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782 GENERAL ANESTHESIA
Purpose: This is the second of two reviews evaluating the man- Objectif : Cest la seconde revue qui value la prise en charge de
agement of patients with selected medical conditions undergoing patients, dont les pathologies mdicales ont t cibles, qui doivent subir
ambulatory anesthesia and surgery. Conditions highlighted in this une anesthsie en chirurgie ambulatoire. Les situations choisies com-
review include: diabetes mellitus; morbid obesity; the ex-prema- prennent : le diabte, lobsit morbide, lenfant n prmaturment,
ture infant; the child with an upper respiratory infection; malignant lenfant atteint dinfection des voies respiratoires suprieures, lhyper-
hyperthermia; and the use of monoamine oxidase inhibitors. thermie maligne et lusage dinhibiteurs de la monoamine-oxydase.
Source: Medline search strategies and the framework for the eval- Source : Les stratgies de recherche dans Medline et le cadre de l-
uation of clinical evidence are presented in Part I. valuation de la preuve clinique sont prsents dans la partie I.
Principal findings: Diabetes mellitus has not been linked with Constatations principales : Le diabte na pas t reli des
adverse events following ambulatory surgery. The morbidly obese vnements indsirables la suite dune opration ambulatoire. Le
patient trs obse est plus risque de complications respiratoires pri-
patient is at an increased risk for minor respiratory complications in
opratoires mineures, ce qui naugmente pas les admissions hospitalires
the perioperative period but these events do not increase unantici-
imprvues. Lenfant prmatur est admis en chirurgie ambulatoire si
pated admissions. The ex-premature infant may be considered for
lge post-conception est > 60 semaines et si lhmatocrite est > 30 %.
ambulatory surgery if post-conceptual age is > 60 weeks and hema- Lenfant qui a une infection rcente des voies respiratoires suprieures
tocrit is > 30%. The child with a recent upper respiratory tract infec- est plus risque de complications respiratoires priopratoires, surtout si
tion is at an increased risk for perioperative respiratory complications, lintubation endotrachale est requise. Le patient souffrant dhyperther-
particularly if endotracheal intubation is required. Patients with malig- mie maligne est admis en chirurgie ambulatoire, mais ncessite quatre
nant hyperthermia may undergo outpatient surgery but require four heures de monitorage postopratoire de la temprature. Des cas spo-
hours of postoperative temperature monitoring. Sporadic cases of radiques dinteractions de mdicaments ont t signals quand la
drug interactions have been reported when meperidine and indirect- mpridine et des catcholamines action indirecte sont administres
acting catecholamines are administered in the presence of monamine en prsence dinhibiteurs de la monoamine-oxydase. En labsence de
oxidase inhibitors. Ambulatory anesthesia and surgery is safe if these ces combinaisons, lanesthsie et la chirurgie ambulatoires sont sans
combinations of drugs are avoided. risque.
Conclusion: Ambulatory anesthesia can be performed in, and is Conclusion : Lanesthsie ambulatoire peut tre ralise chez divers
being offered to, a variety of patients with significant coexistent dis- patients qui prsentent des affections coexistantes importantes. Elle
ease. In many cases there is little evidence documenting the out- leur est dailleurs offerte. Dans de nombreux cas, il y a peu de preuve
comes expected in such patients. Prospective observational and documentant lvolution postopratoire attendue chez ces patients.
interventional trials are required to better define perioperative Des tudes prospectives observationnelles et interventionnelles sont
management. ncessaires pour mieux dfinir la prise en charge priopratoire.
From the Department of Anesthesiology, The Ottawa Hospital,* Ottawa, Ontario; Department of Anesthesia, Toronto Western Hospital,
Toronto; Ontario; Department of Anesthesia, Alberta Childrens Hospital, Calgary, Alberta; Dpartement dAnesthsiologie, Hpital
Ste-Justine, Montral, Qubec; Department of Anesthesia and Perioperative Care, St. Josephs Health Care, London, Ontario;
Department of Anesthesia, Vancouver General Hospital, Vancouver, British Columbia; Department of Anesthesiology and Pain Medicine,
University of Alberta,** Edmonton, Alberta; Department of Anesthesia, Mount Sinai Hospital, Toronto, Ontario; Department of
Anesthesiology, Kingston General Hospital, Kingston, Ontario, Canada.
