Perioperative Management for Chronic Schizophrenic Patients

1
Perioperative Management for Chronic
Schizophrenic Patients

• R3 ???

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
• 1015 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, Ad, Aß 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
• 520 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 blockade? ?? hypothalamic
  thermoregulation? ???? ??
• 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 ???? postop.
  confusion? ????? ?? (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.?? surgical stress? ?? plasma
  norepinephrine, ACTH, cortisol response ??

14
Intraoperative Problems and Management

• Malignant Hyperthermia
• neuroleptic malignant syndrome (NMS)
• unusual side effect of antipsychotics
• BT? ???, muscle rigidity, ANS instability
• 0.022.4 of pts. exposed to antipsychotics
• malignant hyperthermia(MH)? ????? ??
• (by inhaled anesthetics and
  succinylcholine)
• sarcoplasmic reticulum? Ca2 release channel
  (ryanodine receptor) ??? MH? ???? ???? ??

15
Intraoperative Problems and Management

• Malignant Hyperthermia
• Miyatake et al.
• ryanodine receptor gene? MH-susceptible mutation?
  NMS pts.?? ???? ??
• Adnet et al.
• halothane-caffeine contracture study?? NMS? MH
  ??? ??? ??
• NMS history ?? ?? ? MH? ??? ?? ??? ???? ????
  ???? ? ?? ???

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.?? abd. surgery ? ??? ? ? ?? serious
  side effect
• 28 (control 5)
• surgical stress? ?? sympathetic hyperactivity?
  ???? ???
• epidural local anesthetics? spinal reflex?
  stress-related sympathetic hyperactivity ? ?
  ?????? intestinal motility ??

18
Postoperative Problems and Management

• Confusion
• 28 in postop. 3 days (control 6)
• may be asso. with increased cortisol and
  norepinephrine
• postop. confusion? ??? ???? ?? ?, ?? plasma
  norepinephrine? cortisol conc.? ???
• epidural anesthesia? postop. confusion ???? ???
• plasma IL-6? ??? postop. confusion ??? ??

19
Postoperative Problems and Management

• Pain
• pain responsiveness is impaired
• postop. pain score ?? pain relief ?? postop.
  analgesic ??? ??
• chr. SCZ pts. appear to be less sensitive to
  postop. pain
• postop. pain? postop. confusion? ??? risk
  factor??? ??? postop. pain relief ??

20
Postoperative Problems and Management

• Sudden Death
• ?? ??? ?? 5?
• QT prolongation (m/c), aspiration resulting from
  excessive sedation, heat stroke, NMS
• Matsuki et al.
• increased mortality rate in chr. phenothiazine
  therapy
• 12? ? 11?? postop. 12? ??? ??
• phenothiazine overdosing? ?? ??? ??

21
Postoperative Problems and Management

• Sudden Death
• Chute et al.
• agitated mental state? ?? sympathetic and
  parasympathetic discharge? ???? ???? ??
• Laposata et al.
• agitated delirium? ?? ??? ??
• ??? ??? postop. confusion?? agitation? ????
  sudden death? ???? ?? ??

22
Postoperative Problems and Management

• Immune System
• increased rates of infectious disease
• immune system dysregulation? ??
• postop. wound infection and pneumonia
• postop. plasma IL-6 and IL-8? ??? ?? ??? control
  pts.? ?? ????? ??
• chr. SCZ pts.?? surgical stress? ?? cytokine?
  ??? ??? antipsychotics? pituitary-adrenal
  dysfunction? ?? ?? ?

23
Postoperative Problems and Management

• Antidiuretic Hormone
• life-threatening water intoxication
• vasopressin hypersecretion (chr. antipsychotics
  ??)
• ??? ?? plasma vasopressin? atrial natriuretic
  peptide? ??? ? ??? aldosterone? ??? ? ???
• ?? ???? ?? ? vasopressin, aldosterone, ANP?
  abnormal secretion?? ?? postop. water
  intoxication? ?? ? ??? ?? ??

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