Any attendings do any "Ultra-rapid detox"

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lvspro

lvspro

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Hey all
A few of the attendings were talking about this the other day. Does anyone here do this?
Just curious. It seems like it would need a ton of monitoring, and you'd prolly see some pretty interesting physiologic changes. I couldn't work with addicts myself, but I wouldn't mind doing a stint for a month or so to see it in action.
I realize it's highly controversial... but I still wanna know about it.
 
There was a study in JAMA published in August which concluded that the practice was less effective and more dangerous than standard detox. There are lots of people that do it however, as there isn't a whole lot published on the practice. Also, there are lots of rich people addicted to narcotics who will pay a lot of money for a supposed quick cure.
 
Hey bogy
Yeah, I read about the study in some news reports, but I haven't read the actual study b/c I don't have JAMA access. I'm not interested in whether it works or not, I'm a little more interested in common physio trends involved. It's a little nerdy, I know, but I'm still kinda interested.
 
Visited a friend on the west coast during the week of Thanksgiving and found out that he does this on a semi frequent basis for high paying customers.

To recap what he does:

Patient and family read the riot act and informed of the potential risks involved (AUA, death, CVA, MI, etc.).

Next step is comprehensive blood work and stress echo based on age and risk factors.

Waivers signed. Ready to go.

Standard GETA induction, lubricated ETT, Forane, multiple infusions ready to go including nicardipine, esmolol, epinephrine, levophed, cisatracurium, lidocaine or amiodarone, sufentanil depending on type of addiction, phenytoin, and some type of TPA.

Monitors: standard plus CVP, large bore IV, A line, and EEG.

Usually takes about 48 hours for him for one patient, sometimes 72 hours. He stays in house, but as this is not a surgical procedure, he is in comfortable clothing and can usually sleep in 6-8 hour increments.

The amiodarone, esmolol, and nicardipine are the keys to a smooth rapid detox. The esmolol is quickly metabolized when shut off and allows for a rapid assessment of the patient's autonomic responses.

His final criteria for termination of GA are stable vital signs for 4-6 hours after termination of all infusions except TPA, stable body temperature, appropriate pupillary reflexes, and normal response to noxious stimuli.

He has done 34 of them thus far at a private facility, including two notable celebrities without mortality, although one older patient suffered a minor CVA, which was prior to the more thorough workup that he now requests as well as prior to the use of nicardipine and dilantin.

Charge per patient? Facility fees plus his $50K up front fee. This type of detox is NOT sanctioned by the state medical board, but it is available to anyone who thinks a quick fix rapid detox is better than a balanced and gradual withdrawal with psychosocial support systems in place.
 
UTSouthwestern said:
Visited a friend on the west coast during the week of Thanksgiving and found out that he does this on a semi frequent basis for high paying customers.

To recap what he does:

Patient and family read the riot act and informed of the potential risks involved (AUA, death, CVA, MI, etc.).

Next step is comprehensive blood work and stress echo based on age and risk factors.

Waivers signed. Ready to go.

Standard GETA induction, lubricated ETT, Forane, multiple infusions ready to go including nicardipine, esmolol, epinephrine, levophed, cisatracurium, lidocaine or amiodarone, sufentanil depending on type of addiction, phenytoin, and some type of TPA.

Monitors: standard plus CVP, large bore IV, A line, and EEG.

Usually takes about 48 hours for him for one patient, sometimes 72 hours. He stays in house, but as this is not a surgical procedure, he is in comfortable clothing and can usually sleep in 6-8 hour increments.

The amiodarone, esmolol, and nicardipine are the keys to a smooth rapid detox. The esmolol is quickly metabolized when shut off and allows for a rapid assessment of the patient's autonomic responses.

His final criteria for termination of GA are stable vital signs for 4-6 hours after termination of all infusions except TPA, stable body temperature, appropriate pupillary reflexes, and normal response to noxious stimuli.

He has done 34 of them thus far at a private facility, including two notable celebrities without mortality, although one older patient suffered a minor CVA, which was prior to the more thorough workup that he now requests as well as prior to the use of nicardipine and dilantin.

Charge per patient? Facility fees plus his $50K up front fee. This type of detox is NOT sanctioned by the state medical board, but it is available to anyone who thinks a quick fix rapid detox is better than a balanced and gradual withdrawal with psychosocial support systems in place.
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WOW, UT.

