Saturday, January 25, 2020

Methamphetamine-Anesthesia Considerations and Timing of Operation



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); Reviewed 9/26/24 (A Bernard)