Address correspondence to: Dr. Gregory L Bryson, Department of Anesthesiology, Head, Pre-Admission Units, The Ottawa Hospital,
1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada. Phone: 613-761-4169; Fax: 613-761-5209;
E-mail:glbryson@ottawahospital.on.ca
Meeting facilities were sponsored by Purdue Pharma.
Accepted for publication February 2, 2004.
Revision accepted May 14, 2004.
T
HIS is the second of two articles from the persist when other variables were accounted for.
Canadian Ambulatory Anesthesia Research Diabetes per se does not predict adverse outcome fol-
and Education (CAARE) Group discussing lowing minor ambulatory surgery (grade A)
selection criteria for ambulatory surgery
within an evidence-based framework. Details of the Is this patient at particular risk of airway problems?
methods employed and a summary of the Center for A complication of unique concern to anesthesiologists
Evidence Based Medicine Levels of Evidence and is the diabetic "stiff joint syndrome." Glycosylation of
Grades of Recommendation used in this article may be collagen decreases mobility of the cervical spine and
found in part I.1 A list of the individual articles cited the temporomandibular joint and may increase the
and their Level of Evidence (Appendix A) may be likelihood of difficult laryngoscopy and intubation.
found as Additional Material at www.cja-jca.org Stiffness of the fourth and fifth interphalangeal joints
(the prayer sign) assessed using palm prints is a sensi-
Diabetes mellitus tive predictor of difficult intubation.13 A retrospective
Scenario review of 725 patients undergoing renal or pancreatic
You are asked to see a 28-yr-old female prior to a transplantation found diabetics were at a fourfold
laparoscopic ovarian cystectomy. She has had diabetes increased risk of minimally to moderately difficult
for 22 years complicated by retinopathy and peripher- intubation.14 All were successfully intubated by con-
al neuropathy. She is taking gabapentin, metformin, ventional means. A large prospective cohort study
and synthetic human insulin 30/70: 20 U before associated diabetes with an increased risk of critical
breakfast and 14 U prior to dinner. respiratory events but not difficult intubation.6,15
Individual diabetic patients may be at an increased risk
Discussion of difficult laryngoscopy but this does not appear to
The Current World Health Organization estimates sug- apply to diabetics as a group (grade B).
gest that 2 million Canadians suffer from diabetes, a
number expected to increase to 3.5 million over the How long before surgery should the patient discontinue
next 30 years.2 Diabetes is diagnosed if random fasting metformin?
plasma glucose exceeds 11.1 mmolL1 or repeated fast- Lactic acidosis is an infrequent complication of met-
ing plasma glucose exceeds 7.0 mmolL1. Diabetes is formin therapy with an estimated incidence of 0.03 per
now classified as type 1 if resulting from pancreatic islet 1,000 patient years of treatment. Intercurrent illness
cell destruction and type 2 if associated with defective associated with hypotension, hypoxia, renal insufficien-
insulin secretion and insulin resistance.3 cy, and use of radiocontrast dye are suggested to
Disease states associated with diabetes render the increase the risk of acidosis.16 A recent editorial recom-
diabetic at an increased risk of perioperative complica- mended that metformin be discontinued 48 hr before
tions.4 Diabetics requiring insulin are at an increased elective surgery.13 Published correspondence following
risk [odds ratio (OR) 3.0, 95% confidence interval the recommendation revealed that there is no evidence
(CI) 1.3-7.0] of perioperative cardiac complications.5 supporting 48-hr abstinence.17 A Cochrane review of
Critical respiratory events are more common [relative 176 randomized controlled trials of metformin did not
risk (RR) 2.08, 95% CI 1.42-3.04] among diabetics.6 identify a single episode of lactic acidosis in over 35,000
Wound infections are more prevalent in diabetics fol- patient-years of therapy.18 There have been no specific
lowing both cardiac7 and noncardiac8 surgery. Blood trials evaluating perioperative metformin withdrawal
glucose readings on the first postoperative day > 12.2 but systematic review suggests that metformin-related
mmolL1 are associated with a 2.7 fold increased risk lactic acidosis is unlikely (grade B).
of infection (P < 0.05).9
Is there a preferred means of managing her insulin?
