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Paradoxical reaction in ADHD

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Abstract

In our outpatient clinic for adults with attention deficit hyperactivity disorder (ADHD), 10–20% of those affected repeatedly complained about abnormally extended (24 hours) or (more often) notably shortened or reduced effectiveness of local anesthesia injections for dental treatment. Some patients reported paradoxical reactions to postoperative administration of tranquillizers (including benzodiazepines). These drugs made them “even more awake”, much to their doctor’s surprise. One female patient reported that she had followed the surgeons’ conversations during the initial 10 minutes of the operation under full anesthesia and complete muscle relaxation. The surgeons were surprised at the amount of details she remembered. In other patients, anesthetics worked for ”too long” or had “too strong an effect.” Many people with ADHD have next to no reaction or react paradoxically to caffeine (coffee/black tea/cola) and other stimulants (nicotine, “Red Bull,” amphetamines). One female patient also reported excessive awareness —and better cognition—when taking antihistamines (for example, “Fenistil” [dimethindene maleate]). Such “idiosyncratic” reactions seem to be stable over time, which means that the different effects are predictable. We therefore advise our ADHD patients to inform their anesthesiologist before an operation that they may react differently to caffeine, antihistamines/low-potency neuroleptics, benzodiazepines (and also central and peripheral anesthetic drugs). Many mentally healthy people also react in a primarily unexpected way to caffeine, etc. It therefore may make sense to ask patients preoperatively about untypical reactions to this (not very long) list of different substances, in order to anticipate possible intraoperative and postoperative problems and to avoid these where possible. Presumably such atypical reactions are genetically determined. Therefore “idiosyncrasies” in family members may as well provide a hint for an increased risk of abnormal reactions to anesthetics. REFERENCES
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2011; 108(31–32)
541
MEDICINE
CORRESPONDENCE
Paradoxical Reaction in ADHD
In our outpatient clinic for adults with attention deficit
hyperactivity disorder (ADHD), 10–20% of those
affected repeatedly complained about abnormally
extended (24 hours) or (more often) notably shortened
or reduced effectiveness of local anesthesia injections
for dental treatment. Some patients reported paradoxi-
cal reactions to postoperative administration of tran-
quillizers (including benzodiazepines). These drugs
made them “even more awake”, much to their doctor’s
surprise.
One female patient reported that she had followed
the surgeons’ conversations during the initial 10
minutes of the operation under full anesthesia and com-
plete muscle relaxation. The surgeons were surprised at
the amount of details she remembered. In other
patients, anesthetics worked for ”too long” or had “too
strong an effect.”
Many people with ADHD have next to no reaction or
react paradoxically to caffeine (coffee/black tea/cola)
and other stimulants (nicotine, “Red Bull,” ampheta-
mines). One female patient also reported excessive
awareness —and better cognition—when taking anti-
histamines (for example, “Fenistil” [dimethindene ma-
leate]).
Such “idiosyncratic” reactions seem to be stable
over time, which means that the different effects are
predictable.
We therefore advise our ADHD patients to inform
their anesthesiologist before an operation that they may
react differently to caffeine, antihistamines/low-
potency neuroleptics, benzodiazepines (and also central
and peripheral anesthetic drugs).
Many mentally healthy people also react in a pri-
marily unexpected way to caffeine, etc. It therefore
may make sense to ask patients preoperatively about
untypical reactions to this (not very long) list of differ-
ent substances, in order to anticipate possible intraoper-
ative and postoperative problems and to avoid these
where possible.
Presumably such atypical reactions are genetically
determined. Therefore “idiosyncrasies” in family
members may as well provide a hint for an increased
risk of abnormal reactions to anesthetics.
