Propofol misuse in medical professions: a scoping review.

PURPOSE: We aimed to describe the current literature concerning propofol misuse in medical professionals, specifically relating to the individual demographics of those misusing propofol and the outcomes of propofol misuse. METHODS: We conducted a retrospective scoping review of the literature using a modified PRISMA approach. We used MEDLINE, EMBASE, and PsycINFO databases to identify relevant studies based on search terms. Studies describing individual medical professionals misusing propofol were included. RESULTS: Twenty-four articles describing 88 individual cases of propofol misuse were included for data charting and analysis. Anesthesiologists and certified registered nurse anesthetists were most commonly identified. Death was a common method of identification of misuse, while rehabilitation and death were common final outcomes associated with propofol misuse. CONCLUSIONS: Despite knowledge of the pharmacokinetic and pharmacodynamic properties of propofol by those misusing this medication, death was a common outcome reported in the literature. Data related to long-term outcomes including re-entry to clinical practice or success of rehabilitation were limited.

RéSUMé: OBJECTIF: Nous avons cherché à décrire la littérature actuelle concernant l'abus de propofol chez les professionnels de la santé, en particulier en ce qui concerne les données démographiques individuelles de ceux qui abusent du propofol et les issues d'un tel abus. MéTHODE: Nous avons réalisé une étude de portée rétrospective de la littérature à l'aide d'une approche PRISMA modifiée. Nous avons utilisé les bases de données MEDLINE, EMBASE et PsycINFO pour identifier les études pertinentes en fonction des termes de recherche. Les études décrivant des professionnels de la santé abusant du propofol ont été incluses. RéSULTATS: Vingt-quatre articles décrivant 88 cas individuels d'abus de propofol ont été inclus pour la cartographie et l'analyse des données. Les anesthésiologistes et les infirmières anesthésistes autorisées certifiées ont été le plus souvent identifiés. La mort était une méthode courante d'identification de l'abus, tandis que la réhabilitation et la mort étaient des issues finales fréquemment associées à l'abus de propofol. CONCLUSION: Malgré la connaissance des propriétés pharmacocinétiques et pharmacodynamiques du propofol par ceux qui abusent de ce médicament, le décès était une issue fréquente rapportée dans la littérature. Les données relatives aux issues à long terme, y compris le retour à la pratique clinique ou le succès de la réhabilitation, étaient limitées.

Extreme variability in succinylcholine dose for muscle relaxation in electroconvulsive therapy.

OBJECTIVES: To determine what dose of succinylcholine falls outside the range of 2 SD above or below the mean optimal dose of 0.9 mg/kg used for electroconvulsive therapy (ECT). METHODS: In this retrospective chart review, for all patients who received ECT at our institution within the 5-year study period, the initial dose of succinylcholine in milligrams per kilogram was compared with subsequent doses after adjustments were made for individual patient responses. Mean and SD were calculated using the dose of succinylcholine, once the optimal dose for each patient had been determined, based on clinical response. RESULTS: Five hundred patients treated during the 5-year period met inclusion criteria, 180 (36%) of whom required an adjustment of the succinylcholine dosing either above (119 patients) or below (61 patients) the 0.9 mg/kg standard after their first treatment. CONCLUSIONS: In those patients who required an adjustment of 2 SD either above or below the mean dose of succinylcholine (29 patients, 5.8%), adequate neuromuscular blockade was only achieved with either an increased dose of up to 2.10 mg/kg or a decreased dose as low as 0.29 mg/kg.

The opioid epidemic and the current prevalence of substance use disorder in anesthesiologists.

PURPOSE OF REVIEW: There has been a substantial increase in prescription and illicit opioid abuse in the general population observed over the last two decades. Initially fueled by an influx of prescription opioid medications, the opioid epidemic now includes increasingly potent heroin and illicit fentanyl. Younger anesthesiologists, those currently in training or recent graduates, have come of age in a society where opioid abuse is much more prevalent. RECENT FINDINGS: The current prevalence of substance use disorder (SUD) in the physician population is slightly higher than in the general population and appears to be increasing. Although most anesthesiologists with SUD will abuse alcohol as their drug of choice, the incidence of opioid and nonopioid anesthetic agent abuse, especially propofol, is increasing. The incidence of SUD among the anesthesia resident population decreased somewhat during the 1990s but has been steadily increasing since the year 2000. SUMMARY: The increasing incidence of substance use disorder in anesthesia residents may reflect the significantly increased number of persons addicted to opioids and other drugs of abuse in the general population. Despite educational and surveillance programs put in place to prevent diversion, susceptible individuals with access are still abusing anesthetic agents.

¿Debería desempeñar un papel la mascarilla laríngea en la terapia electroconvulsiva? / Should the laryngeal mask airway play a role in electroconvulsive therapy?

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Individualized Anesthetic Management for Patients Undergoing Electroconvulsive Therapy: A Review of Current Practice.

Electroconvulsive therapy (ECT) remains an indispensable treatment for severe psychiatric illness. It is practiced extensively in the United States and around the world, yet there is little guidance for anesthesiologists involved with this common practice. Communication between the anesthesiologist and the proceduralist is particularly important for ECT, because the choice of anesthetic and management of physiologic sequelae of the therapeutic seizure can directly impact both the efficacy and safety of the treatment. In this review, we examine the literature on anesthetic management for ECT. A casual or "one-size-fits-all" approach may lead to less-than-optimal outcomes; customizing the anesthetic management for each patient is essential and can significantly increase treatment success rate and patient satisfaction.

The impaired anesthesiologist: what you should know about substance abuse.