Very, very interesting.

Opiod addiction is a bad deal....had a friend who was a heroin addict...what I didnt realize until I went to some of the support meetings, if I remember correctly, was that opiod withdrawal, despite its quite-terrible symptoms (nausea, vomiting, rigors, diaphoresis, palpitations, etc), carries a very low morbidity/mortality rate, unlike delerium tremens from alcohol withdrawal, which carries a significant risk.

UT, does he use this protocol for any abused substance? In other words, do cocaine/heroin/opiod/alcohol addicts all get the same regime?
 
UT - phenomenal post. Thanks.

Any chance for a sticky, Vent? I'm not really sure as to under what heading, but UT's post is good ****.

If any of you anesthesia Jedi can explain to a lowly medical student HOW these drugs "detox" the patient, I'd be interested in hearing about it. (If UT already explained it with that esmolol bit, please excuse my ignorance.)

dc
 
all i can say is $50K x 34 detoxes x 2-3 days each = $1.7 million for about 3 months worth of work. not a bad gig.
 
bigdan said:
UT - phenomenal post. Thanks.

Any chance for a sticky, Vent? I'm not really sure as to under what heading, but UT's post is good ****.

If any of you anesthesia Jedi can explain to a lowly medical student HOW these drugs "detox" the patient, I'd be interested in hearing about it. (If UT already explained it with that esmolol bit, please excuse my ignorance.)

dc
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From what I've gathered, Big D, (and I'm far from an expert in this subspecialty) the above mentioned drugs dont "detox" the patient.

What they do is control the patient's hemodynamics during the opiod withdrawal...so essentially the "detox" happens by itself, and the general anesthetic/hemodynamic drugs shields the patient from the unwanted discomfort.

So in essence, a crack addict who wants to renew their life can check in, be put to sleep, and awaken after all the havoc is over, instead of enduring the painful withdrawal.

Correct me if I'm wrong, UT.
 
UT,

What's the TPA for? GA for 3 days would definitely require very aggressive DVT prophylasis...perhaps even full anti-coagulation, but TPA?

Or is the TPA for something else?
 
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Hi Everyone!

I did a year of research on an addictions unit - and for psych, rapid detox is over 3 days, replacing a benzo for the opioid. I was taught (from text and every attending as well) that a patient will NOT die from withdrawal (opioid) EVER, that they may FEEl like they want to die, but worst case scenario is a slight metabolic disturbance that can be monitored easily, corrected, but is not life threatening.

My question is - why do people do this? This ultra rapid detox? What are the benefits of it?
 
The one detox I observed was similar to what UT described with a glaring difference - they used high doses of Narcan and only were under GA for 10-12 hours. The theory is that the Narcan rapidly downregulated the opioid receptors, and in fact the patients were able to decrease their narcotic requirement. These were being done in a pain clinic (inpatient) to decrease the patient's opioid requirements and to restore their efficacy, not to cure addiction.
 
militarymd said:
UT,

What's the TPA for? GA for 3 days would definitely require very aggressive DVT prophylasis...perhaps even full anti-coagulation, but TPA?

Or is the TPA for something else?
Click to expand...

maybe he meant TPN...
 
bogatyr said:
The one detox I observed was similar to what UT described with a glaring difference - they used high doses of Narcan and only were under GA for 10-12 hours. The theory is that the Narcan rapidly downregulated the opioid receptors, and in fact the patients were able to decrease their narcotic requirement. These were being done in a pain clinic (inpatient) to decrease the patient's opioid requirements and to restore their efficacy, not to cure addiction.
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thank you boga for the information 🙂
 
UTSouthwestern said:
Forane, sometimes 72 hours.
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Wowsers. 72 hours of forane? Could probably cut gas off at 60 hour mark, leave low flow and he'd become a forane-producing factory for the last 12 at 0.25-0.15 ET. At least most of the Hollywood A list are a skinny lot..

What is the longest continuous run of forane anybody has run a patient on?
Where are the marathon men on this board?
 
TPN, not TPA. Don't know where I pulled that out of.

My friend noticed with the first few patients he detoxed that despite the control of heart rate, blood pressure, etc. with the infusions, the patients still underwent a tremendous metabolic stress and his patients would literally burn off a couple of dozen pounds and awaken tremendously weakened from the experience, aside from the expected weakness from being under GA for 2-3 days.