Are diabetics at an increased risk of complications fol- Managing insulin therapy is a challenge for periopera-
lowing outpatient surgery? tive physicians. Patients randomly assigned to continu-
Despite the increased likelihood of complications in a ous iv infusion of glucose-insulin-potassium following
variety of major surgical procedures, diabetes is not an minor inpatient surgery had lower median blood glu-
independent predictor of morbidity10 or mortality11 cose readings and were more likely to deliver readings
following day case surgery. A univariate analysis iden- in the target range of 5 to 10 mmolL1 (48 vs 26%)
tified diabetics to be at an increased risk (OR 2.0, 95% than those given insulin subcutaneously.19 These find-
CI 1.32.2) of unanticipated admission following ings have not been supported in other trials involving a
ambulatory surgery.12 This finding did not, however, wider variety of surgical procedures.2022 No trial has
784 CANADIAN JOURNAL OF ANESTHESIA
evaluated insulin regimens for the outpatient. For also be defined by the body mass index (BMI). BMI is
ambulatory procedures there is no evidence denoting calculated by dividing the body weight in kilograms by
superiority of sc or iv insulin replacement (grade D). the square of the height in metres. Overweight is
defined as BMI 25 to 30 kgm2, obesity as BMI $ 30
Does choice of anesthetic technique influence periopera- kgm2, and morbid obesity as BMI $ 35 kgm2.27
tive glycemic control? In 1992, the Royal College of Surgeons issued
Regional anesthesia blunts the increases in cortisol, guidelines for ambulatory surgery. Patients with a
glucagon, and glucose commonly seen following BMI > 30 kgm2 were deemed unsuitable for opera-
major surgery.23 Epidural blockade facilitates glucose tions performed on an ambulatory basis.28 A subse-
uptake and reduces protein catabolism.24 It is surpris- quent postal questionnaire of ambulatory surgery
ing therefore to find only a single study comparing the units within the United Kingdom revealed that 85% of
influence of regional and general anesthesia on the units surveyed were not adhering to the guidelines
glycemic control in diabetics. Barker randomly and anesthetized patients with a BMI > 30 kgm2.29
assigned 20 patients with type 2 diabetes and 20 con- Canadian anesthesiologists also frequently provide
trol patients to either regional or general anesthesia ambulatory care for the morbidly obese. Ambulatory
for cataract surgery. The use of regional anesthesia in surgery for otherwise healthy patients with a BMI =
both diabetic and control patients abolished the 35 to 44 kgm2 and BMI > 45 kgm2 was deemed
increase in glucose and cortisol seen in those patients acceptable by 91% and 50% of Canadian anesthesiolo-
undergoing general anesthesia.25 Extrapolation of gists, respectively.30 Unfortunately many obese
these findings suggests that regional anesthesia may patients are not "otherwise healthy."
ameliorate the adverse effect of surgery on periopera- A health survey found the prevalence of any car-
tive glycemic control (grade B). diovascular diseases was 37% in adults with a BMI of
> 30 kgm2, 21% in those with a BMI of 25 to 30
Conclusion diabetes mellitus kgm2, and only 10% in those with a BMI of < 25
Diabetic patients are undoubtedly suitable for a variety kgm2.31 Hypertension and congestive heart failure
of ambulatory surgical procedures. Comorbid condi- are common among the obese because of increased
tions, including the difficult airway, must be identified cardiac output and blood volume. Approximately 5%
and managed appropriately. Recommendations to with- of morbidly obese patients have obstructive sleep
draw metformin > 48 hr preoperatively are not sup- apnea.32 The presence of cardiovascular or respiratory
ported by evidence. Tighter control of perioperative comorbidity significantly reduced willingness of
glucose is encouraged. Administration of half of the Canadian anesthesiologists to provide ambulatory care
patients total morning insulin dose as an intermediate to the obese.30 Ambulatory surgery for obese patients
duration insulin with control of perioperative hyper- with cardiovascular or respiratory comorbidity was
glycemia using adjusted dose short- or ultra-short act- acceptable among 18% and 5% of anesthesiologists
ing insulin provides glycemic control comparable to caring for patients with a BMI = 35 to 44 kgm2 and
other more complex strategies. BMI > 45 kgm2, respectively.30
related to both gestational age and PCA. Apnea which the risk for postoperative apnea should be neg-
occurred in fewer than 5% of patients 60 weeks PCA ligible. There is no benefit in delaying surgery, as
regardless of gestational age. A hematocrit < 30% was incarceration of the hernia has already occurred. A
significantly correlated with the likelihood of apnea, hemoglobin level of 105 gL1 is acceptable41,44 and
particularly in those children greater than 43 weeks the baby is on an iron supplement already. Few anes-
PCA. Assuming no apnea was witnessed in the PACU thesiologists would recommend transfusion for mild
and a hematocrit > 30%, a 60-week PCA infant under- to moderate anemia (80100 gL1) in the absence of
going herniorrhaphy could be expected to experience symptoms. From the viewpoint of postoperative
apnea in less than < 0.05% of cases. apnea, it would seem that the baby could undergo
Several points arise from Cots analysis. Firstly, the surgery as an outpatient, assuming no intraoperative
eight clinical studies that contributed to these data complications or apneic spells are encountered in the
were published between 19871993. Anesthetic tech- PACU (grade A). As pointed out by Sims,45 however,
niques have advanced somewhat since that period very few infants older than 60 weeks PCA have been
when halothane and muscle relaxants were the norm. studied.
