General Surgery Rotation

Patient will present as →  a 26-year-old man is seen in the emergency department for abdominal pain that began after returning home from a party where he consumed pizza and eight beers. The pain is constant, located in the upper part of his abdomen, and radiates to his back. Approximately 3 to 4 hours after the onset of the pain, the patient vomited a large amount of undigested food, but the emesis did not resolve his pain. His past medical history is unremarkable, and he consumes alcohol daily and on the weekends when he attends parties with his friends. On examination, the patient appears uncomfortable. His temperature is 38.8°C (101.8°F), heart rate 110 beats/min, blood pressure 110/60 mm Hg, and respiratory rate 28 breaths/min. The abdomen is distended and tender to palpation in the epigastric and periumbilical areas. Laboratory studies reveal a WBC count of 18,000/mm3, hemoglobin 17 g/dL, hematocrit 47%, glucose 210 mg/dL, total bilirubin 3.2 mg/dL, aspartate aminotransferase (AST) 380 U/L, alanine aminotransferase (ALT) 435 U/L, lactose dehydrogenase (LDH) 300 U/L, and serum amylase 6800 IU/L. Arterial blood gas studies (room air) reveal pH 7.38, Paco2 33 mm Hg, Pao2 68 mm Hg, and HCO3 21 mEq/L. Chest radiography reveals the presence of a small pleural effusion

Key Features of Substance Abuse

• The substance is often taken in larger amounts over a longer period than intended
• Unsuccessful efforts to cut down
• A great deal of time spent obtaining the substance or recovering from its effects
• Craving
• Social, occupational, or recreational
• Recurrent despite hazards
• Tolerance or withdrawal

Alcohol or drug dependence: 5% to 10% of the population

• Approximately 15% of patients in primary care practice have an at-risk pattern of drug and/or alcohol use; lifetime prevalence of any alcohol use disorder: 30%; prescription drug misuse is on the rise with 5% past-year prevalence.
• Males > females

Surgical problems due to drug misuse

• Venous access: Repeated use of veins for intravenous self-administration of drugs leads to major damage to superficial veins, which are very likely to become thrombosed.
• Arterial injury: Attempted deep venous access brings with it the risk of arterial damage. This is a particular risk in the femoral region where critical ischemia of the entire leg may result from arterial damage or thrombosis. This may require urgent vascular surgical intervention, repair, and/or embolectomy.
• Deep venous thrombosis (DVT)
• Abscess formation and gas gangrene
• Tissue compression, crush injury, and ischemia: Other complications of prolonged immobility following illicit drug administration include compartment syndrome and neuropraxia.

Obtain serum or urine tests on those who are likely by history, physical examination, or circumstances to be intoxicated.

• Blood alcohol content (BAC) measured on the breath is practical to define intoxication and provides a rough measure of impairment. In general, two standard drinks may cause a BAC of 0.08% or higher, which is considered legally impaired.
• Obtain a toxicology screen in urine or blood samples.
• Biologic markers such as elevated mean corpuscular volume (MCV), γ-glutamyltransferase (GGT), liver function tests (AST and ALT), and carbohydrate-deficient transferrin (CDT) may also be used to diagnose and monitor.

Tracks secondary to intravenous heroin abuse.

A history of drug abuse could be considered a contraindication to day-case surgery.

• Operations on acutely intoxicated patients should be delayed if possible.
• Local, regional, or axial (spinal and epidural) anesthetic techniques may be particularly useful.

Those caring for substance users postoperatively should be wary of the potential for hemodynamic compromise, poor wound healing, altered consciousness, and difficulty with pain management

Anesthesia: Information regarding a patient's drug habit may be very important in planning their anesthetic care.

• Opioid users may display both tolerance and physical dependence, making a prediction of their analgesic needs difficult.
• Patients that smoke or inhale illicit substances may have considerable airway damage and significant chronic obstructive pulmonary disease
• The use of sympathomimetic drugs such as cocaine, amphetamines, and related compounds may be associated with greater pressor responses to stimuli such as oro-tracheal intubation and surgical incision, a greater amount of anesthetic agent may be required including a higher concentration of volatile anesthetic.
• The abuse of volatile solvents can mimic alcohol intoxication and is most commonly seen in school-age males. Chronic use can lead to cardiomyopathy and dysrhythmia, a sensitivity to sympathomimetic agents, and myocardial depression with volatile anesthetic agents.
• Patient-controlled analgesia (PCA) usually involves morphine and is a commonly used mode of postoperative pain management. However, in opioid-abusing patients, there is a risk of increased use for chemical gratification.
• Re-exposure to opioids in ‘recovered’ addicts risks re-establishment of drug-craving. Intravenous boluses of opioids in an unanaesthetised drug user patient should be avoided.

Treatment options