Rochlen, Lauryn R. MD; Fraumann, Robert K. MD, JD
From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan.
Accepted for publication April 27, 2013.
The authors declare no conflicts of interest.
Address correspondence to Lauryn R. Rochlen, MD, Department of Anesthesiology, University of Michigan, 1H247 University Hospital, SPC 5048, 1500 E. Medical Center Dr., Ann Arbor, MI 48109. Address e-mail to email@example.com.
It is estimated that between 10% and 20% of hospitalized patients chronically abuse alcohol, and the incidence of chronic alcohol abuse is more frequent in surgical patients due to alcohol-related trauma requiring surgical intervention.1,2 The sequelae of chronic alcoholism may also necessitate surgical care. As many as 50% of patients presenting with cancer of the gastrointestinal tract are chronic alcohol users.3 It is therefore likely that anesthesiologists will encounter patients with alcohol use–related disorders as they present for surgical or diagnostic procedures. We discuss the case of an achondroplastic dwarf with an unstable cervical spine actively withdrawing from alcohol on presentation for surgery. Written consent was obtained from the patient for publication of this case report.
A 49-year-old achondroplastic male dwarf presented with acute loss of upper and lower extremity strength. The previous evening he was intoxicated with alcohol and fell down a flight of stairs. The following morning he awoke with complete loss of lower extremity function and upper extremity extension. Magnetic resonance imaging revealed a spinal cord contusion and ligamentous injury at C4 and C5. Computed tomography showed a descending aortic arch dissection involving the innominate artery, carotid arteries, left subclavian artery, and the thoracic and abdominal aorta. He transferred to our facility for further management.
Our patient’s medical history included hypertension, gastric ulcers, and significant alcohol abuse. The vascular dissections were thought to be chronic, and his systolic blood pressure was maintained <130 mm Hg with esmolol infusion, oral metoprolol, and hydralazine as needed. An arterial catheter was inserted for direct arterial blood pressure monitoring. The neurosurgical team evaluated his spinal cord injury, and he had no movement below the level of C5-6. They wished to proceed with surgical intervention the following day. Spinal cord injury precautions were in place and continued.4,5 In accordance with our hospital guidelines, the Michigan Alcohol Withdrawal Severity Scale was initiated.6,7 This is a treatment protocol used to assess the severity of alcohol withdrawal symptoms and guide management (Fig. 1). On the evening of hospital day #1, the patient became agitated, uncooperative, hemodynamically unstable, and managed to chew through the arterial line.
On hospital day #2, the neurosurgery team planned to proceed to the operating room for posterior cervical decompression and fusion.8 The concerns of the anesthesiology team included difficult airway management, the patient’s inability to cooperate with an awake fiberoptic intubation, and the potential for hemodynamic instability during the acute withdrawal period. Risks were balanced with cervical spinal cord injury and need for urgent intervention. Discussion was held with the neurosurgery team, and the decision was jointly made to delay the procedure and allow the patient’s condition to stabilize from a neurologic and hemodynamic perspective.
On hospital day #5, the patient was cooperative and hemodynamically stable. His mental status returned to his baseline, and his neurologic examination improved slightly to include function of C7 and C8 and he was taken to the operating room. Given the patient’s cervical spine injury and history of achondroplasia, awake fiberoptic tracheal intubation was performed.9,10 The patient tolerated the surgical procedure well and returned to the intensive care unit postoperatively for management.
His hospital course was complicated by hypoxic respiratory failure due to aspiration pneumonia, ileus requiring total parenteral nutrition, and sacral decubitus ulcers requiring surgical debridement. The patient was discharged to acute inpatient rehabilitation on hospital day #29 with moderate return of neurologic function. He was seen by the neurosurgeon for a 3-month follow-up and was standing with assistance, but still unable to walk.