Secondly, marked differences in the incidence of post-
operative apnea were noted in the various centres like- Is caffeine indicated to reduce the risk of apnea?
ly related to differences in monitoring technology. The influence of caffeine on the incidence of postop-
Thirdly, the risk for postoperative apnea gradually erative apnea was evaluated in 32 otherwise healthy
declined with advancing age, but there was no point at ex-premature infants undergoing inguinal herniorrha-
which risk was absent. Fisher in his accompanying edi- phy at < 44 weeks PCA. Subjects were randomly
torial also questions "whether a consistent policy assigned to caffeine 10 mgkg1 iv or matching place-
regarding postoperative disposition of these patients bo. Caffeine-treated infants experienced no adverse
can be determined based on current information."42 events, compared to an 81% incidence of apnea and a
Although it is known that gestational age, PCA, and 50% incidence of desaturation in those receiving place-
anemia are significant predictors of postoperative bo.46 A systematic review suggests that treatment with
apnea (grade A), the risks and benefits of an ambula- caffeine is associated with a 91% reduction in the RR
tory procedure should nevertheless be evaluated for of apnea (RR 0.91; 95% CI 0.660.98) and an
each individual patient. absolute risk reduction of 58%. Only two patients
would require caffeine to prevent one episode of
How long should the patient be monitored in the apnea.47 Caffeine is undoubtedly helpful in reducing
PACU? the risk of apnea in younger ex-premature infants but
Since Cots analysis was published, other reports have should not replace careful patient selection and appro-
been written. Most of these evaluate the benefits of priate monitoring (grade A).
regional anesthesia (spinal or caudal) in ex-prema-
tures. One study did seek to evaluate the factors that Is regional anesthesia the technique of choice?
are associated with postoperative complications in ex- Awake regional techniques in the form of caudal48,49
prematures as well as the safe period for postoperative or spinal5056 anesthesia have been reported extensive-
observation.43 Based upon this retrospective review of ly. Many of these studies are case series. However,
57 patients, the authors concluded that "outpatient there are four randomized controlled trials comparing
inguinal herniorrhaphy under general anesthesia in the spinal with general anesthesia.50,5355 Welborn noted a
ASA class I ex-premature infant is safe" and recom- marked increase in the risk of apnea in patients under-
mend a six- to eight-hour period of monitoring. They going spinal anesthesia with im ketamine premedica-
make this claim despite the retrospective nature of tion. Patients undergoing general anesthesia or spinal
their study and the fact that 8.8% of their subjects anesthesia without premedication had similar out-
failed extubation. Furthermore, few pediatric anesthe- comes.50 Three other studies found an association
siologists would designate an ex-premature baby as between general anesthesia and postoperative desatu-
ASA class I. The optimal length of PACU monitoring ration, bradycardia, and apnea but all excluded ran-
is therefore poorly defined (grade C). domized patients in whom spinal anesthesia was
inadequate or could not be obtained.5355 Withdrawal
Can the babys medical condition be improved preoper- rates in these studies ranged from 11 to 28%. Failure
atively? to follow an intention-to-treat methodology is a seri-
In the case of our patient, the baby is generally well, is ous threat to the validity of these findings. Williams
not anemic by Cots definition and is at a PCA at questions "routinely subjecting our patients to an
Bryson et al.: AMBULATORY ANESTHESIA 787
awake technique that is potentially stressful for the TABLE Characteristics associated with respiratory complications
infant and associated with a clinically significant failure in the child with URI
rate."55 To date no published direct comparison of Tait62 Parnis63
spinal vs caudal anesthesia in this population has
Endotracheal intubation Endotracheal intubation
appeared in the literature. Postoperative apnea has
Second hand smoke Second hand smoke
been noted after both caudal57 and spinal58 anesthesia Nasal congestion Nasal congestion
in ex-prematures, although these cases all involved Copious secretions Productive cough
infants with comorbidities. The choice of a regional or History of reactive airway disease Parent states child has URI
general anesthetic technique is best left to the individ- History of prematurity (< 37 weeks) Parent states child snores
Surgery involving the airway Thiopental
ual anesthesiologist as the evidence does not favour
Failure to reverse muscle
one technique over the other (grade D). It would relaxants
seem prudent to manage the postoperative care in the
same fashion, irrespective of whether a regional or URI = upper respiratory infection.