Jet, the technique he uses is his standard formula for all types of detox. He will use Narcan if the patient is addicted to only an opioid, but 95% of his patients are multi-substance abusers wherein Narcan would not benefit the patient from a total time on treatment perspective.

Make no mistake: This is a very dangerous, DANGEROUS procedure and he has spent hours at a time literally coding patients to pull them out of a physiologic danger zone. For example, his all time high heart rate was 350+ in a 22 year old athlete! Had the esmolol on max dose and finally achieved control with a total of 25 mg of metoprolol over 10 minutes with the esmolol still cranked up. Two hours later, heart rate went the other way all the way down to 12 and he had to pace the patient after several doses of atropine and epinephrine failed to bring his HR and BP up.

DVT prophylaxis was originally mostly mechanical with SCD's, wave/motion beds, and nurse/PT range of motion exercises every 2-4 hours. He has added SC Lovenox Q 12 hours to the regimen but never has had problems with DVT's/PE's with the mechanical prophylaxis he uses.

Finally, at my suggestion, he has started to use Precedex toward the end of the regimen to smooth the transition at the end of the procedure. I have encouraged him to use it throughout the process as another adjunct to his cocktail, but he is not yet sold on its value at that stage.
 
UTSouthwestern said:
TPN, not TPA. Don't know where I pulled that out of.

My friend noticed with the first few patients he detoxed that despite the control of heart rate, blood pressure, etc. with the infusions, the patients still underwent a tremendous metabolic stress and his patients would literally burn off a couple of dozen pounds and awaken tremendously weakened from the experience, aside from the expected weakness from being under GA for 2-3 days.

Jet, the technique he uses is his standard formula for all types of detox. He will use Narcan if the patient is addicted to only an opioid, but 95% of his patients are multi-substance abusers wherein Narcan would not benefit the patient from a total time on treatment perspective.

Make no mistake: This is a very dangerous, DANGEROUS procedure and he has spent hours at a time literally coding patients to pull them out of a physiologic danger zone. For example, his all time high heart rate was 350+ in a 22 year old athlete! Had the esmolol on max dose and finally achieved control with a total of 25 mg of metoprolol over 10 minutes with the esmolol still cranked up. Two hours later, heart rate went the other way all the way down to 12 and he had to pace the patient after several doses of atropine and epinephrine failed to bring his HR and BP up.

DVT prophylaxis was originally mostly mechanical with SCD's, wave/motion beds, and nurse/PT range of motion exercises every 2-4 hours. He has added SC Lovenox Q 12 hours to the regimen but never has had problems with DVT's/PE's with the mechanical prophylaxis he uses.

Finally, at my suggestion, he has started to use Precedex toward the end of the regimen to smooth the transition at the end of the procedure. I have encouraged him to use it throughout the process as another adjunct to his cocktail, but he is not yet sold on its value at that stage.
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UT nailed exactly what I was looking for. The physiological changes, and our preferred method of correction. With regards to how lucrative it may be, I think I would have trouble practicing medicine that has questionable evidence at best, regardless of the payoff. It doesn't help that I want nothing to do with addiction medicine. It's an interesting field, just not my cup of tea.

Yo UT, thanks for posting that case. I always find it interesting to see/hear real-life encounters of physiologic extremes being fended off by an anesthesiologist. Heart rate of 350 to 12 :wow:

Anyhow, I noticed the EEG in UT's first response... any interesting changes there compared to a patient under GA for some other procedure?

Finally, the news reports say that the study in JAMA reported no measured difference in the post-detox withdrawl efx (piloerection, myalgias etc...) vs the classic detox regimens. Has your friend experienced better outcomes? Besides being interesting in and of itself, rapid detox seems to have a ton of teaching potential. I could be wrong, but thats what I'm getting from your posts. Who knows, maybe I'll try to make that shadow period at a detox center a reality.
 
lvspro said:
UT nailed exactly what I was looking for. The physiological changes, and our preferred method of correction. With regards to how lucrative it may be, I think I would have trouble practicing medicine that has questionable evidence at best, regardless of the payoff. It doesn't help that I want nothing to do with addiction medicine. It's an interesting field, just not my cup of tea.

