Phenteremine and General Anesthesia

[Neogenesis]

What does everyone do about pts taking phenteremine for weight loss presenting for purely elective cases under GETA? Are people requiring them to hold x2 wks? If pt was still taking, would you cancel the case?

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[Planktonmd]

What does everyone do about pts taking phenteremine for weight loss presenting for purely elective cases under GETA? Are people requiring them to hold x2 wks? If pt was still taking, would you cancel the case?

Just ignore it and move on...
Think about it, we do anesthesia all the time on people who are abusing Cocaine and don't tell us or are on ADHD medications chronically so why should this be any different?

 

[Mman]

our preop clinic tells them to stop it for 7 days preop. I'll let it slide to 2 or 3 days off it when they come in if they got the instruction wrong. If they show up not having stopped it for purely elective, we will cancel. Why? Why not? It's elective. I don't really have a leg to stand on if they had a bad outcome since I can find 100s of examples of pre-op policies telling them to stop it ahead of time.

It's like NPO status. We do cases all the time on people that lie about NPO status but when they tell you the truth you don't really have much choice.

 

[neuroride]

We also have a 7 day off the drug policy. We have cancelled several cases because of this when it is purely elective. Most of the surgeons now know this and have them stop in enough time for their surgery.

 

[Planktonmd]

Do you also tell the ones with ADHD to stop their Adderall for a week before surgery?

 

[Mman]

Do you also tell the ones with ADHD to stop their Adderall for a week before surgery?

does anybody? Adderall is definitely more important to their life quality in the short term than a weight loss pill.

 

[deleted171991]

does anybody? Adderall is definitely more important to their life quality in the short term than a weight loss pill.

That is one of the most overprescribed drugs in America. "Life quality" my behind. It goes hand in hand with special accommodations for exams, anything that can give an unfair competitive edge. And it probably translates into lifetime dependency.

I have a pediatrician friend in Europe (you know, that strange continent where children are allowed to do a lot of things unsupervised and yet they all survive). How many of her patients are on amphetamines? None. 😉

ADHD is just another almost fairytale crutch like dyslexia.

 

[Planktonmd]

Well regardless of how real ADHD is, why is it OK to do anesthesia on someone taking Amphetamines for ADHD while it's not OK if the patient was taking Phentermine for obesity???

 

[deleted171991]

Or why is it OK to postpone elective procedures for cocaine, but not for amphetamine use?

 

[Planktonmd]

Or why is it OK to postpone elective procedures for cocaine, but not for amphetamine use?

Exactly!

 

[Mman]

Or why is it OK to postpone elective procedures for cocaine, but not for amphetamine use?

Because I've never seen anybody suggest they should be postponed for adderall use and you will get near unanimity in the profession to cancel for cocaine use.

I think the question people are getting to is why should one be different than the other. Unfortunately in our legal environment, they are different. Why is marijuana treated differently than alcohol? I don't know, that's just the way it is right now.

The question of whether it should be or not is a different question.

 

[Planktonmd]

Because I've never seen anybody suggest they should be postponed for adderall use and you will get near unanimity in the profession to cancel for cocaine use.

I think the question people are getting to is why should one be different than the other. Unfortunately in our legal environment, they are different. Why is marijuana treated differently than alcohol? I don't know, that's just the way it is right now.

The question of whether it should be or not is a different question.

So you are saying that it's OK to do GA on a patient with depleted adrenergic reserve caused by chronic Amphetamines but it's not OK if the adrenergic depletion was due to chronic Cocaine because the lawyers say so?

 

[Promethean]

So you are saying that it's OK to do GA on a patient with depleted adrenergic reserve caused by chronic Amphetamines but it's not OK if the adrenergic depletion was due to chronic Cocaine because the lawyers say so?

Define "OK."

If you are only concerned about the clinical picture, then you win the point.

If you have some concerns about legal outcomes should the plane go down in flames, then Mman is being prudent.

Depends on what you will feel comfortable explaining to the judge, I guess.

 

[Mman]

So you are saying that it's OK to do GA on a patient with depleted adrenergic reserve caused by chronic Amphetamines but it's not OK if the adrenergic depletion was due to chronic Cocaine because the lawyers say so?

What do you do? Do you do elective cases if they are on cocaine or adderall or do you cancel in either scenario?

 

[Planktonmd]

What do you do? Do you do elective cases if they are on cocaine or adderall or do you cancel in either scenario?

The only time I consider canceling a case is if they appear acutely intoxicated on Cocaine.

 

[Mman]

The only time I consider canceling a case is if they appear acutely intoxicated on Cocaine.

So if they said they used a bunch yesterday but appear fine today, you'd go ahead with their elective case?

 

[Planktonmd]

So if they said they used a bunch yesterday but appear fine today, you'd go ahead with their elective case?[/QUOTE

They never say that!
And by the way do you know for a fact how many days they need to not use cocaine for the anesthetic to be safe? is 3 days OK? or is it 5 or maybe 13 and 6 hours ...?

 

[Mman]

They never say that!
And by the way do you know for a fact how many days they need to not use cocaine for the anesthetic to be safe? is 3 days OK? or is it 5 or maybe 13 and 6 hours ...?

I've had patients admit to cocaine use to the exact date and time. And no there is no evidence as to what the duration they should be off it is other than avoiding if they are acutely intoxicated, but I can assure you it won't look good if the preop RN documents they were using cocaine Wednesday night and you put them to sleep for their rotator cuff repair Friday morning.

Drug screen will usually clear within 5 days.

 

[pgg]

The only time I consider canceling a case is if they appear acutely intoxicated on Cocaine.

If the tox screen is positive, I don't know if they last used 5 days ago or 45 minutes ago. I won't do an elective case in a patient with a + cocaine or meth screen. These patients can't be trusted.

Even the cowboyest of the cowboy surgeons are usually happy to cancel those cases too. Typically the billing sheet says self/no-pay and that patient group has a very high rate of noncompliance with postop care with resulting wound infections, re-fractures, etc etc.

 

[sigrhoillusion]

It's me again... so tomorrow I have a mammoplasty on an obese patient.

Looks like she was seen in our pre-op center at end of October with no real issues. But then saw her PCP at start of November and started taking phentermine. Honestly, I'm not even sure what my new places policies are on this drug. I'm planning on doing the case unless there is a specific document which tells patients to stop the drug. Again, she started it after she was seen in the PAT so not sure if they were aware she was going to start it.

Again, planning on doing the case and just having CRNA be vigilant, unless there are specific guidelines saying they should stop the drug or the patient is twerking out in holding area... I'll shoot it by chairman tomorrow, and it's not the first case so not an immediate decision. I just want to make him aware that way I don't do the case, have something go wrong, and then have a piece of paper thrown in my face that says they should have stopped the drug a few days before. As someone else said, probably no different than being on ADHD. That being said, why the heck do PCPs decide to start new drugs a few days before scheduled surgeries that aren't designed to optimize the patient...? Unless they were trying to help me out by having her lose 150 pounds prior to the case... 🙄

 

[Planktonmd]

Usually the PCP has no clue what we do nor does he/she care to try to know.
As for your case I wouldn't hesitate to do it.