DOI: 10.3238/arztebl.2011.0541a
In Reply:
Our correspondents describe idiosyncratic reactions to
several medications used in the context of anesthesia in
ADHD patients. The complexity of possible patho-
physiological models of explanation becomes clear
from the clinical diversity of the described mechanisms
of action. These range from paradoxical reactions to
reduced reactions to hypersensitive reactions. The
predictability of the desired mechanisms of action,
especially of anesthetic drugs, is therefore hampered,
made more difficult or even impossible, as the authors
explain. On this background, it is easily understandable
from an anesthesiological perspective that finding the
right dosage for anesthetic drugs that is required to
achieve an adequate level of anesthesia is problematic
in ADHD patients, and that patients with ADHD should
undoubtedly be counted among the risk groups for
intraoperative awareness.
Awareness Under General Anesthesia
by Prof. Dr. med. Petra Bischoff, PD Dr. med. Ingrid Rundshagen
in volume 1–2/2011
REFERENCES
1. Bischoff P, Rundshagen I: Awareness during general anaesthesia.
Dtsch Arztebl Int 2011; 108(1–2): 1–7.
PD Dr. med. Berthold Langguth
Klinik und Poliklinik für Psychiatrie,
Psychosomatik und Psychotherapie
Bezirksklinikum Regensburg
Dr. med. Rüdiger Bär
PD Dr. med. Norbert Wodarz
Dr. med. Markus Wittmann
Abteilung Psychiatrie
Bezirksklinikum Regensburg
Dr. med. Rainer Laufkötter
Ambulanz für ADHS im Erwachsenenalter
Universitätsklinik für Psychiatrie,
Psychosomatik und Psychotherapie
Bezirksklinikum Regensburg
Rainer.Laufkoetter@medbo.de
Conflict of interest statement
Dr Langguth holds patents for cyclobenzaprine in the therapy of tinnitus and
naltrexone in the therapy of tinnitus. He has received honoraria for acting as
an adviser to Merz and Novartis. He has received a publication-related hono -
rarium from Merz. He has received conference, travel, and hotel expenses, as
well as honoraria for speaking at continuing medical educational events from
ANM, AstraZeneca, Pfizer, Servier, Merz and Medtronic. Furthermore, he has
received funding for research projects that he himself initiated, from the
German Research Foundation (DFG), Tinnitus Research Initiative, the American
Tinnitus Association and AstraZeneca.
Dr Bär declares that no conflict of interest exists .
Dr Wodarz has received honoraria for acting as an adviser and conference ex-
penses from Essex Pharma. He has received travel expenses and hotel ex-
penses as well as honoraria for speaking at continuing medical educational
events from Janssen-Cilag and Essex Pharma. He has received honoraria from
Lundbeck, Essex-Pharma, MSD, IFE Europe, and Novartis for conducting com-
missioned clinical studies.
Dr Wittmann has received honoraria for acting as an adviser from Bristol-
Meyer-Squibb and conference, travel, and hotel expenses, as well as hono -
raria for continuing medical educational events, from Astra Zeneca, Lilly, Glaxo
Smith, Wyeth, Janssen, Servier, Pfizer, and Bristol-Myers Squibb. He has re-
ceived a publication-related honorarium from Servier.
Dr Laufkötter has received conference, travel, and hotel expenses from
Janssen and AstraZeneca.
542
Deutsches Ärzteblatt International
|
Dtsch Arztebl Int 2011; 108(31–32)
MEDICINE
The authors recommend taking a preoperative his-
tory from ADHD patients to optimize anesthesiological
therapy; this is already an integral part of routine
anesthesiology.
In preparing for scheduled surgical interventions that
require anesthesia, it is standard procedure to ask all
patients about diagnoses, abnormalities, intolerances,
and reactions to medications/anesthetic drugs that devi-
ate from the normal range in the context of the so called
premedication consultation. This evaluation includes
family members so that usually, known diagnoses or
earlier abnormal events are captured and documented.
No firm conclusion can be drawn about whether this
helps to reduce the frequency of the awareness phe-
nomenon in ADHD patients because data are lacking.
However, it may be assumed that particular attention,
targeted patient information all contribute to optimizing
anesthetic procedures for all patients, including those
with ADHD.
DOI: 10.3238/arztebl.2011.0541b
REFERENCES
1. Bischoff P, Rundshagen I: Awareness during general anaesthesia.
Dtsch Arztebl Int 2011; 108(1–2): 1–7.
