Protracted Psychological and Cognitive Dysfunction

After Anesthesia: A Case Report

7th Annual Updates in Clinical Anesthesia 2016

John Wisniewski CRNA, MS, MSN

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

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

Anesthesia Synopsis

• D51/2NSS IV 24 G

• 20 mg IV Xylocaine

• 160 mg Propofol titration

• 10 mg Ketamine (~ 0.125 mg/kg)

Anesthesia Record

PACU Documented

• Zofran 4 mg IV

• Decadron 8 mg IV

• Versed 1 mg ordered, not given, marked as error

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

PACU Patient Experience

• Nausea and vomiting (new)

• Began to panic

• Wanted to “get out”

• Remembers anesthesiologist placing flashlight in her eyes

Extended Postoperative Course

• Restless • Closing eyes would cause panic • Intermittent panic attacks: extremities

shaking, palpitations • Pacing all over the house

Extended Postoperative Course

• Had to keep moving and or watch TV to distract herself

• Insomnia, insomnia, insomnia

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

Postoperative Functional Limitations Persist

• Began seeing psychiatrist/psychologist • Pharmacologic initiated • Perpetual crying • Insomnia • Nightmares going back to day of surgery

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

Emerging Diagnoses

• Bipolar disorder

• Post-traumatic stress disorder

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

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

DIAGNOSIS

KETAMINE INDUCED PSYCHOSIS

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

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

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

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

Mechanisms of Action

• Dose dependent blockade of the

N-methyl-D-asparate (NMDA) receptor

• Blockade of excitatory synaptic activity likely causes loss of responsiveness

Mechanisms of ActionOther Cellular Processes

• NO-cyclic guanosine-mono-phopshate system • Nicotinic acetylcholine channels • Non-NMDA glutamate receptors

Mechanisms of ActionOther Cellular Processes

• Increased release of aminergic neuromodulators (dopamine and noradrenaline)

• Reduction in cholinergic modulation • Delta and mu opioid agonism

Ketamine Pharmacologic Effects

• Hypnosis-psychotomimetic effects at low concentrations

• Intense analgesia—anti-nociception • Increased sympathetic activity • Maintenance of airway tone and

respiration

Unique Pharmacologic Effects

• Sedation • Catalepsy • Somatic analgesia • Bronchodilatation • Sympathetic nervous system stimulation

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

Established Unchallenged Ketamine Applications

• Shock and profoundly hypotension • Reactive airway disease • Burns • Prehospital and battlefield medicine • Children with congenital heart disease

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

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

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

Don’t Forget the Midazolam

• Midazolam can significantly reduce the incidence of psychological effects and agitation after ketamine procedural sedation and analgesia