Anesthetic Considerations for Patients on Antidepressant Therapy—Part I

Abstract

Millions of patients take antidepressant medications in the United States for the treatment of depression or anxiety disorders. Some antidepressants are prescribed off-label to treat problems such as chronic pain, low energy, and menstrual symptoms. Antidepressants are a broad and expansive group of medications, but the more common drug classes include tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and monoamine oxidase inhibitors. A miscellaneous or "atypical" category covers other agents. Some herbal supplements that claim to have antidepressant activity will also be discussed. In Part I of this review, antidepressant pharmacology, adverse effects, and drug interactions with adrenergic agonists will be discussed. In part II, drug interactions with sedation and general anesthetics will be reviewed. Bleeding effects and serotonin syndrome implications in anesthetic practice will also be highlighted.

New Serotonin-Norepinephrine Reuptake Inhibitors and Their Anesthetic and Analgesic Considerations

“…As leaders in perioperative medicine, it is critical for anesthesiologists to appropriately counsel patients on the continuation of these medications. The concerns over the continuation of SNRIs through the perioperative period are largely related to a theoretically increased risk of intraoperative bleeding and the risk of developing serotonin syndrome, as discussed below [61]. These risks must be weighed against the clinical consequences of discontinuing an SNRI.…”

“…The effects of SNRIs have also been investigated as related to the transfusion requirements for patients undergoing cardiac surgery. Serotonin reuptake is known to effect platelet aggravation, and evidence suggests that significant serotonin reuptake is a risk for spontaneous bleeding [61,63]. This risk may be exacerbated with concurrent nonsteroidal anti-inflammatory use [61,64].…”

“…Serotonin reuptake is known to effect platelet aggravation, and evidence suggests that significant serotonin reuptake is a risk for spontaneous bleeding [61,63]. This risk may be exacerbated with concurrent nonsteroidal anti-inflammatory use [61,64]. However, Smith et al found that SNRI/SSRI use was not associated with significantly increased transfusion or risk of bleeding during cardiac surgery.…”

Perioperatives Management psychiatrischer und neurologischer Dauermedikation

“…Elektrolytstörungen sollten überwacht und ausgeglichen werden [6]. Das individuelle Risiko eines Patienten bedarf einer sorgfältigen Abwägung und letztlich einer interdisziplinären Entscheidung im Einzelfall, je nach Dringlichkeit des Eingriffs [7].…”

“…Die QT C -Zeit sollte bei Frauen unter 460 ms und bei Männern unter 440 ms liegen. Ein hohes Risiko für die Entwicklung von Arrhythmien besteht bei einer QT C -Zeit über 500 ms [6,7]. Torsade-de-Pointes-Tachykardien treten nur selten durch die Einnahme eines QT-Zeit-verlängernden Medikaments alleine auf.…”