Yo UT, thanks for posting that case. I always find it interesting to see/hear real-life encounters of physiologic extremes being fended off by an anesthesiologist. Heart rate of 350 to 12 :wow:

Anyhow, I noticed the EEG in UT's first response... any interesting changes there compared to a patient under GA for some other procedure?

Finally, the news reports say that the study in JAMA reported no measured difference in the post-detox withdrawl efx (piloerection, myalgias etc...) vs the classic detox regimens. Has your friend experienced better outcomes? Besides being interesting in and of itself, rapid detox seems to have a ton of teaching potential. I could be wrong, but thats what I'm getting from your posts. Who knows, maybe I'll try to make that shadow period at a detox center a reality.
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EEG's showed readings of being fully awake despite up to a MAC and a half of Forane and at times seizure like activity which is what he was specifically looking for to ensure that such episodes were appropriately treated.

I wouldn't say that his patients have had better outcomes, in terms of long term avoidance of substance abuse, however, his patients are relieved to get through the first 48-72 hours off the substance(s) of abuse under anesthesia, which they believe are the worst times of withdrawal. Beyond that time frame, the effects of withdrawal are similar, but the most intense period is done while they are anesthetized.
 
UTSouthwestern said:
Make no mistake: This is a very dangerous, DANGEROUS procedure and he has spent hours at a time literally coding patients to pull them out of a physiologic danger zone. For example, his all time high heart rate was 350+ in a 22 year old athlete! Had the esmolol on max dose and finally achieved control with a total of 25 mg of metoprolol over 10 minutes with the esmolol still cranked up. Two hours later, heart rate went the other way all the way down to 12 and he had to pace the patient after several doses of atropine and epinephrine failed to bring his HR and BP up.


Finally, at my suggestion, he has started to use Precedex toward the end of the regimen to smooth the transition at the end of the procedure. I have encouraged him to use it throughout the process as another adjunct to his cocktail, but he is not yet sold on its value at that stage.
Click to expand...

Has he tried enteral feeds? Seems like a Dobhoff with elemental nutrition (ala pancreatitis) would be simpler and safe than TPN.

Trans esophageal LA pacing right?

Seems like dexmedetomidine from beginning to end would make more sense.
 
militarymd said:
Has he tried enteral feeds? Seems like a Dobhoff with elemental nutrition (ala pancreatitis) would be simpler and safe than TPN.

Trans esophageal LA pacing right?

Seems like dexmedetomidine from beginning to end would make more sense.
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He has tried enteral feeds, but has had patients vomit on emergence despite a preemptive regimen of Reglan, Zofran, Decadron, Droperidol, Phenergan, and Pepcid/Zantac 1-4 hours prior to anticipated emergence.

He did not pace via transesophageal LA pacing. He slapped on pace pads and paced transcutaneously.

Agree with the Precedex, but I can't seem to convince him that it would be of great benefit.
 
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Sorry to ask again, UT, Jet, are they doing this just to avoid withdrawal? I still don't see why they're putting themselves through this? Why not just do a rapid detox since this takes 3 days anyway?
 
Anyone who has worked in the ICU occasionally will kind of have done this....the alcoholic withdrawals, addict admitted with a medical condition....endocarditis, pneumonia, MVA, etc....

It is very interesting to read about it in an elective nature.

Last question....maybe....what kind of fluids does he run?

and how frequently, and what laboratories studies are done if at all?
 
Poety said:
Sorry to ask again, UT, Jet, are they doing this just to avoid withdrawal? I still don't see why they're putting themselves through this? Why not just do a rapid detox since this takes 3 days anyway?
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because going through withdrawal sucks, and the cohort of folks who are willing to shell-out this kinda dough to avoid the pain (and inconvenience) of withdrawal are probably used to getting/doing whatever they want in the first place without having to put too much effort or sacrifice into it. this is rapid detox. in other words and no matter how you slice it, if your unconscious and amnestic you can't remember how much it sucked to go through it. (i'd also be interested in seeing the relapse rate in such folks.)

and, what MMD said too. there are a lot of icu folks we "involuntarily" detox while they stay with us, be it ethanol, drugs, or even just plain-old nicotine. typically, i've seem them weaned and having a clonidine patch slapped on them. of course, either way (involuntary or elective) you haven't really dealt effectively with the psychological part of the addiction. "i was hooked on the horse, i went to sleep for the weekend, and now WEEEEEEEEEEEE i'm all better!"

