Treatments in Specific Patient Populations for Anesthesiology

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There is a high percentage of questions focused on the treatment in medical board exams, as one of the reasons patients see the physician is for appropriate treatment. There are three treatment aspects tested in the specialty board exams:

• Specific treatment intervention details
• Treatment of disease variants and specific patient populations
• Treatment algorithms

This blog post focuses on deciding on the appropriate treatment for a patient with regards to the particular population the patient belongs to or a specific form of the disease the patient is suffering from. Writers of the board exam questions test your ability to figure out which treatment interventions are advised for a particular patient population with a specific variant of the disease. Diseases or conditions with well-developed guidelines or recommendations for the treatment are chosen for such specific questions.

For example, patients who are using beta blockers, it is recommended to continue beta blockade perioperatively to prevent increased contractility and heart rate due to beta-blocker withdrawal. (Fleisher LA, Fleischmann KE, Auerbach AD, et al.: 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol 2014 Jul 29.)

Another example: in patients who are susceptible to developing malignant hyperthermia during anesthesia induction should not be given volatile anesthetics and succinylcholine. Instead, it is recommended to use safe anesthetics that include nitrous oxide, barbiturates, etomidate, propofol, opiates, tranquilizers, and non-depolarizing neuromuscular blocking drugs. (Miller’s Anesthesia, Eighth Edition 2018)

Example Exam Question from Anesthesia

A 28-year-old woman is admitted for cholecystectomy. The patient has a history of the major depressive disorder and currently takes MAOIs. Following the surgery, which of the following pain medications should be avoided in this patient?

1. Meperidine
2. Morphine
3. Ibuprofen
4. Acetaminophen
5. Celecoxib

Question Explanation

In a patient who is taking MAOIs, meperidine should be avoided as it can result in serotonin syndrome which occurs due to an over-activation of peripheral and central serotonin receptors. MAO inhibitor and meperidine are both serotonergic drugs and should not be used concurrently. Meperidine acts by inhibiting serotonin uptake, increasing serotonin release and activating serotonin receptors, and MAOIs act by decreasing serotonin metabolism, all of these actions will eventually lead to an increase in the serotonin levels and result in serotonin syndrome. Morphine is an opioid analgesic similar to meperidine but is considered safe and does not induce serotonin syndrome in patients taking MAOIs. Other opioids are also serotonergic and can be associated with serotonin syndrome due to drug interactions with MAOIs, SSRIs, SNRIs or triptans. For example, levomethorphan, levorphanol, methadone, pentazocine, tapentadol, and tramadol inhibit serotonin uptake, oxycodone increases serotonin release, and fentanyl activates serotonin receptors.  Ibuprofen, acetaminophen, and celecoxib are all non-steroidal anti-inflammatory drugs that can be safely prescribed to patients taking MAOIs.

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