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COMMENTARY
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 67-68  

Various manifestations and their interactions in a patient with multiple comorbidity: A dilemma!


Department of Onco-Anaesthesiology and Palliative Medicine, Dr. BRAIRCH, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication9-Jan-2017

Correspondence Address:
Rakesh Garg
Department of Anaesthesiology, Pain and Palliative Care, Room No. 139, Ist Floor, Dr. BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.197908

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How to cite this article:
Garg R. Various manifestations and their interactions in a patient with multiple comorbidity: A dilemma!. Med J DY Patil Univ 2017;10:67-8

How to cite this URL:
Garg R. Various manifestations and their interactions in a patient with multiple comorbidity: A dilemma!. Med J DY Patil Univ [serial online] 2017 [cited 2024 Mar 28];10:67-8. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2017/10/1/67/197908

This issue publishes a case of child with  Stevens-Johnson syndrome More Details (SJS), attention deficit hyperkinetic disorder (ADHD), and seizure disorder scheduled for circumcision under anesthesia.[1] Perioperative management of patient with multiple comorbidities is always challenging. This is related to interaction of the disease manifestations and need of various drugs in the perioperative care. The concurrence of individual comorbidity is not so common. However, many syndromes would have many manifestations that would corroborate with individual disease identity. This mandates extensive search of the underlying etiology and pathology that may be related to common path for variable manifestation mimicking different diseases.

Seizures have many etiologies and one of them is inborn errors of metabolism (IEM).[2],[3] The drug metabolism may be altered in such patients. This may be linked to the unusual drug reactions as well and may be responsible for allergic reactions including skin eruptions. In addition, patients with IEM may have risk of seizures and nonepileptic motor events. Hyperactivity disorder may be a part of this spectrum as well. Literature reports an increased incidence of ADHD among children with epilepsy.[2] Epileptic patients have been reported to have behavioral disturbances including hyperactivity and inattention.[2] This is related to inattention could be due to subclinical seizures, anticonvulsant drugs, or associated attention deficit disorder [a]. Such association needs a careful assessment of the underlying pathology as the perioperative management of any acute event would differ.

The presence of a working venous access remains essential in perioperative period as the presence of multiple comorbidity may decompensate requiring drug administration emergently. However, it remains a concern with skin lesion such as the presence of SJS. Child with hyperkinetic neurodevelopmental disorder may not cooperate with such procedures.[4] Airway management would also be issue in such patients. The occurrence of seizures may mandate an urgent airway control. However, the presence of SJS would make the airway difficult and risk of airway trauma.

The sensitivity testing would be prudent for various drugs in such patients as they would manifest acute event when drugs are administered in perioperative period. This becomes important because the early signs to drug interaction may not be observed under general anesthesia. However, there are no specific guidelines for drug sensitivity testing in perioperative anesthetic management. The other important issue related to the appropriate use of drugs in perioperative care. The safety profile of a drug for a particular disease may be adversely impacted by the presence of other concurrent disease. The use of antisialagogues agent like glycopyrrolate is not routinely used. It becomes more concern when the mucosal disease is preexisting like that in SJS; it would further precipitate the mucosal damage risk. The authors have used suxamethonium in their patient in the published case. Although the drug is as such is not contraindicated, dilemma may arise between the convulsion, ADHD-related movements, and drug-induced muscle twitching. Child with ADHD may be on psychostimulants or tricyclic antidepressants drugs which may be interact with anesthetic drugs by prolonging the drug action.[3] This mandates careful drug history and selecting appropriate drugs in perioperative period along with their optimal doses. Antiepileptic drugs are well associated with SJS. The anesthesiologists should document the safe use of the drug in such patient. If they have observed some reactions that need to be documented as SJS may occur with many drugs and suitable sensitivity is not routinely done. These children may require some surgical intervention in later life and hence, such documentation would be helpful to future safe management of the child.

The drugs used for ADHD such as methylphenidate interact with general anesthetics and may lead to hemodynamic fluctuations in the perioperative period.[5] This is due to depletion of catecholamine stores, or receptor downregulation.[5] In addition, it has been reported that ADHD medications lower the seizure threshold, leads to alterations in minimum alveolar concentration of volatile anesthetic agents, altered responses to premedication, increased the incidence of postoperative nausea and vomiting.[5],[6] This mandates anesthesiologists to be aware of such drug used and appropriate monitoring for the surgical intervention under general anesthesia.

Perioperative management of patients with SJS are challenging in view of increased risk of sepsis, acute respiratory distress syndrome, and multiple organ failure. In addition, SJS may have long-term sequelae such as pulmonary complications including chronic bronchitis/bronchiolitis, bronchiectasis, or obstructive lung pathologies.

To conclude, management of a child with multiple comorbidities remains challenging. Not only the disease themselves may be linked but also the perioperative management may influence the manifestations of the disease. It requires a great vigilance in management such cases in the perioperative period.

 
  References Top

1.
Chowdhury D, Khatavkar S, Samuel M. A rare case of Stevens-Johnson Syndrome with attention deficit kinetic disorder and seizure for circumcision: An anesthetic challenge. Med J DY Patil Univ 2017;10:67-9.  Back to cited text no. 1
    
2.
Schubert R. Attention deficit disorder and epilepsy. Pediatr Neurol 2005;32:1-10.  Back to cited text no. 2
    
3.
Wernicke JF, Holdridge KC, Jin L, Edison T, Zhang S, Bangs ME, et al. Seizure risk in patients with attention-deficit-hyperactivity disorder treated with atomoxetine. Dev Med Child Neurol 2007;49:498-502.  Back to cited text no. 3
    
4.
Tait AR, Voepel-Lewis T, Burke C, Doherty T. Anesthesia induction, emergence, and postoperative behaviors in children with attention-deficit/hyperactivity disorders. Paediatr Anaesth 2010;20:323-9.  Back to cited text no. 4
    
5.
Chang CH, Yang CF, Huang YC, Tang GJ, Chan KH, Ting CK. General anesthesia in a juvenile with attention-deficit hyperactivity disorder accompanied by long-term use of methylphenidate. Acta Anaesthesiol Taiwan 2009;47:208-11.  Back to cited text no. 5
    
6.
Forsyth I, Bergesio R, Chambers NA. Attention-deficit hyperactivity disorder and anesthesia. Pediatr Anesth 2006;16:371-3.  Back to cited text no. 6
    




 

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