general technique is used.
with a doubling (OR 2.05; 95% CI 1.213.45) of the Can the child at risk for complications be identified?
odds of developing laryngospasm.60 Children man- Two cohort studies evaluating risk factors for periop-
aged by inexperienced anesthesia staff were nearly erative respiratory complications in over 3,000 chil-
twice as likely (OR 1.75; 95% CI 1082.86) to devel- dren with URI symptoms have been published.62,63
op laryngospasm. In summary, current URI symp- Characteristics associated with respiratory events are
toms increase the risk of perioperative respiratory shown in the Table. Features common to models such
events. Desaturation, coughing, and breath holding as endotracheal intubation, second hand smoke, nasal
events are the most consistently reported (grade A). congestion, and productive cough/secretions high-
light the child with URI in whom respiratory events
How serious are the respiratory complications associated should be anticipated (grade A).
with URI?
Studies grading the severity of respiratory events Conclusion - the child with an URI
found significant increases in the severity of surrogate This five-year-old patient with no history of sleep
events such as cough, breath holding, and secre- apnea is a candidate for tonsillectomy on an outpatient
tions.62,66,68 Episodes of laryngospasm or bron- basis. URI symptoms within the past four weeks place
chospasm in these studies were no more frequent or him at an increased risk of minor perioperative respi-
severe in those with URI. True outcomes such as ratory events. These events should not contraindicate
unanticipated hospital admission, pneumonia, and anesthesia when perioperative care is managed by an
death were rare. Of the nearly 1,300 children in these experienced anesthesiologist. However, the further
studies only two were admitted to hospital with pneu- risks associated with airway surgery and endotracheal
monia and two were treated for stridor. The majority intubation should be weighed against the benefits of a
of respiratory events associated with URI are transient four-week delay. A frank discussion with the parents
and relatively minor in nature (grade A). should highlight the risks of proceeding at this time.
"very likely" to be MH; the other six were evenly split Is postoperative fever an indication for hospital admis-
between "somewhat less than" or "somewhat more sion?
than" likely to be MH. The incidence of MH trigger- Ongoing monitoring is indicated for MHS patients
ing in MHS patients undergoing a non-triggering demonstrating clinical signs of MH. In Yentis study
anesthetic has been estimated to be less than 1%.71,73 ten suspected MHS children developed postoperative
The Malignant Hyperthermia Association of the pyrexia greater than 38.5C.69 None of these pro-
United States (MHAUS) advises that the MHS gressed to MH. The five patients with postoperative
patients may be discharged three to five hours follow- fever considered by Carr to have had MH all demon-
ing an uneventful anesthetic.74 The Malignant strated temperatures above 38C.71 Unfortunately this
Hyperthermia Association of Canada (MHA Canada) study failed to document whether pyrexia occurred in
recommends a four-hour monitoring period.75 There other patients. The rate of rise of temperature is of
is no contraindication to ambulatory anesthesia for greatest significance, rising as fast as 1C in five min-
MHS patients as long as a minimum of four hours of utes in a MH crisis.79 There is little available evidence
postoperative monitoring can be performed (grade to support recommendations for the management of
C). As many ambulatory surgical centres close in the isolated postoperative pyrexia in MHS patients but
early evening, scheduling of MHS patients must take admission to hospital for observation is advised by
postoperative monitoring considerations into account. authorities (grade D).74,75
Classic MAOI, phenelzine and tranylcypromine, irre- potentiating barbituates and opioids.80 Three cases of
versibly inhibit MAO for two to three weeks until a excessive barbiturate/opioid effects were reported
new enzyme is synthesized.80 Moclobemide, a from 1960 to 1970.80,84 Since then, numerous reports
reversible inhibitor of MAO-A (RIMA) causes enzyme have described uneventful anesthetics using barbitu-
inhibition for less than 24 hr.81,82 Selegiline, an anti- rates and various opioids: remifentanil,89 alfen-
Parkinsonian agent, is a short-acting, reversible MAO- tanil,89,90 sufentanil,91 fentanyl,80,81 hydromorphone91
