Background:
The use of methamphetamine, usually consumed as crystal
methamphetamine, has increased in the United States. In 2014, a National Survey on Drug Abuse and
Health indicated that 4.9% of Americans aged greater than 12 years will have
used methamphetamine during their lifetime and another statistic reported that
as many as 33 million individuals are methamphetamine abusers.(1) Methamphetamine is available in liquid, powder,
and crystalline form, which may be smoked.
It usually creates a euphoric psychosis. It increases brain monoamine
(primarily dopamine) levels in the acute phase.
It also increases norepinephrine levels.
Chronic use may result in neurotoxicity in the dopaminergic axon
terminals, with reduced dopamine production.(2)
Methamphetamine prevents catecholamine uptake and stimulates
catecholamine release, resulting in a rapid increase in heart rate and blood
pressure. Use of methamphetamine is associated
with vasospasm of the coronary arteries, resulting in myocardial ischemia or
infarction. It also may result in
pulmonary hypertension. Pulmonary
hypertension from methamphetamine is more common in men and in patients who
inhale the medication through smoking.
According to the World Health Organization, methamphetamine use is
considered a likely risk factor for pulmonary hypertension.(3) There are three cardiac morbidities
associated with methamphetamine.
Myocardial infarction is the second leading cause of death from
methamphetamine. There is also a 27%
increase in risk of sudden cardiac death from methamphetamine. The drug may prolong the QT, placing the
patient at risk. Finally, the patient is
at risk for cardiomyopathy.
Echocardiography demonstrates LV dilation and impaired LV ejection
fraction.(4) Methamphetamine is
associated with severe heart failure with severely depressed ejection fraction.
The most common symptom is dyspnea. Finally,
methamphetamine increases body temperature, placing the patient at risk of
rhadbomyolysis.(5) In regard to
providing anesthesia to patients having positive results for methamphetamine, a
retrospective review was conducted of 94 patients who had multiple orthopedic
trauma. The overall rates of
perioperative cardiovascular complications and perioperative medical
complications were 2.1% and 3.2%. One
patient required cancellation after induction of anesthesia due to hypotension
not responsive to vasopressors.(6) The
2.1% is greater than the incidence established for orthopedic trauma patients
through analysis of the American College of Surgeons National Surgical Quality
Improvement Program (1.3%).
References
1.
Ben-Yehuda O, Siecke N. Crystal Methamphetamine: A drug and
cardiovascular epidemic. JACC: Heart
Failure 208;6:219-221.
2.
Kevil CG, Goeders NE, Woolard MD, et al. Methamphetamine use and cardiovascular
disease. Arterioscler Thromb Vasc Biol
2019;39:1739-1746.
3.
Ramirer RL, Perez VJ, Zamanian RT. Methamphetamine and the risk of pulmonary
arterial hypertension. Curr Opin Pulm
Med 2018;24:416-424.
4.
Schuerer S, Klingel K, Sandri M, et al. Clinical characteristics, histopathological
features, and clinical outcome of methamphetamine-associated
cardiomyopathy. JCC: Heart Failure
2017;6:435-45.
5.
Beaulieu P.
Anesthetic implications of recreational drug use. Can J Anesth 2017;64:1236-1264.
6.
Githens T, Debaun MR, Campbell ST, et al. Rates of perioperative complications among
patients undergoing orthopedic trauma surgery despite having positive results
for methamphetamine. Orthopedics
2019;42:192-196.
Perioperative Recommendations:
1.
Patients who test positive for Methamphetamine
and are an “A” emergency
a.
If possible obtain EKG
i. Proceed
to OR – anesthesia management based upon EKG
ii. May
need postoperative cardiology management
b.
If possible obtain serum CPK
i. Proceed
to OR without waiting for result of CPK – if result available during case, may
help with intraoperative management
2.
Patients who test positive to Methamphetamine and
are a “B” emergency
a.
Consent
i. Patient
should be able to provide consent
ii. If
patient is unable to provide consent, family member will provide consent
iii. If
patient is unable to provide consent and family member is not present, attempt
to contact family by phone
iv. If
patient is unable to provide consent, family member is not present, and unable
to contact family by phone, will proceed to OR documenting measures taken
b.
EKG
i. If
EKG is normal, proceed to OR
ii. If
EKG is suggests on-going cardiac ischemia check previous EKG (if available) and
check for symptoms
1.
If asymptomatic, proceed to OR and cardiology
consulted while in PACU
2.
If patient with chest pain, shortness of breath,
evidence of cardiac failure, seek input from cardiology
a.
Cardiology available – follow recommendations
b.
Cardiology unavailable – Manage symptoms and
cardiology involvement postoperative
c.
Serum CPK
i. If
CPK is normal, proceed to OR
ii. If
CPK is abnormal, consider rhabdomyolysis and manage accordingly
1.
Proceed to OR
2.
Follow rhabdomyolysis protocol
3.
Patients who test positive for Methamphetamine
and are a “C” emergency
a.
Consent
i. Patient
should be able to provide consent
ii. If
patient is unable to provide consent, family member will provide consent
iii. If
patient is unable to provide consent and family member is not present, attempt
to contact family by phone
iv. If
patient is unable to provide consent, family member is not present, and unable
to contact family by phone, wait until able to complete i, ii, or iii.
b.
EKG
i. If
EKG is normal, proceed to OR
ii. If
EKG is abnormal, check previous EKG (if available) and check for symptoms
1.
If asymptomatic, proceed to OR
2.
If patient with chest pain, shortness of breath,
or symptoms of cardiac failure, cardiology consultation must be obtained prior
to operating room
c.
Serum CPK
i. If
CPK is normal, proceed to OR
ii. If
CPK is abnormal, consider rhabdomyolysis and manage accordingly
1.
Proceed to OR
2.
Follow rhabdomyolysis protocol
4.
Patients who test positive for methamphetamine
and are elective procedures
a.
Given the half-life of methamphetamine is 10.7
hours and that from a clinical standpoint, it is common to
assume that a drug is effectively eliminated after 4-5 half-lives, elective
procedures be delayed 48 hours.
5.
Patients with a history of methamphetamine use must
have an EKG prior to procedure.
January 25, 2020 (Eric Johnson PharmD; A Bernard)
