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, BSL)

·     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

Intra-op

Induction:

·     Benzodiazepine if abstaining

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

·     Rapid sequence induction

Maintenance:

·     Titrate drugs to effect

Post-op

·     Alcohol withdrawal scale + PRN benzodiazepine

·     Consider acute pain service review