LETTERS TO THE EDITOR
ANESTH ANALG 1992;75461-71
Suicide Attempt After Anesthesia To the Editor:
A 58-yr-old man was admitted to a municipal hospital for an inguinal herniorraphy. He was otherwise healthy and was taking no medications. He had a negative medical and psychiatric history but was described as being excessively talkative, and the resident who took the history believed that the patient might be having paranoid delusions. Although a psychiatric consultation was requested, it was not carried out before the surgical procedure. The patient received general anesthesia (isoflurane, nitrous oxide, midazolam, fentanyl, thiopental, and atracurium) and had the hernia repaired. He had an uneventful recovery in the postanesthesia care unit, and there were no reports of unusual behavior. Several hours later, after the patient had been discharged to the ward, he was found on his bed with a deep bleeding wound across the neck. He was taken to the operating room, the neck was explored, and the hemorrhage was brought under control. He later admitted that he had tried to kill himself with a razor blade and was diagnosed as suffering from schizophrenia. Many factors surrounding anesthesia and surgery may trigger emergence delirium and postoperative psychosis. These include drugs, fever, pain, hypoxia, metabolic derangements, and psychological factors (1). This patient was already suffering from an undiagnosed psychiatric disorder that made the initial differential diagnosis somewhat difficult. The incidence of schizophrenia is much higher in the lower socioeconomic groups (2). Given the fact that municipal hospitals tend to serve this patient population, a high index of suspicion should be maintained in this setting. An elective preoperative psychiatric evaluation may be warranted in a patient suspected of suffering from a mental illness. This will not only help with the differential diagnosis of postoperative psychosis, but may also and most importantly, prevent the patient from harming himself or others. Rafael Ortega,
MD
Department of Anesthesiology Boston University Medical Center 88 East Nezuton Street Boston, MA 02118
References 1. Olympio MA. Postanesthetic delirium: historical perspectives. J Clin Anesth 1991;3:603. 2. Tucker GH. Psychiatric disorders in medical practice. In: Wyngaarden JB, Smith LH, eds. Cecil textbook of medicine. Philadelphia: WB Saunders, 19882091-103.
How Does Epidural Anesthesia and Analgesia Influence Perioperative Coagulability? To the Editor: We read with great interest the editorial by Steele and colleagues (1)accompanying the paper by Tuman et al. (2). We would like to commend Steele et al. for their review of
463
the current literature regarding the influence of epidural anesthesia and analgesia (EAA) on perioperative coagulability. Tuman et al. have put forth an outstanding effort that helps better differentiate why those of us performing general anesthetics with epidural catheters placed for postoperative pain control believe that this is superior to the more traditional approach of general anesthetics with ondemand postoperative analgesics (intermittent intramuscular, intravenous, or oral pain medications). Anesthesiologists have discovered that appropriate management of perioperative hemodynamic abnormalities can influence outcome in ”high-risk” patients, although stable perioperative hernodynamics do not necessarily ensure uneventful cardiovascular outcome. Tuman has put forth an interesting proposal of ”perioperative hypercoagulability” as another issue that must be dealt with in ”high-risk patients. How blockade of the ”perioperative stress response” may influence this propensity for hypercoagulability in the postoperative period is still not well understood. We would like to qualify and expound upon one idea put forth in the editorial by Steele et al. stating: “Fibrinogen, a glycoprotein essential to hemostasis and blood viscosity, is frequently increased in patients with vascular disease. Perhaps EAA reduces fibrinogen.” It is important to remember that the half-life of fibrinogen in humans is 3 4 days and in Tuman’s study the average utilization of epidural catheters was 2.4 -+ 0.98 days. Speculation that this intervention, administered for such a period of time, would influence fibrinogen levels significantly in the postoperative period must take the long half-life into account. It might be that augmented fibrinogen production is reduced by EAA, although this will be difficult to prove in clinical studies owing to the large variability involved in performing functional fibrinogen assays. Fibrinogen plays an essential role in hemostasis and the maintenance of blood viscosity. It mediates the formation of platelet aggregates and, in the coagulation cascade, is transformed by thrombin into fibrin monomers that polymerize to form the basis of a hemostatic plug. Ten to twenty-five percent of the total body fibrinogen is extravascular. Of the circulating fibrinogen in blood, about 3% is located in the platelet alpha granules, although it is unclear if this is the result of fibrinogen biosynthesis by megakaryocytes or due to platelet uptake from the plasma. Plasma levels of fibrinogen and a subset of other hepatic proteins increase during the “acute-phase response” to injury and infection (3). For fibrinogen, the protein level reflects a coordinated increase in the hepatic production of the mRNAs that direct the synthesis of the three pairs of nonidentical polypeptide chains that compose fibrinogen. The increase is predominantly in response to interleukin-6 (IL-6) produced by monocytes/macrophages. Interleukin-6, a key mediator in the inflammatory response, preferentially stimulates the synthesis of fibrinogen in human hepatoma cells. Whether the influence of EAA on the stress response may have some effect on the inflammatory response is unknown. The effects of stress on the inflammatory response are likely complex. Perhaps EAA decreases hypercoagulability by direct or indirect modulation of the inflammatory response (decreased production of IL-6) and subsequent inhibition of the “acute-phase response.” Little
