Alcohol

 

Issues:

Alcohol itself

·      Intoxicated vs withdrawing vs in between (safe to proceed?)

·      Unfasted (risk of aspiration)

·      Dehydrated (risk of CVS collapse at induction)

Liver disease

·      Synthetic dysfunction -> coagulopathy (bleeding, clotting)

·      Portal hypertension -> thrombocytopaenia (bleeding)

Associated disease

·      Renal impairment (risk of peri-op renal failure)

·      Cardiomyopathy (risk of peri-op heart failure)

·      Immune dysfunction (risk of wound breakdown)

·      Bone marrow suppression (risk of inadequate O2 delivery)

·      Peripheral neuropathy (risk of block complication muddiness)

·      Brain damage (post-op delirium)

Variable drug effects

·      Enzyme induction -> ↑drug metabolism rate

·      Synthetic dysfunction -> ↓drug metabolism rate

·      Acute intoxication: ↓anaesthetic requirement

·      Acute withdrawal: ↑anaesthetic requirement

 

Pre-op assessment:

Questions

·      Is there alcohol abuse?

·      Is there liver disease? If so, how bad?

·      Is there associated disease? If so, how bad?

·      Should we proceed or defer? (lean towards proceed with RSI)

History

·      CAGE

·      HOPC

·      PMHx

·      Systems review

·      Exercise tolerance

Examination

·      Signs of chronic liver disease

·      Signs of intoxication vs withdrawal

·      Signs of encephalopathy

·      Signs of heart failure

Investigations

·      FBE

·      UEC

·      LFT

·      Coags

·      BSL

·      Alcohol

·      Echo

 

Anaesthesia management:

Goals

·      Prevent aspiration at induction and emergence

·      Prevent CVS collapse at induction

·      Prevent haemorrhage

·      Prevent delirium

·      Prevent neuro damage

·      Prevent wound breakdown

Pre-op

·      Optimise comorbidities: physician review

·      Optimise nutrition: thiamine + protein bro

·      Optimise coagulation: d/w haem, likely no products

Intra-op

Induction:

·      Fluid pre-load 10mL/kg and metaraminol 2.5mg/h

·      Rapid sequence induction

Maintenance:

·      Titrate anaesthetic and reflex suppressant to effect

Post-op

·      Alcohol withdrawal scale + PRN benzodiazepine

·      Consider acute pain service review