PURPOSE: Despite our considerable experience with the problem of addiction in our specialty, most anesthesia care providers don't know how to identify or help an impaired colleague. The purpose of this article to provide sufficient information on substance use disorder (SUD) to aid in its identification amongst colleagues and to assist in its management. PRINCIPAL FINDINGS: Depending on the region, 10-15% of the general population is prone to developing a SUD and will abuse drugs or alcohol at some point in their life. Physicians and other healthcare professionals are not immune to the disease of addiction and are just as prone to developing SUD as laypersons. Even so, the risk of mortality is significantly increased because of access to potent and highly addictive anesthetic agents with a narrow therapeutic index when self-administered. Also, the number of anesthesia residents who are identified as having SUD is currently increasing. CONCLUSIONS: Due to the considerable morbidity and mortality associated with the abuse of anesthetic agents as well as the continuous increase in the rate of substance abuse by anesthesia providers, it is essential for anesthesia care providers to become familiar with the presenting signs and symptoms of substance abuse and impairment.

Preventable drug waste among anesthesia providers: opportunities for efficiency.

BACKGROUND: Health care service bundling experiments at the state and regional levels have showed reduced costs by providing a single lump-sum reimbursement for anesthesia services, surgery, and postoperative care. Potential for cost savings related to the provision of anesthesia care has the potential to significantly impact sustainability. This study defines and quantifies routine and preventable anesthetic drug waste and the patient, procedure, and anesthesia provider characteristics associated with increased waste. METHODS: Over a 12-month period, the type and quantity of clean drugs prepared by the anesthesia team for the first case of the day were recorded. The amount of each drug administered was obtained from the computerized anesthesia record, and data were analyzed to determine the incidence and cost of routine and preventable drug waste. The monthly and yearly cost of preventable waste, including the cost of pharmacy tech labor and materials where applicable, was estimated based on surgical case volume at the study institution. All analyses were performed using SAS software v9.2. RESULTS: Anesthetic drugs prepared for 543 separate surgical cases were observed. Less than 20% of cases generated routine waste. Preventable waste was generated most frequently for ephedrine (59.5% of cases), succinylcholine (33.7%), and lidocaine (25.1%), and least frequently for ondansetron (1.3%), phenylephrine (2.6%), and dexamethasone (2.8%). The estimated yearly cost of preventable anesthetic drug waste was $185,250. CONCLUSIONS: Significant potential savings with little impact on clinically significant availability may be achieved through the use of prefilled syringes for some commonly used anesthetic drugs. An intelligently implemented switch to prefilled syringes for select drugs is a potential cost saving measure, but savings might be diminished by disposal of prefilled syringes when they expire, hidden costs in the hospital pharmacy, and inability to supply some medications in prefilled syringes due to stability or manufacturing issues.

Neurologic, psychiatric, and other medical manifestations of nitrous oxide abuse: A systematic review of the case literature.

BACKGROUND/OBJECTIVES: Nitrous oxide (N2 O) is known to have abuse potential, although debate regarding the toxic effects of such abuse continues. Our objective was to review the case literature and present the neurologic, psychiatric and medical consequences of N2 O abuse. METHODS: A systematic literature review was completed for case reports using keywords "nitrous oxide" with "abuse/abusing" or "misuse/misusing" or "overuse/overusing" or "addiction." Non-English-language cases and cases not involving direct toxic effects of N2 O were excluded as were commentaries or personal essays. Clinical presentation, frequency of N2 O abuse, laboratory studies, imaging, ancillary tests, treatments and outcomes were collected from case reports. RESULTS: Our review returned 335 Pubmed, 204 Web of Science, 73 PsycINFO, 6 CINAHL, 55 EMBASE and 0 Grey Literature results, and after exclusion and removal of duplicates, 91 individual cases across 77 publications were included. There were also 11 publications reporting 29 cases of death related to N2 O abuse. The majority of cases (N = 72) reported neurologic sequelae including myeloneuropathy and subacute combined degeneration, commonly (N = 39) with neuroimaging changes. Psychiatric (N = 11) effects included psychosis while other medical effects (N = 8) included pneumomediastinum and frostbite. Across all cases N2 O abuse was correlated with low or low-normal Vitamin B12 (cyanocobalamin) levels (N = 52) and occasionally elevated homocysteine and methylmalonic acid. CONCLUSIONS/SCIENTIFIC SIGNIFICANCE: N2 O abuse represents a significant problem because of the difficulty involved with identification and the toxicity related to chronic abuse including possible death. Health professionals should be aware of the toxic effects of N2 O and be able to identify potential N2 O abuse. (Am J Addict 2016;25:358-369).

General Anesthesia in a Patient With Urticaria Pigmentosa Referred for Electroconvulsive Therapy.

Urticaria pigmentosa is a rare disorder characterized by an abnormal systemic proliferation of mast cells. In this condition, various triggers can induce either cutaneous histamine release, resulting in rash, or generalized histamine release, resulting in symptomatic hypotension, syncope, or in its severest form, an anaphylactoid reaction resistant to most resuscitative measures. Many anesthetic agents and adjuncts are known potential triggers, and patients who require surgery or procedures under anesthesia must be managed carefully. In this review, we describe the safe use of general anesthesia for electroconvulsive therapy in a patient with urticaria pigmentosa and discuss the association between psychiatric disorders and mastocytoses.

The Safe Use of Electroconvulsive Therapy in a Patient With a Repaired Arteriovenous Malformation: Images Showing Surgical Clips.

We present images showing surgical clips from a remotely repaired cerebral arteriovenous malformation in a patient treated safely with electroconvulsive therapy.