Anaesthetic problems

1. Venous access may be difficult.

2. Problems of management of HBV- or HIV-positive patients.

3. Physical dependence and withdrawal signs and symptoms. Symptoms include yawning, sweating, lacrimation, and rhinorrhoea. Signs include tachycardia, tremors, acute anxiety, sweating, piloerection, mydriasis, nausea, and vomiting.There is evidence to suggest that brain catecholamines play some part in the aetiology of this syndrome (McGoldrick 1980). Signs begin about 12 h after the last dose of opioid and peak at about 48—72 h.

4. Tolerance to all the effects of opiates occurs. Anaesthetic techniques relying on opioids may be unsuitable, because very high doses will be required to suppress sympathetic responses to surgical stimulation.

5. The administration of partial or pure narcotic antagonists may precipitate a withdrawal state.

6. Hypotension may occur.

7. Problems of the pregnant opioid user who appears in late pregnancy (Gerada et al 1990).

8. Morphine tolerance can occur in patients undergoing long-term use of opiates on the ITU.Two children undergoing IPPV for severe thermal injury and treated with morphine had dramatically increased requirements for sedation (Williams et al 1998).The mechanism for this is unknown. However, substitution of methadone for morphine produced rapid control of sedation.

9. The time course of the individual abstinence syndromes has been described (McCammon 1980):

Drug

Onset

Peak

Duration

Pethidine

3h

8-12 h

4—5 days

Morphine

8-12 h

36-48 h

7-10 days

Heroin

8-12 h

36-48 h

7-10 days

Methadone

1-2 days

3-6 days

2-3 weeks

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