ANESTH ANALG 1992;75461-71
Suicide Attempt After Anesthesia To the Editor:
A 58-yr-old man was admitted to a municipal hospital for an inguinal herniorraphy. He was otherwise healthy and was taking no medications. He had a negative medical and psychiatric history but was described as being excessively talkative, and the resident who took the history believed that the patient might be having paranoid delusions. Although a psychiatric consultation was requested, it was not carried out before the surgical procedure. The patient received general anesthesia (isoflurane, nitrous oxide, midazolam, fentanyl, thiopental, and atracurium) and had the hernia repaired. He had an uneventful recovery in the postanesthesia care unit, and there were no reports of unusual behavior. Several hours later, after the patient had been discharged to the ward, he was found on his bed with a deep bleeding wound across the neck. He was taken to the operating room, the neck was explored, and the hemorrhage was brought under control. He later admitted that he had tried to kill himself with a razor blade and was diagnosed as suffering from schizophrenia. Many factors surrounding anesthesia and surgery may trigger emergence delirium and postoperative psychosis. These include drugs, fever, pain, hypoxia, metabolic derangements, and psychological factors (1). This patient was already suffering from an undiagnosed psychiatric disorder that made the initial differential diagnosis somewhat difficult. The incidence of schizophrenia is much higher in the lower socioeconomic groups (2). Given the fact that municipal hospitals tend to serve this patient population, a high index of suspicion should be maintained in this setting. An elective preoperative psychiatric evaluation may be warranted in a patient suspected of suffering from a mental illness. This will not only help with the differential diagnosis of postoperative psychosis, but may also and most importantly, prevent the patient from harming himself or others. Rafael Ortega,
MD
Department of Anesthesiology Boston University Medical Center 88 East Nezuton Street Boston, MA 02118
References 1. Olympio MA. Postanesthetic delirium: historical perspectives. J Clin Anesth 1991;3:603. 2. Tucker GH. Psychiatric disorders in medical practice. In: Wyngaarden JB, Smith LH, eds. Cecil textbook of medicine. Philadelphia: WB Saunders, 19882091-103.
How Does Epidural Anesthesia and Analgesia Influence Perioperative Coagulability? To the Editor: We read with great interest the editorial by Steele and colleagues (1)accompanying the paper by Tuman et al. (2). We would like to commend Steele et al. for their review of
463
the current literature regarding the influence of epidural anesthesia and analgesia (EAA) on perioperative coagulability. Tuman et al. have put forth an outstanding effort that helps better differentiate why those of us performing general anesthetics with epidural catheters placed for postoperative pain control believe that this is superior to the more traditional approach of general anesthetics with ondemand postoperative analgesics (intermittent intramuscular, intravenous, or oral pain medications). Anesthesiologists have discovered that appropriate management of perioperative hemodynamic abnormalities can influence outcome in ”high-risk” patients, although stable perioperative hernodynamics do not necessarily ensure uneventful cardiovascular outcome. Tuman has put forth an interesting proposal of ”perioperative hypercoagulability” as another issue that must be dealt with in ”high-risk patients. How blockade of the ”perioperative stress response” may influence this propensity for hypercoagulability in the postoperative period is still not well understood. We would like to qualify and expound upon one idea put forth in the editorial by Steele et al. stating: “Fibrinogen, a glycoprotein essential to hemostasis and blood viscosity, is frequently increased in patients with vascular disease. Perhaps EAA reduces fibrinogen.” It is important to remember that the half-life of fibrinogen in humans is 3 4 days and in Tuman’s study the average utilization of epidural catheters was 2.4 -+ 0.98 days. Speculation that this intervention, administered for such a period of time, would influence fibrinogen levels significantly in the postoperative period must take the long half-life into account. It might be that augmented fibrinogen production is reduced by EAA, although this will be difficult to prove in clinical studies owing to the large variability involved in performing functional fibrinogen assays. Fibrinogen plays an essential role in hemostasis and the maintenance of blood viscosity. It mediates the formation of platelet aggregates and, in the coagulation cascade, is transformed by thrombin into fibrin monomers that polymerize to form the basis of a hemostatic plug. Ten to twenty-five percent of the total body fibrinogen is extravascular. Of the circulating fibrinogen in blood, about 3% is located in the platelet alpha granules, although it is unclear if this is the result of fibrinogen biosynthesis by megakaryocytes or due to platelet uptake from the plasma. Plasma levels of fibrinogen and a subset of other hepatic proteins increase during the “acute-phase response” to injury and infection (3). For fibrinogen, the protein level reflects a coordinated increase in the hepatic production of the mRNAs that direct the synthesis of the three pairs of nonidentical polypeptide chains that compose fibrinogen. The increase is predominantly in response to interleukin-6 (IL-6) produced by monocytes/macrophages. Interleukin-6, a key mediator in the inflammatory response, preferentially stimulates the synthesis of fibrinogen in human hepatoma cells. Whether the influence of EAA on the stress response may have some effect on the inflammatory response is unknown. The effects of stress on the inflammatory response are likely complex. Perhaps EAA decreases hypercoagulability by direct or indirect modulation of the inflammatory response (decreased production of IL-6) and subsequent inhibition of the “acute-phase response.” Little
