Protracted Psychological and Cognitive Dysfunction After ...
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Protracted Psychological and Cognitive Dysfunction
After Anesthesia: A Case Report
7th Annual Updates in Clinical Anesthesia 2016
John Wisniewski CRNA, MS, MSN
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Patient Profile
• 51 year old female • 80 kg , 66 inches • ASA 2 • NKDA • Medical and major surgical history
negative • 4 mo prior: cervical facet injection • 1 mo prior: ESI L4L5 • Both procedures uneventful
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Procedural Summary
• Diagnosis: Cervicalagia, Cervical Facet Pain
• Procedure: C3-C4, C4-C5, C5-C6, C6-C7 Facet Injection
• Skin localization with 1% Xylocaine • Omnipaque • Injection with 0.5% Sensorcaine and
Kenalog
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Anesthesia Synopsis
• D51/2NSS IV 24 G
• 20 mg IV Xylocaine
• 160 mg Propofol titration
• 10 mg Ketamine (~ 0.125 mg/kg)
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Anesthesia Record
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PACU Documented
• Zofran 4 mg IV
• Decadron 8 mg IV
• Versed 1 mg ordered, not given, marked as error
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PACU Perioperative Experience
• Felt as if her head was exploding • Hearing voices • Felt as is she were being stabbed to
death • Being held down • Wanted it to stop
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PACU Patient Experience
• Nausea and vomiting (new)
• Began to panic
• Wanted to “get out”
• Remembers anesthesiologist placing flashlight in her eyes
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Extended Postoperative Course
• Restless • Closing eyes would cause panic • Intermittent panic attacks: extremities
shaking, palpitations • Pacing all over the house
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Extended Postoperative Course
• Had to keep moving and or watch TV to distract herself
• Insomnia, insomnia, insomnia
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The Return to Work Issue
• 2 days post-procedure • On Lorazepam • Initially ok in total joint room • Had to work as circulator in pain room • Felt as in everything closing in on her • Had to be relieved and she left work
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Postoperative Functional Limitations Persist
• Began seeing psychiatrist/psychologist • Pharmacologic initiated • Perpetual crying • Insomnia • Nightmares going back to day of surgery
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Postoperative Functional Limitations Persist
• Tough time studying
• Could not concentrate; dropped course
• Seemed as if she lost control of mind
• Forgetful—leave water running, dog outside
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Emerging Diagnoses
• Bipolar disorder
• Post-traumatic stress disorder
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Pharmacologic InterventionDATE DRUG DRUG
August 2015
September 2015 Propanalol, Quentiapine, Aplrazolam
Inderal, Seroquel, Xanax
October 2015 Lamotrigine Lamictal
December 2015 Quentiapine, Lamotrigine, Clonazepam
Seroquel, Lamictal, Klonopin
January 2016 Lamotrigine, Clonazepam, Neurontin
Lamictal, Klonopin, Gabapentin
Summer 2016 Clonazepam Klonopin
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Negative Psychosocial Impact
• 5 months without work • Lost job; procured new one • Does not know how she will be same
person again • Panic attacks prior to wellness
colonoscopy June 2016
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DIAGNOSIS
KETAMINE INDUCED PSYCHOSIS
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Literary Evidence 20 Plus Years
• Subanesthetic doses of ketamine 0.1mg/kg in 19 healthy volunteers: – Produced behaviors similar to
schizophrenia – Elicited alterations in perception – Impaired performance on tests of vigilance
and verbal fluency – Evoked symptoms similar to dissociative
states
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Literary Evidence 20 Plus Years
• In a study of 17 healthy volunteers, ketamine produced: – Focal increases in metabolic activity in the
prefrontal cortex – An acute psychotic state – Conceptual disorganization
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Background PCP
• Phencyclidine (PCP) also antagonizes NMDA receptors (major site of excitatory neurotransmission in the brain)
• Produces a broad range of cognitive and behavioral disturbances including an acute psychotic state that resembles schizophrenia—thought disorder, delusions, and perceptual alteration
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Ketamine Different With Ability to Produce Psychosis?
• Low potency NMDA antagonist • Short half-life • However……… • Subanesthetic doses of ketamine
produce a range of cognitive and behavioral effects similar to PCP including psychotic symptoms
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Mechanisms of Action
• Dose dependent blockade of the
N-methyl-D-asparate (NMDA) receptor
• Blockade of excitatory synaptic activity likely causes loss of responsiveness
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Mechanisms of ActionOther Cellular Processes
• NO-cyclic guanosine-mono-phopshate system • Nicotinic acetylcholine channels • Non-NMDA glutamate receptors
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Mechanisms of ActionOther Cellular Processes
• Increased release of aminergic neuromodulators (dopamine and noradrenaline)
• Reduction in cholinergic modulation • Delta and mu opioid agonism
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Ketamine Pharmacologic Effects
• Hypnosis-psychotomimetic effects at low concentrations
• Intense analgesia—anti-nociception • Increased sympathetic activity • Maintenance of airway tone and
respiration
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Unique Pharmacologic Effects
• Sedation • Catalepsy • Somatic analgesia • Bronchodilatation • Sympathetic nervous system stimulation
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Logic of Contemporary Use
• The availability of newer drugs, the disturbing emergence reactions of ketamine, popularity of the drug with abuse potential are features would discourage use in contemporary practice
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Established Unchallenged Ketamine Applications
• Shock and profoundly hypotension • Reactive airway disease • Burns • Prehospital and battlefield medicine • Children with congenital heart disease
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Ketamine Applications With Moderate Scientific Evidence
Option to Other Agents
• Pediatric premedicant • Adjunct to IV Regional Anesthesia and
Peripheral Nerve Blocks • Prevention of post-anesthesia shivering
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Ketamine Applications With Moderate Scientific Evidence Low Dose Regimes
• Emergency Department for brief, painful or emotionally disturbing procedures
• In critical care unit • Co-induction and TIVA with propofol/
midazolam/dexometatomidine
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Ketamine Recent Clinical Applications With Limited Scientific Evidence
• Based on a better understanding of the NMDA receptors in pain modulation and on anti-inflammatory properties of ketamine
• Acute Pain Management • Chronic Pain Management
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Don’t Forget the Midazolam
• Midazolam can significantly reduce the incidence of psychological effects and agitation after ketamine procedural sedation and analgesia