General Medical Information

Surgery in the Chemically Dependent

David M. Barrs

No attempt to “withdraw” the addict should be made during the perioperative period. Instead, the medical treatment should be designed to support the addicted patient. Narcotic analgesics should be used for pain control in the immediate postoperative period. Thereafter, support can be maintained by a number of different withdrawal schemes. Clonidine, 0.2 mg orally initially followed by 0.1 to 0.2 mg every 8 hours, helps minimize the opiate abstinence syndrome. As an alternative, methadone 10 to 30 mg orally or intramuscularly is given initially with subsequent doses every 8 to 12 hours, depending on symptoms. Naloxone should be available and given for any drug addict who has a sudden respiratory arrest.

The alcoholic has several specific abnormalities that should be addressed. In the noninebriated state, the alcoholic tends to require large doses of benzodiazepines for delirium tremor control and large doses of anesthetics. Hemostasis in the alcoholic patient can be altered significantly. The patient may have prominent bleeding problems secondary to insufficient or abnormal platelets found in alcoholism. Metabolic problems are also important in alcoholic patients, who are especially susceptible to hypoglycemia due to depleted lactogen stores. For this reason, all preoperative alcoholic patients should have i.v. fluids with glucose before surgery. They should have a minimal fasting period before surgery. Deficiencies in thiamine, folate, and vitamin B12 should be evaluated and treated. All alcoholic patients should receive 20 mg of i.v. thiamine, followed by 100 mg given intramuscularly daily for 3 days. Phosphate and magnesium are frequently low and should be measured and replaced as necessary.