precedex would be interesting (and otherwise not prohibitively expensive either) for these folks who electively do this. you get the double-bonus of the alpha-2 blockade with the sedation. hmmm... may be onto something there.
 
i did a quick google search using "ultra rapid detox" and there doesn't seem to be any type of shortage of people providing the service. In one of the pages, one anesthesiologist charged a little under $10,000. Considering the significantly lower price than the 50k mentioned above, I would imagine it's a much shorter variation of the process described above.

fascinating topic, by the way
 
militarymd said:
Anyone who has worked in the ICU occasionally will kind of have done this....the alcoholic withdrawals, addict admitted with a medical condition....endocarditis, pneumonia, MVA, etc....

It is very interesting to read about it in an elective nature.

Last question....maybe....what kind of fluids does he run?

and how frequently, and what laboratories studies are done if at all?
Click to expand...

What I saw available was variations of D5 (1/2 NS and LR) as well as straight LR, NS, and 1/4 NS. I didn't specifically ask which he uses although I would assume he would want a good amount of free water in his fluids at least part of the time.

Labs were drawn Q2-4 and were primarily electrolytes and glucose. Less frequently, CBC. ABG's were done with the continuous sampling in line arterial blood gas machine (I use them at one of the hospitals here in Dallas, but am blanking on the name. I think it is called the Via). He would sample via the Via very frequently (on the order of once an hour or more).
 
UTSouthwestern said:
What I saw available was variations of D5 (1/2 NS and LR) as well as straight LR, NS, and 1/4 NS. I didn't specifically ask which he uses although I would assume he would want a good amount of free water in his fluids at least part of the time.

Labs were drawn Q2-4 and were primarily electrolytes and glucose. Less frequently, CBC. ABG's were done with the continuous sampling in line arterial blood gas machine (I use them at one of the hospitals here in Dallas, but am blanking on the name. I think it is called the Via). He would sample via the Via very frequently (on the order of once an hour or more).
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UT, you remarked on a previous post that he is able to sleep 6-8 hours at night (of course barring a problem)..does he have an assistant monitoring the patient?
 
UTSouthwestern said:
EEG's showed readings of being fully awake despite up to a MAC and a half of Forane and at times seizure like activity which is what he was specifically looking for to ensure that such episodes were appropriately treated.
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Hey UT, what did he use for siezure-like activity control?
 
VolatileAgent said:
because going through withdrawal sucks, and the cohort of folks who are willing to shell-out this kinda dough to avoid the pain (and inconvenience) of withdrawal are probably used to getting/doing whatever they want in the first place without having to put too much effort or sacrifice into it. this is rapid detox. in other words and no matter how you slice it, if your unconscious and amnestic you can't remember how much it sucked to go through it. (i'd also be interested in seeing the relapse rate in such folks.)

and, what MMD said too. there are a lot of icu folks we "involuntarily" detox while they stay with us, be it ethanol, drugs, or even just plain-old nicotine. typically, i've seem them weaned and having a clonidine patch slapped on them. of course, either way (involuntary or elective) you haven't really dealt effectively with the psychological part of the addiction. "i was hooked on the horse, i went to sleep for the weekend, and now WEEEEEEEEEEEE i'm all better!"

precedex would be interesting (and otherwise not prohibitively expensive either) for these folks who electively do this. you get the double-bonus of the alpha-2 blockade with the sedation. hmmm... may be onto something there.
Click to expand...


Thanks Volatile! I guess we're definitely part of a "now" society 😳

Sorry to ask twice everyone 😳
 
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UTSouthwestern said:
Dilantin. I told him he would be better served just using propofol.
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1.5 mac iso is a lot cheaper (and easier to use) than both. point is, many of the drugs we use routinely have an anti-seizure effect.
 
VolatileAgent said:
1.5 mac iso is a lot cheaper (and easier to use) than both. point is, many of the drugs we use routinely have an anti-seizure effect.
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Seizure or seizure like activity that is already occurring under 1.0 MAC of iso isn't guaranteed to cease by raising it to 1.5 MAC. Terminating it with a second agent immediately is his preferred choice of treatment as opposed to raising the MAC of iso and waiting to see if it has the desired effect.
 