Alcohol withdrawal syndrome (AWS) is a major concern during the perioperative period in patients with alcohol use disorders. Withdrawal symptoms can begin as soon as 6 hours after the last alcohol intake.3 AWS results in autonomic hyperactivity due to upregulation of excitatory neurotransmitters from chronic alcohol consumption and manifests as tremulousness, sweating, nausea, vomiting, anxiety, and agitation.2 Within 12 to 48 hours of abstinence, further neuronal excitation may result in seizures.3 The next phase is delirium tremens, characterized by auditory and visual hallucinations, disorientation, and severe hemodynamic instability. AWS results in increased postoperative morbidity, mortality, intensive care unit admission, and longer hospital stay.2 If treated insufficiently, respiratory and cardiovascular collapse can occur and result in death. Appropriate treatment consists of supportive care and pharmacologic intervention with medications such as benzodiazepines, β-adrenergic blockers, clonidine, and neuroleptic drugs.3
Options for patients with AWS scheduled for elective or urgent surgery include intervention to decrease alcohol intake before the procedure, or prophylactic treatment for AWS and planning the procedure for when the patient is physiologically stable.1,11 There is little evidence on how to proceed with anesthetic management of the patient going through acute withdrawal when emergency surgery is required, such as with our patient.
Ideally, patients should be screened preoperatively to address the extent of their alcohol use. The Cut down, Annoyed, Guilty, Eye-opener (CAGE) and Alcohol Use Disorders Identification Test (AUDIT) questionnaires are well-established screening tools used to assist in the diagnosis of abuse.1,12 Daily consumption of 60 g/d has been determined as the level associated with relevant perioperative risk.2 This level of alcohol use causes a 2- to 5-fold increase in postoperative morbidity.2 Laboratory studies are used as an adjunct to the preoperative interview. Mean corpuscular volume, carbohydrate-deficient transferrin, and γ-glutamyltransferase are useful studies, but not sufficiently sensitive to base a diagnosis of alcohol abuse on alone. Preoperative evaluation also permits the anesthesiologist to determine the extent of comorbidities associated with chronic alcohol use, including cardiovascular, hematologic, hepatic, and immune dysfunction. In the case of emergency surgery, however, thorough preoperative evaluation and preparation is not possible and may result in increased perioperative morbidity.
For our patient, urgent neurosurgical intervention was recommended.8 When cervical spinal cord injury is present, the recommended method for securing the airway is awake fiberoptic intubation.9,10 In conjunction with the American Society of Anesthesiologists’ difficult airway algorithm, an awake fiberoptic intubation requires a cooperative patient.13 This patient presented additional airway concerns due to his achondroplasia. This genetic disease results in dysfunctional fibroblast function leading to faulty endochondrial ossification and an increased risk of sudden death due to brainstem compression and respiratory compromise.14,15 Other anomalies causing difficulty with tracheal intubation include increased secretions, macroglossia, shortened neck, limited cervical mobility secondary to premature fusion of the bones at the skull base, narrowing of the subglottic airway, and kyphoscoliosis.14 However, reports suggest that, despite the theoretical increased chance of encountering difficulty intubating these patients, this is not often the case.16
This patient had hemodynamic instability due to alcohol withdrawal. Guidelines for management of arterial blood pressure for chronic aortic dissection suggest maintaining blood pressure <135/80 mm Hg.17 Guidelines regarding blood pressure management in acute spinal cord injury suggest maintaining mean arterial blood pressure 85 to 90 mm Hg to ensure spinal cord perfusion in the setting of cord injury and edema.4 Tight blood pressure regulation in the setting of an altered autonomic nervous system due to AWS would have been difficult to achieve.
Despite the risks involved with delaying surgical decompression, the risks related to AWS must also be considered. There is little evidence regarding management of AWS in the perioperative period when prompt surgery and patient cooperation are required. There have been reports of using dexmedetomidine sedation to perform awake fiberoptic intubation in patients with cervical spine cord injury acutely withdrawing from alcohol.18,19 This option was not considered in this case, in part, due to the additional concern of hemodynamic instability. A discussion was held between the attending neurosurgeon and anesthesiologist focusing on the risks and benefits of delaying surgery versus proceeding. A joint agreement was reached to delay surgical intervention until the patient was cooperative and hemodynamically stable. Given the patient’s poor mental status at the time this decision was made, he was not able to take part in the discussion. His family was involved with the discussion and accepted the decision proposed.
The patient received supportive care for AWS, and his spinal cord injury was managed medically before surgical intervention. Unfortunately, however, this patient has not had rapid return of spinal cord function. Perhaps dexmedetomidine could have been used as an alternative to delaying the case, and vasoactive medication used to control hemodynamics. He has been compliant with physical therapy and will hopefully continue to improve. When a complicated patient with conflicting management goals presents for urgent surgery, the risks and benefits of delaying the case must be fully explored and discussed with the patient, family, and surgical team.
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