Meth and Anesthesia

[getdown]

Hello all, I am hoping you all can help answer this question I have.

Recently saw a relatively young, healthy patient for elective orthopedic surgery who has been abusing meth for some time. He actually denied it but utox was positive. Now, we all know that the concern with chronic meth use is catecholamine depletion and the associated refractory hypotension and possibly even cardiac arrest on induction. So we would do pre-induction a-line, use direct acting pressors, etc etc. My questions is with elective surgeries, is there a length of time that you would have them wait from their last meth use to potentially allow for the catecholamine stores to build back up? I've tried looking online but it seems pretty varied from several days to several weeks but no consensus. Maybe those that have been practicing a while may have some input? Thanks a bunch.

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[Twiggidy]

Hello all, I am hoping you all can help answer this question I have.

Recently saw a relatively young, healthy patient for elective orthopedic surgery who has been abusing meth for some time. He actually denied it but utox was positive. Now, we all know that the concern with chronic meth use is catecholamine depletion and the associated refractory hypotension and possibly even cardiac arrest on induction. So we would do pre-induction a-line, use direct acting pressors, etc etc. My questions is with elective surgeries, is there a length of time that you would have them wait from their last meth use to potentially allow for the catecholamine stores to build back up? I've tried looking online but it seems pretty varied from several days to several weeks but no consensus. Maybe those that have been practicing a while may have some input? Thanks a bunch.

I'm not sure there is evidence to delay. The fact is that a person using meth will probably keep doing meth so I think the way you approached the case was fine to get it done and let that person get on with their life. The chances the patient returns having used meth are high. At the point the question is does the ortho want to keep dealing with it. You could do the ortho a solid by getting the case done so may he/she can get that patient away from his practice. Just shooting from the hip, but that's how I'd probably approach it

 

[Noyac]

So because he won’t stop using meth we must proceed with elective surgery?

 

[Twiggidy]

So because he won’t stop using meth we must proceed with elective surgery?

i honestly have no idea. I'm just saying I'd probably do it to get it done with and just fight his pressure in the OR. I think the OP's plan of action was appropriate. Although I didn't ask what the ortho procedure is. maybe a block could be used.

 

[nimbus]

Half our trauma patients are on meth. They do fine. To quote a recent Nobel laureate, don't think twice it's alright. Preinduction aline in an otherwise healthy meth addict is overkill.

 

[deleted59964]

just be gentle with the induction doses and have a pressor handy ... that is all i'd do. art lines don't help you to avoid hypotension, they just let you know it's happened (but you know it'll happen anyway)

 

[pgg]

Elective case, tox screen positive for meth or cocaine: cancel. Every time.

 

[Onefellswoop87]

From a different perspective - someone with a urine tox positive for meth throws a huge wrench into the informed consent aspect.

 

[deleted162650]

 

[sigrhoillusion]

I'd probably postpone for a purely elective case. I would get an EKG though before any case because of QT prolongation. Could just imagine the ambulance chasing attorney salivating at any post-op complications.

 

[Twiggidy]

Everyday when I consider quitting SDN, SaltyDog comes and pulls me back in.

 

[Twiggidy]

This thread is actually interesting (vs the alt right threads lingering around here).

We don't tox screen all our patients and all our patients definitely aren't saints, so it's interesting this guy would be postponed. Even when the surgeon tells me "This guy has a history of drug use" we don't tox screen them. In the words of Sheldon Cooper, "fascinating".

 

[nimbus]

ACE-I/ARB's are more likely to cause refractory hypotension and we don't cancel patients who forget to stop taking those. Positive meth Utox.....meh. We have so many, we'd be cancelling half our after hours fractures, rectal foreign body extractions, ectopics, and abscesses. Same for all the other positive Utox's.

 

[lobelsteve]

ACE-I/ARB's are more likely to cause refractory hypotension and we don't cancel patients who forget to stop taking those. Positive meth Utox.....meh. We have so many, we'd be cancelling half our after hours fractures, rectal foreign body extractions, ectopics, and abscesses. Same for all the other positive Utox's.

Elective vs emergency?

 

[nimbus]

Elective vs emergency?

Not emergencies. 90% of those cases could wait til the next day but we just get them done and get the patients out of the hospital asap.

 

[deleted162650]

Everyday when I consider quitting SDN, SaltyDog comes and pulls me back in.

Aww come on Twig, you can't go - we need you around here to keep things more . . . colorful? 😉

Inspired by your posts in all the politics/race threads, I found you a theme song:

 

[Twiggidy]

Aww come on Twig, you can't go - we need you around here to keep things more . . . colorful? 😉

Inspired by your posts in all the politics/race threads, I found you a theme song:

 

[deleted59964]

Aww come on Twig, you can't go - we need you around here to keep things more . . . colorful? 😉

I sure woulD miss your voice of reason

 

[Noyac]

This thread is actually interesting (vs the alt right threads lingering around here).

We don't tox screen all our patients and all our patients definitely aren't saints, so it's interesting this guy would be postponed. Even when the surgeon tells me "This guy has a history of drug use" we don't tox screen them. In the words of Sheldon Cooper, "fascinating".

We don’t either but I’ve had some that should have been postponed. They need haldol to wake up safely and not only safely for the pt but for the staff as well. I’d rather not have to do that.

 

[Noyac]

ACE-I/ARB's are more likely to cause refractory hypotension and we don't cancel patients who forget to stop taking those. Positive meth Utox.....meh. We have so many, we'd be cancelling half our after hours fractures, rectal foreign body extractions, ectopics, and abscesses. Same for all the other positive Utox's.

Those are not exactly elective cases tho

 

[deleted171991]

From a different perspective - someone with a urine tox positive for meth throws a huge wrench into the informed consent aspect.

Big point here. If something goes wrong, they can always argue they weren't consentable. Actually, this is exactly the angle I use when I approach the surgeon, before arguing the physiologic aspects (which they consider anesthesia whining until they see one near miss).

 

[nimbus]

Those are not exactly elective cases tho

They're not all emergencies either. Fractures and abscesses can generally wait if there's a need. And we do wait for npo and medical optimization. How long would you wait? I've never repeated a utox on someone who was utox+ on admission. Do you retest and wait for the tox screen to be negative? I've never heard of anyone doing that. I haven't actually seen this catecholamine depletion either and I do a lot of anesthesia on tweakers. There's a good chance the OP's case will never be done if they demand a clean tox screen before proceeding. Maybe that's okay.

 

[ranvier]

Make it an E and be done with it.

 

[deleted171991]

Make it an E and be done with it.

That's the surgeon's job. If they tell me it's an emergency (and why), I document and we go.