UTSouthwestern said:
Dilantin. I told him he would be better served just using propofol.
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I agree
 
UTSouthwestern said:
Dilantin. I told him he would be better served just using propofol.
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I agree. The only reason we don't use propofol for ALL seizures is because of the side effects associated with using propofol >>>>> decreased mental acuity.
 
UTSouthwestern said:
Seizure or seizure like activity that is already occurring under 1.0 MAC of iso isn't guaranteed to cease by raising it to 1.5 MAC. Terminating it with a second agent immediately is his preferred choice of treatment as opposed to raising the MAC of iso and waiting to see if it has the desired effect.
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takes an hour (or longer) to load/get an effect with dilantin. so, you won't be "terminating it immediately" with that agent. propofol you'd get your results quick, agreed. but a propofol drip is a lot more expensive than iso at 1.5 mac. you can also stop it with a benzo, unless that's what you're trying to get the patient to kick (and i'm not sure such a patient would be a candidate for rapid detox anyway). thiopental. phenobarb... etc.

i'd be inclined just to crank up the iso for a few minutes. it really wouldn't take that long to get to 1.5 mac (as fast as you could find and draw-up ativan and push it, i'd bet). but, that's just me. you'd get your answer before a seizure is going to do any damage. protocols are protocols, though (if they're irb approved, etc.). not that any of this stuff has been extensively studied in any rigorous trials anyway.
 
by the way, 1.0 mac is not considered generally deep enough to suppress burst firing and seizure-like propagation. you need like a ED99 (i.e., 1.5 mac) to really have an effect.

of course, that is unless you did something stupid like grab the ketamine at induction.
 
VolatileAgent said:
takes an hour (or longer) to load/get an effect with dilantin. so, you won't be "terminating it immediately" with that agent. propofol you'd get your results quick, agreed. but a propofol drip is a lot more expensive than iso at 1.5 mac. you can also stop it with a benzo, unless that's what you're trying to get the patient to kick (and i'm not sure such a patient would be a candidate for rapid detox anyway). thiopental. phenobarb... etc.

i'd be inclined just to crank up the iso for a few minutes. it really wouldn't take that long to get to 1.5 mac (as fast as you could find and draw-up ativan and push it, i'd bet). but, that's just me. you'd get your answer before a seizure is going to do any damage. protocols are protocols, though (if they're irb approved, etc.). not that any of this stuff has been extensively studied in any rigorous trials anyway.
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A propofol drip is not necessary to terminate seizure activity. A bolus of 50 mg can terminate seizure activity immediately. Rarely will you have to go up to 2 mg/kg or follow up with an infusion of 1-3 mg/kg/hr. Thiopental in small bolus doses can also be used. Benzos are not a choice in his treatment scheme.

Loading Dilantin in the setting of central access and immediate hemodynamic support is something he does regularly. Typically he has to run some Levophed for a half hour or less but the bolus terminates the seizure activity within a couple of minutes or less and the 10-15 hour half life provides coverage for further episodes. Immediate termination is usually what he sees with the first 1/3 of the bolus dose in likely due to the co-suppressing effect of the general anesthetic.
 
Interesting ethical questions for sure.

Except for the much longer time under anesthesia, how is this really any different than some of the extended plastic surgery total body revisions we do? Facelift, blephs, lipo, nose, etc., all in one long drawn-out case - totally elective, no medical indication to do the procedure, just something the patient wants and is willing to pay for.
 
UTSouthwestern said:
A propofol drip is not necessary to terminate seizure activity. A bolus of 50 mg can terminate seizure activity immediately. Rarely will you have to go up to 2 mg/kg or follow up with an infusion of 1-3 mg/kg/hr. Thiopental in small bolus doses can also be used. Benzos are not a choice in his treatment scheme.

