my rotation that believe the "stress dose" is not needed regardless of prior steriod use.

 

[esclavo]

This is just a guess, but I believe meperidine decreases respiratory rate, and therefore oxygen saturation, so I would be concerned about that.

Meperidine's advantage is that it doesn't have the respiratory depressive effects that morphine does.

I would also have thought about the steroid. I know some anesthesiologists don't believe in the "stress dose" theory of adrenal suppression, but if you add a stressful procedure to that general anesthetic then I think you need to be safe. An adrenal crisis is pretty scary if you have ever seen one. Cortisol does a lot to help us deal with pretty routine stress, sleep/wake cycle, basic circadium rhythms, capillary wall integrity, etc. The real debate is what dosage and what time of supraphysiological steroid use constitutes adrenal suppression. We supplement if the patient's use has been more than 14 days of suprphysiological steroids in past 10-12 months. But the debate rages on about length of time of steroid use and time since that use. I believe the medrol dose pack was made to not cause adrenal suppression, that is why we go with around 14 days of total supraphysiologic steroid use.

 

[aphistis]

Meperidine's advantage is that it doesn't have the respiratory depressive effects that morphine does.

I would also have thought about the steroid. I know some anesthesiologists don't believe in the "stress dose" theory of adrenal suppression, but if you add a stressful procedure to that general anesthetic then I think you need to be safe. An adrenal crisis is pretty scary if you have ever seen one. Cortisol does a lot to help us deal with pretty routine stress, sleep/wake cycle, basic circadium rhythms, capillary wall integrity, etc. The real debate is what dosage and what time of supraphysiological steroid use constitutes adrenal suppression. We supplement if the patient's use has been more than 14 days of suprphysiological steroids in past 10-12 months. But the debate rages on about length of time of steroid use and time since that use. I believe the medrol dose pack was made to not cause adrenal suppression, that is why we go with around 14 days of total supraphysiologic steroid use.

14 days in the past 10-12 months? Can it really take anywhere near that long to reestablish normal adrenal function? Or does that include the generous lawyer CYA window too?

 

[toofache32]

14 days in the past 10-12 months? Can it really take anywhere near that long to reestablish normal adrenal function? Or does that include the generous lawyer CYA window too?

That's how I learned it in dental school.

 

[esclavo]

14 days in the past 10-12 months? Can it really take anywhere near that long to reestablish normal adrenal function? Or does that include the generous lawyer CYA window too?

No one really knows for sure. Variations in philosophy on adrenal suppression abound. Giving a 100 mg of solucortef is much easier than managing hypovolemic type shock in a person having a massive adrenal suppressive crisis....