Post-op Confusion

[Noyac]

I just pre-op'd a guy today who is scheduled for a very long (>4 hr) spine case. He was extremely affraid of having another anesthetic. He underwent a shoulder procedure 2 yrs ago. He received a interscalene block and a GETA. After surgery he had severe pain in the recovery room ( guess the ISB didn't work) and nausea. He was admitted for pain control and confusion. I retrieved the old chart and there is not much mention of the confusion but labs were normal. He described some hallucinations (narcotic?) and confusion as to time and place. Everything essentially resolved after 3-5 days. What are your thoughts and how would you do the case? Tomorrow, I'll tell you how I did the case.

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[militarymd]

You are describing persistent post-operative cognitive dysfunction. Not a whole lot you can do about it other than minimizing the number of anesthetic agents you use, and providing adequate pain control with regional anesthesia if possible....although, in the elderly, use of regional anesthesia does not necessarily prevent this post operative complication.

 

[jetproppilot]

I just pre-op'd a guy today who is scheduled for a very long (>4 hr) spine case. He was extremely affraid of having another anesthetic. He underwent a shoulder procedure 2 yrs ago. He received a interscalene block and a GETA. After surgery he had severe pain in the recovery room ( guess the ISB didn't work) and nausea. He was admitted for pain control and confusion. I retrieved the old chart and there is not much mention of the confusion but labs were normal. He described some hallucinations (narcotic?) and confusion as to time and place. Everything essentially resolved after 3-5 days. What are your thoughts and how would you do the case? Tomorrow, I'll tell you how I did the case.

Precedex is an awesome drug that, as you already know Noy, enables one to significantly redude opiod/volatile requirements. Great drug for CABGs, big spine cases, crani's etc IMHO.

I'd build my anesthetic around Precedex for this case. You could probably get away with running Des at 3-4% and give 250 ug or less of fentanyl for the whole case.

 

[jetproppilot]

Precedex is an awesome drug that, as you already know Noy, enables one to significantly redude opiod/volatile requirements. Great drug for CABGs, big spine cases, crani's etc IMHO.

I'd build my anesthetic around Precedex for this case. You could probably get away with running Des at 3-4% and give 250 ug or less of fentanyl for the whole case.

sorry...REDUCE opiod/volatile requirements...

 

[Noyac]

Precedex is an awesome drug that, as you already know Noy, enables one to significantly redude opiod/volatile requirements. Great drug for CABGs, big spine cases, crani's etc IMHO.

I'd build my anesthetic around Precedex for this case. You could probably get away with running Des at 3-4% and give 250 ug or less of fentanyl for the whole case.

Yeah, I have started to use precedex for these cases as well and definitely plan on using it tomorrow. I generally run sevo at 0.7-1.2 ET (we only have sevo) when using Precedex while running a low dose sufenta infusion. I think its important to have these pts awake and alert as soon as possible. Pain is bad also in these pts. I avoid versed almost always in this type of case since it is one drug linked to post-operative cognitive dysfunction.

 

[jetproppilot]

Pain is bad also in these pts.

Hmmmmm....

Very true statement that made me wonder...

Is there something we could do preoperatively to ameliorate this? Like preoperative administration of some of the chronic-pain realm stuff...clonidine, amitryptiline, etc...with continuation of same post op?

Or some other thinking-outside-the-box ideas?

We (clinical anesthesiologists) are not real aggressive with this kind of stuff.

Wonder if it would make a difference in post-op pain scores.

??

 

[zippy2u]

This guy sounds like your run-o'-tha-mill squirrel; does the guy tell you he's allergic to 30 different drugs including epinephrine and has a severe case of fibromyalgia? Hell, just put him to sleep like any other spine case--chances are that he'll do fine. Regards ---Zip

 

[DrDre']

Ah Zip,
A cynic after my own heart!

 

[Noyac]

Hmmmmm....

Very true statement that made me wonder...

Is there something we could do preoperatively to ameliorate this? Like preoperative administration of some of the chronic-pain realm stuff...clonidine, amitryptiline, etc...with continuation of same post op?

Or some other thinking-outside-the-box ideas?

We (clinical anesthesiologists) are not real aggressive with this kind of stuff.

Wonder if it would make a difference in post-op pain scores.

??

Well, now you have got me thinking. This pt population does have a decrease amount of serotonin production as well as the other neurotransmitters. If you were to give these pts amitryptiline pre and post op you would improve their sleep which is one of the reasons for POCD. By decreasing serotonin and NE reuptake we would put them in a more physiologc environment resembling a younger pt. I also think clonidine has some pain implications that are still not fully understood and may prove beneficial in this population. So remind me Jet, what are we doing in private practice?

 

[militarymd]

I avoid versed almost always in this type of case since it is one drug linked to post-operative cognitive dysfunction.

Actually, benzodiazepine levels, in a study recently published, was not correlated with POCD.