Loading Dilantin in the setting of central access and immediate hemodynamic support is something he does regularly. Typically he has to run some Levophed for a half hour or less but the bolus terminates the seizure activity within a couple of minutes or less and the 10-15 hour half life provides coverage for further episodes. Immediate termination is usually what he sees with the first 1/3 of the bolus dose in likely due to the co-suppressing effect of the general anesthetic.
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hmmm... i think we may be talking about two different things here, UT. there's terminating seizure activity. and then there's maintaining seizure-free activity.

i'm suggesting that if you crank up the iso, you can accomplish both relatively quickly and with little additional cost both financially (which is key in purely private cases like this) and in potential sequalae to the patient. i'm not arguing that you can't ablate seizure activity with propofol. i'm not even suggesting that loading dilantin isn't the right thing to do to maintain seizure control. i'm suggesting that you can likely accomplish both simply by cranking the little purple dial up a bit. after all, we're not talking about head trauma or epilepsy. we're talking about withdrawal seizures. when having to dig into the trenches and start enduring a long case, why make things more complicated right off the bat with worrying about central lines and levophed (and etc., etc.)? deep is good, especially in this specific case.

now, you might be able to convince me that you could potentially screw-up the hemodynamics going deep, but it's worth a shot before you get all fancy, dontcha think?
 
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hi guys. interesting thread, and I have a few questions.

first, I'd like to second the point the earlier poster made- narc withdraw doesn't kill, won't produce this vast autonomic instability, and it doesn't seem like you'd need more than some good old sedation to get through it comfortably.

which leaves us with alocohol and benzos to be detoxing from, so polysub abusers I can see wanting this. but even then why would dilantin come into the picture?? GABA agonist withdraw seizures are treated with GABA agonists, not phenytoin.........
 
VolatileAgent said:
hmmm... i think we may be talking about two different things here, UT. there's terminating seizure activity. and then there's maintaining seizure-free activity.

i'm suggesting that if you crank up the iso, you can accomplish both relatively quickly and with little additional cost both financially (which is key in purely private cases like this) and in potential sequalae to the patient. i'm not arguing that you can't ablate seizure activity with propofol. i'm not even suggesting that loading dilantin isn't the right thing to do to maintain seizure control. i'm suggesting that you can likely accomplish both simply by cranking the little purple dial up a bit. after all, we're not talking about head trauma or epilepsy. we're talking about withdrawal seizures. when having to dig into the trenches and start enduring a long case, why make things more complicated right off the bat with worrying about central lines and levophed (and etc., etc.)? deep is good, especially in this specific case.

now, you might be able to convince me that you could potentially screw-up the hemodynamics going deep, but it's worth a shot before you get all fancy, dontcha think?
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In his experience, taking the anesthetic depth to 1.5 MAC does not terminate the seizures either timely or completely.

For the question on why not just use GABA agonists, it is likely just his philosophy not to reintroduce the substance of abuse or something similar into the patient's system.
 
UTSouthwestern said:
In his experience, taking the anesthetic depth to 1.5 MAC does not terminate the seizures either timely or completely.

For the question on why not just use GABA agonists, it is likely just his philosophy not to reintroduce the substance of abuse or something similar into the patient's system.
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I would think you could titrate off a short acting benzo and avoid seizures all together in that amount of time... but what do I know. very sketchy compared to the medical detoxes I've seen.
 
nutmegs said:
I would think you could titrate off a short acting benzo and avoid seizures all together in that amount of time... but what do I know. very sketchy compared to the medical detoxes I've seen.
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I don't necessarily disagree with you, however, it's his show and one that I want no part of.
 
UTSouthwestern said:
I don't necessarily disagree with you, however, it's his show and one that I want no part of.
Click to expand...

Very informative, cool posts, Norm.

Thanks for taking the time to post the details. They gave me a mental picture of that detox area...something I always wondered about.

:horns:
 
I am a 60 year old physician. I suffered a major spinal injury about 20 years ago and have had several surgeries. The pain was only controlled by nactoics. I have to take a holiday about every 08 to 24 months as I chase the dosage up the ladder until it no longer works without severe side effects. My wife workes as an anesthelogist and she will bring me home an appropriate dose of Narcan and put me in immediate withdrawl. She monitors my vitals including b/p for the next three days. The first day is misery, the second day, I am afraid I am going to die, and the the third day, I am afraid that i will not die. The fourth day brings some relief and withing a week, I am feeling half my age. This is from a dosage of 60mg oxycontin 4 times per day as prescribed by my personal physician who is a pain specialist. I don't recommend the Narcan for the faint of heart or who just want to stick their toe in the water, but I have tried all kinds of cessation methonds over the past twenty years and the total misery seems to be about the same. YOu can drag it out for weeks or you can just get it over with. Personally, I prefer the latter. Care shoud be taken with this method to closely monitor blood pressure. Good luck all!!!!
 
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