What are the considerations for anesthesia in patients with a history of intravenous (IV) drug use?

Anesthetic Considerations for Patients with a History of Intravenous Drug Use

For patients with a history of intravenous drug use, alternative routes of administration such as intramuscular ketamine should be considered when intravenous access is difficult, followed by establishing peripheral, central, or intraosseous access once sedated. 1

Vascular Access Challenges

• Difficult IV access: Patients with history of IV drug use often have scarred, thrombosed, or collapsed veins making traditional peripheral IV access challenging
• Alternative approaches:
  • Intramuscular sedation with ketamine (preferred agent) when IV access is difficult 1
  • Once sedated, establish peripheral, central, or intraosseous access 1
  • Consider ultrasound guidance for vascular access in patients with difficult veins

Pharmacological Considerations

Sedation and Induction

• Dose adjustments: Patients with chronic substance use may require higher doses of anesthetic agents due to cross-tolerance

• Ketamine considerations:

  • Advantageous for IV drug users with difficult access (4-5 mg/kg IM) 2
  • Preserves respiratory drive and protective airway reflexes better than benzodiazepine/opioid combinations 2
  • Contraindicated in patients with severe hypertension, recent MI, or cerebrovascular disease 2

• Propofol considerations:

  • Avoid rapid bolus induction in these patients 3
  • Use slower titration (approximately 20 mg every 10 seconds) 3
  • May need to adjust dosing based on concurrent substance use

Pain Management

• Multimodal approach: Maximize non-opioid analgesics (NSAIDs, paracetamol) 1
• Opioid considerations:
  • Patients with opioid dependence may require higher doses
  • Monitor closely for respiratory depression, especially when combined with other sedatives

Monitoring Requirements

• Standard monitoring: ECG, SpO2, NIBP, and capnography should be used throughout anesthesia 1
• Additional monitoring:
  • Quantitative neuromuscular monitoring when NMB drugs are administered 1
  • Processed EEG monitoring recommended when using TIVA with neuromuscular blockade 1
  • Close monitoring for withdrawal symptoms during perioperative period

Perioperative Complications to Anticipate

• Cardiovascular instability: Potential for exaggerated hemodynamic responses
• Withdrawal syndromes: May manifest during perioperative period
• Infection risk: Higher incidence of endocarditis, hepatitis, and HIV
• Respiratory complications: Increased risk of aspiration and respiratory depression

Documentation and Consent

• Thorough documentation: Maintain detailed records of all drugs administered, including name and dosage 1
• Standardized forms: Use standardized documentation forms that conform to institutional policies 1
• Quality assurance: Report and analyze all adverse events and near-misses to improve safety 1

Post-Anesthesia Considerations

• Extended monitoring: Consider longer PACU observation for patients with history of substance use
• Withdrawal management: Be prepared to manage acute withdrawal symptoms
• Pain control: Anticipate potentially higher analgesic requirements while maintaining safety

Key Pitfalls to Avoid

• Underestimating tolerance: Patients with substance use history may require higher doses of anesthetic agents
• Overestimating tolerance: Some patients may have organ dysfunction requiring dose reduction
• Inadequate monitoring: Failure to monitor for respiratory depression, especially with combined CNS depressants
• Stigmatization: Avoiding judgment and maintaining professional care is essential for optimal outcomes

Remember that patients with IV drug use history present unique challenges that require careful planning and vigilance throughout the perioperative period.