Anesthesia in the Intoxicated Patient
Trauma is the most common indication for surgery and anesthesia of an acutely intoxicated individual, but other types of surgical emergencies can result from drug misuse, including vascular dissection and hemorrhagic complications linked to certain stimulants. There are particular perioperative and anesthetic considerations to be made for a patient who is acutely intoxicated with one or multiple substances (including but not limited to alcohol, cannabinoids, amphetamines, opioids, benzodiazepines, cocaine, hallucinogens) or with a history of substance use dependency or disorder 1.
Alcohol use is particularly common in the United States, with fourteen percent of the adult American population suffering from alcoholism 2. Particular attention is required for any patient undergoing anesthesia who is alcohol intoxicated. Anesthesiologists need to take into consideration the acute and/or chronic effects of alcohol use at all stages of the patient’s treatment.
A patient who is acutely alcohol-intoxicated presents with a unique set of challenges to the administration of anesthesia. First, the patient may have a depressed consciousness level, making it hard to interact with them, obtain a medical history prior to the procedure, or obtain informed consent. Alcohol consumption can also produce a significant degree of psychomotor impairment.
In the most extreme cases, if a procedure cannot be delayed until the effects of intoxication have cleared up, the patient may have to be treated as if they lacked the capacity to take an informed decision. In addition, a certain degree of alcohol-fueled confusion, aggression, and psychomotor impairment mean that the patient may be at risk of causing injury to others or themselves 3.
Furthermore, an intoxicated patient may be at increased risk of vomiting due to either anesthesia or the drug. The need to secure the airway for imaging or ongoing management means that intubation is often indicated.
During the operation, the findings of a recent retrospective chart review have demonstrated the presence of alcohol-induced hemodynamic dysregulation in intoxicated trauma patients suffering from a presumed intra-abdominal injury 4. It is thus critical for the anesthesiologist to be prepared to support blood pressure in order to maintain adequate perfusion in acutely intoxicated patients.
Chronic alcohol misuse also creates special considerations for surgery and anesthesia. A history of alcohol use should always be sought preoperatively in all adults and adolescents presenting for surgery. The CAGE questionnaire can be used to this end. A score of >2 is strongly indicative of alcohol use at a level likely to incur significant medical or social consequences.
Based on a patient’s condition, preoperative vitamins or medications may be indicated to better control vitals 5. Intraoperatively, rapid sequence induction is also often indicated, and chronic alcohol use tends to increase dose requirements for general anesthetic agents.
Historically, it has been believed that chronic heavy alcohol use is associated with a 2 to 5-fold increase in post-operative complications, linked to higher rates of admission to intensive care units and increased lengths of hospital stays 5. In particular, a recent retrospective, single-center cohort study at a Level 1 trauma center found that the need for postoperative mechanical ventilation increased in the acutely intoxicated trauma patients 6. Various targeted interventions should be leveraged in order to minimize the incidence of post-operative complications.
Finally, at any stage of the operation, alcohol withdrawal is a potentially life-threatening complication that must be diagnosed and actively managed 5. Confusion and delirium may be signs of such acute alcohol withdrawal syndrome, which prophylactic treatment may help prevent 7.
References
1. Anesthesia for patients with substance use disorder or acute intoxication – UpToDate. Available at: https://www.uptodate.com/contents/anesthesia-for-patients-with-substance-use-disorder-or-acute-intoxication. (Accessed: 8th May 2023)
2. ALCOHOL AND ANESTHESIA | Anesthesia Experts. Available at: https://anesthesiaexperts.com/uncategorized/alcohol-anesthesia/. (Accessed: 8th May 2023)
3. Thapar, P., Zacny, J. P., Choi, M. & Apfelbaum, J. L. Objective and subjective impairment from often-used sedative/analgesic combinations in ambulatory surgery, using alcohol as a benchmark. Anesth. Analg. (1995). doi:10.1097/00000539-199506000-00005
4. Mardini, J. et al. Alcohol Intoxicated Trauma Patients: Hemodynamic Effects of General Anesthesia. Anesth. Clin. Res. 11, 1–3 (2020). DOI: 10.35248/2155-6148.20.11.974
5. Chapman, R. & Plaat, F. Alcohol and anaesthesia. Contin. Educ. Anaesth. Crit. Care Pain 9, 10–13 (2009). doi:10.1093/bjaceaccp/mkn045
6. Wolf, B. D., Munnangi, S., Pesso, R., McCahery, C. & Oad, M. Are Intoxicated Trauma Patients at an Increased Risk for Intraoperative Anesthetic Complications? A Retrospective Study. Anesthesiol. Res. Pract. 2020, (2020). doi: 10.1155/2020/2157295.
7. Spies, C. D. & Rommelspacher, H. Alcohol withdrawal in the surgical patient: Prevention and treatment. Anesthesia and Analgesia (1999). doi:10.1213/00000539-199904000-00050