Perioperative Management for Chronic Schizophrenic Patients

1. Perioperative Management for Chronic Schizophrenic Patients R3 정상우

2. Schizophrenia (SCZ) • thought disorders, delusions, hallucinations • m/c psychotic disorder (20%) • increased mortality in postop. period • adverse responses during anesthesia

3. Preoperative Problems and Management • Antipsychotics • SCZ subtype : paranoid, catatonic, disorganized, undifferentiated • antipsychotics • dopamine receptor antagonist • haloperidol, fluphenazine, chlorpromazine, thioridazine • serotonin-dopamine antagonist

4. Preoperative Problems and Management • Antipsychotics • Lanctot et al. • 21% of pts. receiving antipsychotics had a serious side effect • nearly half of SCZ pts. have a comorbid medical condition • chronic SCZ pts. have increased death rates • acute state : haloperidol, benzodiazepine

5. Preoperative Problems and Management • Cardiovascular Disease • increased incidence of cardiovasc. dis. in chr. SCZ pts. • increased body weight • diabetes mellitus • frequent smoking (75% of SCZ pts.) • ECG changes caused by antipsychotics • prolongation of QT and PR intervals, T-wave changes

6. Preoperative Problems and Management • Cardiovascular Disease • prolongation of QT interval • marker for antipsychotic drugs to cause torsade de pointes • thioridazine, droperidol • 10~15 of 10000 pts. • minor cardiovascular adverse effects • postural hypotension • tachycardia

7. Preoperative Problems and Management • Paralytic Ileus • anticholinergic and noradrenergic effect of antipsychotics • asso. with postop. prognosis • Pain Insensitivity • increased threshold of C, Aδ, Aβ function • dysregulation of N-methyl-D-aspartate (NMDA) receptor transmission • analgesic effect of antipsychotics

8. Preoperative Problems and Management • Preoperative Discontinuation of Antipsychotics • preop. use makes pts. more susceptible to hypotensive action of GA • postop. confusion (72h before surgery) • 31% (vs 14%) • hypotension and arrhythmia did not significantly differ • 16% (vs 18%) • continue antipsychotics preoperatively

9. Intraoperative Problems and Management • Anesthetics • controversy : general vs regional • bronchospasm and persistent hypotension during spinal anesthesia • enflurane (combination with antipsychotics) • hypotension, arrhythmias, seizures, malignant hyperthermia

10. Intraoperative Problems and Management • Hemodynamics • increased heart rate • hypotension • during and after anesthesia induction • 5~20% of SCZ pts. • chlorpromazine • risk factors • increased age, use of antihypertensives, increased individual sensitivity to anesthetics, influence of renin-angiotensin system

11. Intraoperative Problems and Management • Thermoregulation • temperature regulation during anesthesia may be impaired • dopamine blockade로 인해 hypothalamic thermoregulation에 직접적인 영향 • core temperature was lower than control groups • hypothermia • important factor affecting postop. mortality and morbidity • Kramer et al. • 54 pts. died from hypothermia asso. with antipsychotics

12. Intraoperative Problems and Management • Ketamine • has been thought to be unsuitable • prolonged hallucination or delirium • Ishihara et al. • 14 chr. SCZ pts. with ketamine → no exacerbations of psychosis (postop. 1 month) • TIVA (ketamine, propofol, fentanyl) : sevoflurane, N2O, fentanyl 마취보다 postop. confusion이 두드러지게 감소 (30% vs 54%) • appropriate anesthetic drug when combined with propofol and fentanyl

13. Intraoperative Problems and Management • Endocrine Response • abnormalities in hypothalamic-pituitary-adrenal and autonomic nerve function • particularly in response to stress • decreased plasma cortisol concentration • chr. SCZ pts.에서 surgical stress에 대해 plasma norepinephrine, ACTH, cortisol response 감소

