Schizophrenia and anaesthesia

Administering anaesthesia for elderly patients with chronic schizophrenia has always been a great challenge to anaesthetists. These patients will usually be on multiple antipsychotic drugs for many years and may lead to delayed awakening, cardiovascular instability, arrhythmias and sudden cardiac death during general anaesthesia. This case report is about the perioperative anaesthetic management of an elderly schizophrenic patient undergoing removal of femur implant. This article will explore important drug interactions and available options for a successful anaesthesia.

Role of risk stratification and genetics in sudden cardiac death

Sudden cardiac death (SCD) is a major public health issue due to its increasing incidence in the general population and the difficulty in identifying high-risk individuals. Nearly 300 000 - 350 000 patients in the United States and 4-5 million patients in the world die annually from SCD. Coronary artery disease and advanced heart failure are the main etiology for SCD. Ischemia of any cause precipitates lethal arrhythmias, and ventricular tachycardia and ventricular fibrillation are the most common lethal arrhythmias precipitating SCD. Pulseless electrical activity, bradyarrhythmia, and electromechanical dissociation also result in SCD. Most SCDs occur outside of the hospital setting, so it is difficult to estimate the public burden, which results in overestimating the incidence of SCD. The insufficiency and limited predictive value of various indicators and criteria for SCD result in the increasing incidence. As a result, there is a need to develop better risk stratification criteria and find modifiable variables to decrease the incidence. Primary and secondary prevention and treatment of SCD need further research. This critical review is focused on the etiology, risk factors, prognostic factors, and importance of risk stratification of SCD.

Investigation of Deaths of Chronically Disabled Persons and Institutionalized Persons

The investigation of deaths involving chronically disabled and/or institutionalized persons represents an important challenge to the medicolegal death investigation community. For the purposes of this review, the chronically disabled and/or institutionalized are considered to include three non-mutually exclusive subcategories: the disabled elderly, the severely disabled, and psychiatric patients. Because deaths within certain of these populations tend to be common and expected, a very important goal when such deaths occur is the appropriate referral of cases to the medical examiner/coroner. Although each subcategory has distinct issues of importance regarding death investigation, there is also a reasonable amount of overlap between the three groups. This review provides an overview of the three subcategories, the reasons such persons may be at risk for premature, unexpected, or unnatural death, the many important issues of concern when investigating deaths within these vulnerable populations, and important preventative strategies within each group.

Sudden adult death

In the investigation of sudden death in adults, channelopathies, such as long QT syndrome, have risen to the fore in the minds of forensic pathologists in recent years. Examples of these disorders are touched upon in this review as an absence of abnormal findings at postmortem examination is characteristic and the importance of considering the diagnosis lies in the heritable nature of these conditions. Typically, a diagnosis of a possible channelopathy is evoked as an explanation for a 'negative autopsy' in a case of apparent sudden natural death. However, the one potential adverse effect of this approach is that subtle causes of sudden death may be overlooked. The intention of this article is to review and discuss potential causes of sudden adult death (mostly natural) that should be considered before resorting to a diagnosis of possible channelopathy. Nonetheless, it becomes apparent that many of the potential causes of sudden death can have a genetic basis. Thus, it becomes an important consideration that there may be a genetic basis to sudden death that extends beyond the negative autopsy.

Perioperative Management for Chronic Schizophrenic Patients

Schizophrenic patients are at increased risk for perioperative complications, as their biological response to stress is impaired. The increased complications are associated with physical disorders, antipsychotic or hazardous health behaviors, and interactions between antipsychotics and anesthetic drugs. Thus, anesthesiologists must not only be aware of the perioperative problems of these patients but must also learn how to manage their perioperative course.

Death of a psychiatric patient during physical restraint. Excited delirium--a case report

We report the case of a young man with a diagnosis of paranoid schizophrenia and multiple drug abuse who died in hospital following a period of prolonged physical restraint. The literature is reviewed, possible factors contributing to death discussed and measures which may reduce the incidence of such deaths in the future highlighted.