 

[jetproppilot]

Well, now you have got me thinking. This pt population does have a decrease amount of serotonin production as well as the other neurotransmitters. If you were to give these pts amitryptiline pre and post op you would improve their sleep which is one of the reasons for POCD. By decreasing serotonin and NE reuptake we would put them in a more physiologc environment resembling a younger pt. I also think clonidine has some pain implications that are still not fully understood and may prove beneficial in this population. So remind me Jet, what are we doing in private practice?

Like Puffy said, Noy, its all about the benjamins.

 

[jetproppilot]

This guy sounds like your run-o'-tha-mill squirrel; does the guy tell you he's allergic to 30 different drugs including epinephrine and has a severe case of fibromyalgia? Hell, just put him to sleep like any other spine case--chances are that he'll do fine. Regards ---Zip

HAHHAHAHHAHAHAHHAHAHAHAHAHAHAHAHAHHAHAHAHAHAHAHAH

Ya gotta love the Zipster.

 

[canjosh]

This guy sounds like your run-o'-tha-mill squirrel; does the guy tell you he's allergic to 30 different drugs including epinephrine and has a severe case of fibromyalgia? Hell, just put him to sleep like any other spine case--chances are that he'll do fine. Regards ---Zip

Zip-
You need to join me in triage for a couple of nights!

Pt: I'm allergic to potassium, toradol, demerol, morphine, NSAIDs, Z-pack, etc. I can only take IV Dilaudid--2mg at least!

Me: Really?! So, if we drew your blood, your potassium would be 0, right?

Pt: Well, yeah I guess so.

Me: What happens when you get Morphine?

Pt: I get nauseated.

Me: That's a side effect, not an allergy. What about Zithromax?

Pt: Well, I get stomach cramps and diarrhea.

Me: Yes we call those side effects.

Pt: Oh...well can I see the doctor so I can get my Dilaudid?

Repeat x 50 per shift.

 

[Noyac]

This guy sounds like your run-o'-tha-mill squirrel; does the guy tell you he's allergic to 30 different drugs including epinephrine and has a severe case of fibromyalgia? Hell, just put him to sleep like any other spine case--chances are that he'll do fine. Regards ---Zip

Actually he takes just 2 meds. Lisinopril and Zocor. He isn't allergic to anything and his wife described the strange conversations that she had with her husband while recovering from the previous surgery. Some of the conversations were hallucinations that seem alot like the ICU psychosis or morphine hallucinations.

 

[Noyac]

Like Puffy said, Noy, its all about the benjamins.

Yeah, its an addiction.

 

[jetproppilot]

Actually he takes just 2 meds. Lisinopril and Zocor. He isn't allergic to anything and his wife described the strange conversations that she had with her husband while recovering from the previous surgery. Some of the conversations were hallucinations that seem alot like the ICU psychosis or morphine hallucinations.

Did you ask his wife if he had a stash of Hawaiin Con Bud that he had utilized the night before surgery?

 

[Noyac]

Did you ask his wife if he had a stash of Hawaiin Con Bud that he had utilized the night before surgery?

Here in Colorado they are calling it G13 (government issue 13). Don't ask how I know. Makes me wonder if its like that **** in Jacob's Ladder. That **** was mean dude.

 

[Disse]

Well, now you have got me thinking. This pt population does have a decrease amount of serotonin production as well as the other neurotransmitters. If you were to give these pts amitryptiline pre and post op you would improve their sleep which is one of the reasons for POCD. By decreasing serotonin and NE reuptake we would put them in a more physiologc environment resembling a younger pt. I also think clonidine has some pain implications that are still not fully understood and may prove beneficial in this population. So remind me Jet, what are we doing in private practice?

This months A & A has a decent review article that may help you.
Here's the citation since I don't know how to do all that fancy attached pdf stuff:

Author White, Paul F. PhD, MD, FANZCA

Institution Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

Title The Changing Role of Non-Opioid Analgesic Techniques in the Management of Postoperative Pain.[Review]

Source Anesthesia & Analgesia. 101(5S) (Supplement):S5-S22, November 2005.

Abstract Given the expanding role of ambulatory surgery and the need to facilitate an earlier hospital discharge, improving postoperative pain control has become an increasingly important issue for all anesthesiologists. As a result of the shift from inpatient to outpatient surgery, the use of IV patient-controlled analgesia and continuous epidural infusions has steadily declined. To manage the pain associated with increasingly complex surgical procedures on an ambulatory or short-stay basis, anesthesiologists and surgeons should prescribe multimodal analgesic regimens that use non-opioid analgesics (e.g., local anesthetics, nonsteroidal antiinflammatory drugs, cyclooxygenase inhibitors, acetaminophen, ketamine, [alpha] 2-agonists) to supplement opioid analgesics. The opioid-sparing effects of these compounds may lead to reduced nausea, vomiting, constipation, urinary retention, respiratory depression and sedation. Therefore, use of non-opioid analgesic techniques can lead to an improved quality of recovery for surgical patients.

p.s. PO clonidine pre-op is the poor man's precedex infusion.