What considerations should be taken into account when administering anesthesia to a patient with Attention Deficit Hyperactivity Disorder (ADHD) who is taking Adderall (amphetamine and dextroamphetamine) prior to surgery?

Perioperative Management of Adderall (Amphetamine) in Patients Undergoing Anesthesia

Continue Adderall on the day of surgery without interruption, as amphetamines do not require preoperative discontinuation and stopping them creates unnecessary risks of withdrawal and behavioral destabilization. 1

Cardiovascular Risk Assessment and Monitoring

The FDA mandates careful cardiovascular evaluation before any stimulant use, and this becomes critically important in the perioperative setting 2. Amphetamines cause modest increases in blood pressure (2-4 mmHg) and heart rate (3-6 bpm), with some individuals experiencing larger increases 2.

Preoperative Cardiac Screening

• Obtain detailed cardiac history including family history of sudden death or ventricular arrhythmia 2
• Perform physical examination specifically assessing for cardiac disease 2
• Order ECG and echocardiogram if any findings suggest structural heart disease, cardiomyopathy, serious arrhythmias, or recent myocardial infarction 2
• Patients with known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac problems should generally not receive stimulants 2

Intraoperative Cardiovascular Management

• Monitor for larger-than-expected changes in heart rate and blood pressure throughout the procedure 2
• Exercise caution in patients whose underlying conditions might be compromised by increases in blood pressure or heart rate, including those with pre-existing hypertension, heart failure, recent myocardial infarction, or ventricular arrhythmia 2
• Amphetamines enhance the adrenergic effect of norepinephrine and may cause severe hypertensive response when combined with local anesthetics containing epinephrine 2, 3

Evidence Supporting Continuation of Amphetamines

A case series of 8 patients taking chronic prescription amphetamines (2-10 years duration) who underwent general anesthesia demonstrated safe intraoperative courses and outcomes 1. These patients ranged from 22-77 years old, with anesthesia times from 30 minutes to 4.25 hours, and 6 of 8 required tracheal intubation 1.

Children taking stimulant medications who ingested their medication on the day of surgery showed no significant difference in bispectral index (BIS) or clinical markers of depth of anesthesia at 1 MAC sevoflurane compared to controls 4. This evidence does not support changing anesthetic dosing or requiring routine depth-of-anesthesia monitoring specifically because of stimulant use 4.

Critical Drug Interactions to Avoid

Contraindicated Combinations

• MAO inhibitors are absolutely contraindicated with amphetamines, as they slow amphetamine metabolism and can cause hypertensive crisis, neurological toxic effects, and malignant hyperpyrexia, sometimes with fatal results 2
• Avoid combining amphetamines with other serotonergic agents (opioids with serotonergic activity, certain antiemetics) due to risk of serotonin syndrome 5, 3

Medications Requiring Caution

• Tricyclic antidepressants combined with amphetamines cause striking and sustained increases in brain d-amphetamine concentration and potentiated cardiovascular effects 2
• Amphetamines potentiate the analgesic effect of meperidine 2
• Amphetamines may antagonize the hypotensive effects of antihypertensive medications 2
• Haloperidol and chlorpromazine block the central stimulant effects of amphetamines 2

Anesthetic Technique Considerations

Induction and Maintenance

• Use short-acting anesthetic agents (desflurane, sevoflurane, or propofol TCI) to allow rapid emergence and neurological assessment 3
• Implement depth-of-anesthesia monitoring to limit anesthetic load 3
• Use neuromuscular monitoring if neuromuscular blockers are employed, ensuring complete reversal before emergence 3

Multimodal Analgesia Strategy

• Implement multimodal opioid-sparing analgesia using local anesthetics and regional techniques to minimize respiratory depression 3
• Avoid long-acting opioids given the risk of postoperative respiratory depression 3
• Consider that amphetamines potentiate meperidine's analgesic effect, requiring dose adjustment 2

Positioning and Airway Management

• Position patient with head elevated 20-30 degrees to optimize respiratory mechanics 3
• Extubate only when patient is fully awake with complete return of airway reflexes, breathing with good tidal volumes, in sitting position 3

Postoperative Monitoring and Complications

Patients with ADHD have significantly higher risk of post-procedural infections and any post-procedural complications compared to non-ADHD patients undergoing surgery 6. This heightened risk was observed across all procedural subcategories 6.

Recovery Room Management

• Continue supplemental oxygen and pulse oximetry monitoring until patient is mobile postoperatively 3
• Observe for signs of hypoventilation, apnea, or hypopnea with associated oxygen desaturation requiring extended PACU monitoring 3
• Monitor for emergence of new psychotic or manic symptoms, which can occur in 0.1% of stimulant-treated patients 2
• Assess for aggressive behavior or hostility, which should be monitored in all ADHD patients beginning or continuing treatment 2

Patient Communication and Compliance

Standardized, multicolored, pictorial medication instruction sheets with both verbal and written communication significantly improve patient medication compliance on the day of surgery (74% vs 60% compliance) 7.

• Provide clear written and verbal instructions about continuing Adderall on the morning of surgery 7
• African-American patients, older patients, and those with greater comorbidities require more concerted effort to achieve adequate preoperative medication compliance 7

Common Pitfalls to Avoid

• Do not discontinue amphetamines preoperatively based on outdated concerns about catecholamine depletion—this is not supported by current evidence 1
• Do not assume amphetamines require increased anesthetic dosing—depth of anesthesia is not altered at therapeutic doses 4
• Do not overlook cardiovascular screening—sudden death has been reported in patients with undiagnosed structural cardiac abnormalities 2
• Do not combine with MAO inhibitors under any circumstances 2
• Do not use local anesthetics with epinephrine without careful blood pressure monitoring 2, 3