B inhibitor at its usual dose.83 and morphine80,81,81,85,89 for patients continuing to
take MAOI. Other agents including propofol,90,92 ket-
What is the evidence linking MAOI to serotonergic amine,93 midazolam,92 ketorolac,92 vecuronium,92 and
crises? atracurium92 have also been used safely. Severe hyper-
Serotonergic reactions to meperidine have been described tension on induction with etomidate and atracurium
for all MAOI,80,84,85 including moclobemide81,82 and has occurred, although the patients blood pressure
selegiline.83 Meperidine blocks neuronal serotonin reup- was 200/90 immediately prior to induction.94
take, resulting in serotonergic overactivity, agitation, Regional anesthesia has been performed without inci-
hyper/hypotension, convulsions, hyperthermia, and dent when hypotension was treated appropriately with
coma.82 However, serotonin concentration must reach a volume and direct-acting sympathomimetics.80,81,95,96
critical level, as evidenced by one patient who reacted to Normal responses to most anesthetic agents can be
meperidine only after increasing her phenelzine dose80 expected (grade C).
and by a randomized, controlled trial, in which 15
patients on MAOI given meperidine and morphine all Is the continuation of MAOI associated with adverse
responded normally.85 Cocaine also reduces serotonin outcomes?
inactivation and blocks monoamine reuptake.80,86 A Much of our understanding of the interactions
delayed excitatory reaction occurred in a patient on between MAOI and anesthetic drugs comes from
phenelzine 70 min after topical laryngeal cocaine.86 reports of isolated events in individual patients. A con-
Serotonergic crises may follow the administration of trolled prospective evaluation of 27 patients chronical-
meperidine or cocaine (grade C). ly treated with MAOI undergoing 36 anesthetics
reported no adverse cardiovascular responses.95
Are MAOI associated with atypical responses to all cat- Changes in blood pressure and heart rate were not sig-
echolamines? nificantly different from control patients without prior
Elevated preganglionic MAO substrates can cause an MAOI exposure. Anesthetic agents included sodium
exaggerated response to indirect-acting sympath- thiopental, etomidate, diazepam, succinylcholine,
omimetics as long as three weeks after classic MAOI nitrous oxide, volatiles, pancuronium, morphine,
are discontinued.80 A patient on selegiline developed spinal tetracaine, epidural bupivacaine, and phenyle-
hypertension and supraventricular tachycardia after phrine.95 Similarly a review of a series of 32 orthope-
receiving ephedrine87 whereas a patient who omitted dic patients on MAOI who underwent 46 general
one dose of moclobemide responded normally to both anesthetics and five regional anesthetics for elective
phenylephrine and ephedrine.81 Indirect-acting cate- surgery found no adverse hemodynamic events.96
cholamines should be avoided (grade C). Agents used in this series included sodium thiopental,
Although it has been recommended to avoid epi- ketamine, volatiles, morphine and meperidine. Aside
nephrine-containing solutions,80 there is no evidence from sporadic case reports, the continued use of
to support this. In fact, direct-acting sympathomimet- MAOI/RIMA has not been associated with adverse
ics such as epinephrine are the recommended pressor perioperative events when meperidine and indirect
agents for patients on MAOI.80,84 Patients on acting catecholamines are avoided (grade B).
MAOI/RIMA do not have clinically significant
potentiation of cardiovascular effects of iv infusions of Conclusion MAOI
norepinephrine or epinephrine.82,88 Vasopressors at Case reports of sporadic MAOI-related drug interac-
concentrations contained in local anesthetics are not tions prompted many to advise discontinuation of
likely to be significantly potentiated in otherwise classic MAOI two to three weeks before surgery.80,84,95
healthy patients on MAOI.88 Direct-acting sympath- Withdrawal of MAOI is not without risks. Many
omimetics may be used safely (grade C). patients have severe depression refractory to other
treatment and are at risk for life-threatening psychi-
Do MAOI interact with anesthetic drugs? atric illness. Acute exacerbation of depression with sui-
MAOI inhibit microsomal enzymes, theoretically cidal ideation has been reported after discontinuation
Bryson et al.: AMBULATORY ANESTHESIA 791
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