14. Intraoperative Problems and Management • Malignant Hyperthermia • neuroleptic malignant syndrome (NMS) • unusual side effect of antipsychotics • BT의 급상승, muscle rigidity, ANS instability • 0.02~2.4% of pts. exposed to antipsychotics • malignant hyperthermia(MH)와 임상적으로 유사 (by inhaled anesthetics and succinylcholine) • sarcoplasmic reticulum의 Ca2+ release channel (ryanodine receptor) 이상이 MH의 원인으로 생각되고 있다

15. Intraoperative Problems and Management • Malignant Hyperthermia • Miyatake et al. • ryanodine receptor gene의 MH-susceptible mutation이 NMS pts.에서 발견되지 않음 • Adnet et al. • halothane-caffeine contracture study에서 NMS와 MH 사이에 관련이 없음 • NMS history 환자 마취 시 MH가 생기기 쉬운 환자와 동일하게 조심해서 마취해야 할 지는 미지수

16. Postoperative Problems and Management • Psychological State • Molnar and Fava • surgical stress worsens the psychotic symptoms after surgery • psychological state before and after surgery did not significantly change in SCZ pts.

17. Postoperative Problems and Management • Ileus • postop. paralytic ileus • chr. SCZ pts.에서 abd. surgery 후 흔하게 볼 수 있고 serious side effect • 28% (control 5%) • surgical stress로 인한 sympathetic hyperactivity로 생긴다고 여겨짐 • epidural local anesthetics는 spinal reflex와 stress-related sympathetic hyperactivity 둘 다 차단함으로써 intestinal motility 향상

18. Postoperative Problems and Management • Confusion • 28% in postop. 3 days (control 6%) • may be asso. with increased cortisol and norepinephrine • postop. confusion이 있었던 환자에서 수술 중, 후의 plasma norepinephrine과 cortisol conc.이 높았다 • epidural anesthesia로 postop. confusion 감소하지 않았다 • plasma IL-6의 증가가 postop. confusion 발생에 관여

19. Postoperative Problems and Management • Pain • pain responsiveness is impaired • postop. pain score 낮고 pain relief 위한 postop. analgesic 요구도 감소 • chr. SCZ pts. appear to be less sensitive to postop. pain • postop. pain은 postop. confusion의 중요한 risk factor이므로 적절한 postop. pain relief 필요

20. Postoperative Problems and Management • Sudden Death • 일반 인구에 비해 5배 • QT prolongation (m/c), aspiration resulting from excessive sedation, heat stroke, NMS • Matsuki et al. • increased mortality rate in chr. phenothiazine therapy • 12명 중 11명이 postop. 12일 이내에 사망 • phenothiazine overdosing에 의한 것으로 제안

21. Postoperative Problems and Management • Sudden Death • Chute et al. • agitated mental state로 인한 sympathetic and parasympathetic discharge의 불균형을 원인으로 추측 • Laposata et al. • agitated delirium이 관계 있다고 설명 • 따라서 환자가 postop. confusion이나 agitation을 일으키면 sudden death의 가능성에 대해 고려

22. Postoperative Problems and Management • Immune System • increased rates of infectious disease • immune system dysregulation의 결과 • postop. wound infection and pneumonia • postop. plasma IL-6 and IL-8의 수술에 대한 반응이 control pts.에 비해 유의적으로 낮음 • chr. SCZ pts.에서 surgical stress에 대한 cytokine의 억제된 반응은 antipsychotics와 pituitary-adrenal dysfunction과 관계 있을 것

23. Postoperative Problems and Management • Antidiuretic Hormone • life-threatening water intoxication • vasopressin hypersecretion (chr. antipsychotics 사용) • 수술에 대한 plasma vasopressin과 atrial natriuretic peptide의 반응은 더 심했고 aldosterone의 반응은 더 적었다 • 위의 결과들은 마취 중 vasopressin, aldosterone, ANP의 abnormal secretion으로 인해 postop. water intoxication이 생길 수 있다는 것을 암시

24. Conclusion • chr. SCZ pts. are at increased risk for developing various periop. Cx. • continuation of antipsychotic drugs before anesthesia and total IV anesthesia with ketamine, propofol, and fentanyl can decrease incidence of postop. confusion • epidural analgesia during and after anesthesia can decrease postop. ileus