Asphyxial death during prone restraint revisited: a report of 21 cases

Determining the cause of death when a restrained person suddenly dies is a problem for death investigators. Twenty-one cases of death during prone restraint are reported as examples of the common elements and range of variation in these apparently asphyxial events. A reasonable diagnosis of restraint asphyxia can usually be made after ruling out other causes and collecting supportive participant and witness statements in a timely fashion. Common elements in this syndrome include prone restraint with pressure on the upper torso; handcuffing, leg restraint, or hogtying; acute psychosis and agitation, often stimulant drug induced; physical exertion and struggle; and obesity. Establishing a temporal association between the restraint and the sudden loss of consciousness/death is critical to making a correct determination of cause of death.

Sudden death during restraint: a study to measure the effect of restraint positions on the rate of recovery from exercise

A small number of mental health patients have died suddenly following violent behaviour and restraint by staff. The safety of certain restraint positions has been questioned. This study evaluates two control and restraint (C & R) positions commonly used by health service staff. A repeated measures design was used to study rate of recovery from exercise in volunteer staff, measured by pulse oximetry, comparing the restraint positions with a seated (control) position. It was found that the recovery time for pulse rate of subjects restrained in a face-down position was significantly longer than for subjects restrained in a face-up position. No significant findings were made in terms of comparison between the control position and the restraint positions, and no significant changes in oxygen saturation were noted during restraint. It is concluded that restraint position may be a factor in death during restraint, but only where other factors contribute to the overall situation.

Pulmonary embolism: a case of sudden unexpected death in a psychiatric hospital

We report a case of suspected fatal physical abuse in which the cause of death was proved to be pulmonary embolism. A patient with mental retardation presenting aggressive behavior was admitted to a psychiatric hospital and was treated with major tranquilizers. She suddenly died subsequent to an angina-like attack. For several days before her death, she had been confined to her bed because of very low physical and mental activity. Bruises and abrasions were observed on the extremities, suggesting the recent restraints. There was no positive evidence of physical abuse. At autopsy, the cause of death was elucidated to be pulmonary embolism originating from thrombi in the left popliteal vein. This case indicates the risk of pulmonary embolism in immobilized patients in psychiatric hospitals.

Schizophrenia and sudden death: a medical examiner case study

This study reviews the causes of sudden death of 66 schizophrenic patients who presented to the Office of the Chief Medical Examiner (OCME) for the State of Maryland over a 3-year period from 1994 through 1996. We identified an increased incidence of suicide compared with the general population of OCME cases. This observation is consistent with reports by other investigators. The majority of the deaths were the result of natural diseases, mostly atherosclerotic cardiovascular disease. Accidents, suicides, and 1 homicide were also present in this group.

A survey of sudden death associated with the use of antipsychotic or antidepressant drugs: 49 cases in Finland

Phenothiazines have repeatedly been found to be associated with cases of sudden death, but the issue of causality has remained controversial. A survey of medicolegal autopsies performed in Finland over a 3-year period revealed that sudden unexpected deaths of 31 women (mean age 44 years, range 25-69) and 18 men (mean age 40 years, range 26-62) were associated with either the use of antipsychotic or antidepressant drugs. Therapeutic use of phenothiazines was documented in all but 3 of these 49 cases and thioridazine was involved in over half of them. Thus, whereas thioridazine was the only antipsychotic drug associated with 15 cases, only 5 cases were associated with any of the other antipsychotic or antidepressant drugs. The differences between the subgroups of psychotropic drugs remained clear after adjustment according to the respective data on drug use in the population. Although there are several uncontrolled confounding factors, the overrepresentation of phenothiazines, especially thioridazine, among psychiatric patients who died suddenly is striking and, taken together with their well-established arrhythmogenic effects, warrants further attention.