Prof. Dr. med . Petra Bischoff
Klinik für Anästhesiologie, Intensivmedizin u. Schmerztherapie
Knappschaftskrankenhaus Bochum-Langendreer
Klinikum der Ruhr-Universität Bochum
petra.bischoff@ruhr-uni-bochum.de
Conflict of interest statement
The author declares that no conflict of interest exists.
Article
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A patient does not expect to be aware of any kind of sensory sensation during general anaesthesia and to remember it afterwards. Intraoperative awareness is present, when the patient, at least in part, perceives sensory input or actively responds to a command while under general anaesthesia. The diagnosis of awareness is verified postoperatively on the basis of a structured interview. The incidence of awareness with explicit memory is 1-2 %o in adults, and up to about 1 % in children (5-18 years) and high- risk patients. Intra-operative awareness may later cause posttraumatic stress disorder in the individual patient. Potential patient-related risk factors for intraoperative awareness are: drug abuse or addiction, difficult intubation, a history of chronic pain or opioid treatment, ASA-classification IV-V, reduced cardiovascular reserve, and an earlier experience of intra-operative awareness. Surgery- or anaesthesia-related factors include emergency operation, caesarean section, cardiac or trauma surgery, muscle relaxant use during the maintenance phase, night-time surgery, non use of benzodiazepine premedication, and total intravenous anaesthesia. During anaesthesia, monitoring of the end-tidal concentration of volatile anaesthetics, careful management by the anaesthesiologist or the monitoring of the depth of anaesthesia might help to avoid awareness. If a patient experiences awareness, appropriate support in the immediate postoperative period is necessary. Should a patient develop symptoms indicative of a posttraumatic stress disorder, psychological or psychiatric help should be initiated.
Article
Awareness while under general anesthesia, and the later recall of what happened during surgery, can be experienced by patients as horrific events that leave lasting mental trauma behind. Patients may have both auditory and tactile perception, potentially accompanied by feelings of helplessness, inability to move, pain, and panic ranging to an acute fear of death. For some patients, the experience of awareness under anesthesia has no sequelae; for others, however, it can lead to the development of post-traumatic stress disorder, consisting of complex psychopathological phenomena such as anxiety, insomnia, nightmares, irritability, and depression possibly leading to suicidality. The literature on the subject was selectively reviewed. In the absence of risk factors awareness phenomena occur in one to two per 1000 operations under general anesthesia (0.1% to 0.2%) and are thus classed as an occasionally occurring critical event. In children, the risk of such phenomena occurring is 8 to 10 times higher. These phenomena are due to an inadequate depth of anesthesia with incomplete unconsciousness. They can be promoted by a number of risk factors that are either patient-related (ASA class III or above, medication abuse), surgery-related (Caesarean section, emergency procedures, surgery at night), or anesthesia-related (anesthesia without benzodiazepines, use of muscle relaxants). Strategies for avoiding awareness phenomena under anesthesia include the training of staff to know about the problem and, specifically, the use of benzodiazepines, the avoidance of muscle relaxants if possible, and shielding the patient from excessive noise. EEG monitoring is effective but provides no guarantee against awareness. If awareness under anesthesia occurs despite these measures, the patient must be given expert, interdisciplinary treatment as soon after the event as possible in order to minimize its potential sequelae.
Schmerztherapie Knappschaftskrankenhaus Bochum-Langendreer Klinikum der Ruhr-Universität Bochum petra.bischoff@ruhr-uni-bochum.de Conflict of interest statement The author declares that no conflict of interest exists
  • Prof
  • Dr
Prof. Dr. med. Petra Bischoff Klinik für Anästhesiologie, Intensivmedizin u. Schmerztherapie Knappschaftskrankenhaus Bochum-Langendreer Klinikum der Ruhr-Universität Bochum petra.bischoff@ruhr-uni-bochum.de Conflict of interest statement The author declares that no conflict of interest exists.