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Symptoms Central Peripheral Lowest age reported is 4
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Central anticholinergic syndrome (CAS)Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics,Ph D
(physiology) Mahatma gandhi medical college and research institute, puducherry, India
• Central anticholinergic syndrome (CAS) is a clinical entity
• which shows central and peripheral effects produced by over dosage
• or abnormal reaction to clinical dosage of anticholinergic drugs
Symptoms • Central
• Peripheral
• Lowest age reported is 4
Central - Young patients
Central old patients
Central • Agitation • Amnesia• Ataxia• Asynergia • Confusion,excitement • Hallucinations• Delirium • Somnolence
Central • Nausea• Emotional instability• Hyperpyrexia,• Hyperalgesia • Convulsions • Muscle incoordination
Peripheral • Dry mouth • Dry skin • Arrhythmias• Mydriasis • Blurred vision • Micturition and bowel dysfunction• Thirst
• Almost no symptom is spared
Basic mechanism • Cholinergic synapses necessary for
memory • and anticholinergics ??• Acetylcholine and anaesthetics • GABA modifies Cholinergic synapses • EEG behavioral dissociation
Incidence • After GA, 9.4 %• After RA with sedation 3.3 % • Reported from 4 year child onwards • From Immediate postop to first week
Old age- more incidence • The decreased cholinergic reserve in
older persons
• Other drugs
Drugs and CAS • Antidepressants • Anticholinergics • Antipsychotics • Antispamodics • Halo,enflurane • Morphine, pethidine • Ketamine • Antiparkinson drugs
What is this ??• An elderly patient is scheduled for
enucleation of a blind, painful eye. Scopolamine, 0.4 mg IM, premedication.
• preoperative holding area, the patient becomes agitated and disoriented.
• The only other medication the patient has received is 1%atropine eye drops.
Differential diagnosis • Metabolic encephalopathy • ABG, renal parameters ,electrolytes
• Neurologic damage • CT scan
How to conclude as CAS • Method of exclusion • Profile • Physostigmine challenge
• 0.04 mg / kg IV or IM • 5 – 15 minutes symptoms improve
Physostigmine • A cholinesterase inhibitor• Rapidly hydrolysed • Raised BP and tachycardia !!
• No problem with neostigmine • Analgesia • Usually one dose is enough •
Other drugs • Galantamine hydrobromide • 4 amino pyridine • Tacrine
• But nonspecific
Delayed recovery • naloxone and flumazenil,
• Usually the patients recover to go back to sleep
• In CAS , recovery after physostigmine is usually complete
How to avoid ??• Atropine • Phenergan • Physostigmine just before recovery
Acta Anaesthesiol Belg. 1976;27(2):45-60
• treated 200 cases in which the CAS was diagnosed with physostigmine salicylate (0.04 mg/kg).
• successfully treated 2 cases of apparently central anticholinergic hyperpyrexia in the same way.
• suggest that physostigmine be included in the armamentarium of every anesthetist
Thank you all