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Acromegaly—use of fiberoptic laryngoscopy to avoid tracheostomy.Anesthesiology 54: 429—30. Pelttari L, Polo O, Rauhala E et al 1995 Nocturnal breathing abnormalities in acromegaly after adenoidectomy. Clinical Endocrinology 43: 175-82.

Rosenow F, Reuter S, Deuss U et al 1996 Sleep apnoea in treated acromegaly: relative frequency and predisposing factors. Clinical Endocrinology 45: 563-9.

Singelyn FJ, Scholtes JL 1988 Airway obstruction in acromegaly.Anaesthesia & Intensive Care 16: 491-2.

Southwick JP, Katz J 1979 Unusual airway difficulty in the acromegalic patient-indications for tracheostomy.Anesthesiology 51:72-3. Stevenaert A, Beckers A 1996 Presurgical octreotide: treatment in acromegaly. Metabolism: Clinical & Experimental 45:72-4. Trotman-Dickenson B,Weetman AP, Hughes JMB 1991 Upper airflow obstruction and pulmonary function in acromegaly: relationship to disease activity. Quarterly Journal of Medicine 290: 527-38.

Venus B 1980 Acromegalic patient—indication for fiberoptic bronchoscopy but not tracheostomy. Anesthesiology 52:100-1. Wass JA 1993 Acromegaly: treatment after 100 years.

British Medical Journal 307:1505-6. Young ML, Hanson CW 1993 An alternative to tracheostomy following transsphenoidal hypophysectomy in a patient with sleep apnea. Anesthesia & Analgesia 76: 446-9.

Addiction (see also Alcoholism, Amphetamine abuse, Cocaine abuse, LSD abuse, Opiate addiction, Solvent (volatile) abuse)

The incidence of drug addiction is increasing. New drugs are being used and hence new complications are being reported. Anaesthesia may be required for addicts in either an acute or a chronic state of intoxication (Larson et al 1997). Alternatively, the anaesthetist is increasingly involved in resuscitation and treatment of patients suffering toxic side effects of drugs or drug cocktails. Hazards exist not only for the patient, but also for staff in the hospital. Accidental rupture of drug packages concealed in body cavities may result in severe acute absorption or intestinal obstruction. Problems are encountered during pregnancy and labour (Gerada & Farrell 1990,Birnbach 1998, Birnbach & Stein 1998).

Terminology may vary geographically, but the following are commonly used terms:

Speedballs—heroin laced with cocaine.

Ecstasy—3,4-methylenedioxy-methamphetamine (MDMA).

Eve—3,4-methylenedioxyethamphetamine (MDEA).

Ice or blue ice—crystalline methamphetamine.

Individual drugs are dealt with separately in the text, but the following comments are generally applicable.

Anaesthetic problems

1. Difficulties in obtaining an accurate history.

2. Problems associated with chronic abuse.

3. Problems of withdrawal syndrome during a period of illness.

4. Difficulties with venepuncture.

5. Associated malnutrition and liver disease.

6. Problems of acute toxicity.The possibility exists that the patient may inject a drug into his/her infusion.

7. Increased risk of hepatitis B and HIV, septicaemia, bacterial endocarditis and tetanus in intravenous drug users.

8. Rhabdomyolysis, and occasionally acute renal failure, may be associated with the consumption of cocaine.

9. During pregnancy there is increased maternal and fetal morbidity and mortality.

10. Problems of resuscitation from overdose of drug or drug cocktails.

11. Problems of mixing drugs and contamination with other substances.

12. Ecstasy (MDMA) and Eve (MDEA), sometimes in combination with other substances, have been associated with a syndrome of convulsions, hyperthermia, hyperkalaemia, rhabdomyolysis, and disseminated intravascular coagulation.

General management

1. In general, drugs should not be withdrawn in the perioperative period.

2. Patients should be treated as if they were infected with hepatitis B virus or HIV

3. An addiction centre may provide information and advice.

Bibliography

Birnbach DJ 1998 Anesthesia and the drug abusing parturient.Anesthesiology Clinics of North America 16:385-95.

Birnbach DJ, Stein DJ 1998 The substance-abusing parturient: implications for analgesia and anesthesia management. Bailliere's Clinical Obstetrics & Gynaecology 12: 443-60.

Caldwell TB 1990 Anesthesia for patients with behavioral and environmental disorders. In: Katz J, Benumof J (eds) Anesthesia and uncommon diseases.WB Saunders, Philadelphia, pp 792-922.

DHSS 1991 Drug misuse and dependence. Guidelines on clinical management. HMSO, London.

Gerada C, Farrell M 1990 Management of the pregnant opiate user. British Journal of Hospital Medicine 43:138-41.

Larson MJ, Samet JH, McCarty D 1997 Managed care of substance abuse disorders. Implications for generalist physicians. Medical Clinics of North America 81:845-65.

McCammon RL 1987 Anesthesia for the chemically dependent patient. Anesthesia & Analgesia Review Course Lectures 47-55.

McGoldrick KE 1980 Anesthetic implications of drug abuse. Anesthesiology Review 7: 12-17.

Wood PR, Soni N 1989 Anaesthesia and substance abuse. Anaesthesia 44: 672-80.

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