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Central anticholinergic syndrome (CAS) Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics,Ph D (physiology) Mahatma gandhi medical college and research institute, puducherry, India
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Central anticholinergic syndrome (CAS) is a clinical entity which shows central and peripheral effects produced by over dosage or abnormal reaction to clinical dosage of anticholinergic drugs
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Symptoms Central Peripheral Lowest age reported is 4
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Central - Young patients
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Central old patients
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Central Agitation Amnesia Ataxia Asynergia Confusion,excitement Hallucinations Delirium Somnolence
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Central Nausea Emotional instability Hyperpyrexia, Hyperalgesia Convulsions Muscle incoordination
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Peripheral Dry mouth Dry skin Arrhythmias Mydriasis Blurred vision Micturition and bowel dysfunction Thirst
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Almost no symptom is spared
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Basic mechanism Cholinergic synapses necessary for memory and anticholinergics ?? Acetylcholine and anaesthetics GABA modifies Cholinergic synapses EEG behavioral dissociation
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Incidence After GA, 9.4 % After RA with sedation 3.3 % Reported from 4 year child onwards From Immediate postop to first week
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Old age- more incidence The decreased cholinergic reserve in older persons Other drugs
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Drugs and CAS Antidepressants Anticholinergics Antipsychotics Antispamodics Halo,enflurane Morphine, pethidine Ketamine Antiparkinson drugs
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What is this ?? An elderly patient is scheduled for enucleation of a blind, painful eye. Scopolamine, 0.4 mg IM, premedication. preoperative holding area, the patient becomes agitated and disoriented. The only other medication the patient has received is 1%atropine eye drops.
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Differential diagnosis Metabolic encephalopathy ABG, renal parameters,electrolytes Neurologic damage CT scan
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How to conclude as CAS Method of exclusion Profile Physostigmine challenge 0.04 mg / kg IV or IM 5 – 15 minutes symptoms improve
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Physostigmine A cholinesterase inhibitor Rapidly hydrolysed Raised BP and tachycardia !! No problem with neostigmine Analgesia Usually one dose is enough
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Other drugs Galantamine hydrobromide 4 amino pyridine Tacrine But nonspecific
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Delayed recovery naloxone and flumazenil, Usually the patients recover to go back to sleep In CAS, recovery after physostigmine is usually complete
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How to avoid ?? Atropine Phenergan Physostigmine just before recovery
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Acta Anaesthesiol Belg. 1976;27(2):45-60 treated 200 cases in which the CAS was diagnosed with physostigmine salicylate (0.04 mg/kg). successfully treated 2 cases of apparently central anticholinergic hyperpyrexia in the same way. suggest that physostigmine be included in the armamentarium of every anesthetist
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Thank you all
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