CUMULATIVE CHOLINOLYTIC EFFECT IN CLINICAL PRACTICE (LITERATURE REVIEW)

Anticholinergic agents are widely used in clinical practice. However, they can cause various cumulative side effects (dry mouth, drowsiness, confusion, residual urine accumulation, etc.). The purpose of the study is to perform an analytical review of the literature dedicated to causes, complications and rehabilitation of patients with cumulative anticholinergic effect. The analytical review of the literature highlights the risks and benefits of using anticholinergic drugs. Anticholinergic agents make up to one third of all medicines for the aged people. Recent data have proved the relationship between the long-term use of anticholinergics and dementia. New results relating to the cholinergic system in the regulation of cerebral vascularisation and in neuritis indicate that anticholinergics may contribute to the absolute risk and progression of neurodegenerative diseases. It has been proven that more than 600 drugs taken by aged patients carry the so-called "anticholinergic load". The number of drugs with anticholinergic properties is constantly increasing, they include: antidepressants, antihistamines, antiparkinsonian, antipsychotic, antispasmodic, mydriatic drugs, drugs for the treatment of overactive bladder and many others. Conclusions. The number of drugs that have anticholinergic activity and can cause complications associated with anticholinergic load is increasing. To assess the anticholinergic action of drugs, several methods have been proposed, taking into account the amount of dose and the intensity of anticholinergic activity of drugs. The research of the general medical community about the anticholinergic load problem and high alertness when prescribing drugs with anticholinergic properties can prevent the cumulative anticholinergic effect development and severe complications, and, thus, save the life and health of patients.

Sudden arrhythmia followed by bradycardia during sagittal split ramus osteotomy: trigeminocardiac reflex

Trigeminocardiac reflex (TCR) is a brainstem reflex triggered by the stimulation of any branch of the fifth cranial nerve along its course, presenting as a reduction in heart rate and blood pressure. Oculocardiac reflex is a well-known subtype of TCR. In the case reported here, remarkable arrhythmia followed by bradycardia occurred suddenly in a healthy patient undergoing orthognathic surgery. The heart rhythm recovered when the surgical manipulation ceased, but bradycardia was reproduced when the surgery resumed. This case of TCR is unique in that remarkable arrhythmia first appeared and led to bradycardia; accordingly, intravenous lidocaine and an anticholinergic agent were administered simultaneously instead of anticholinergic agents alone, and were protective. Although TCR rarely occurs during orthognathic surgery, clinicians should be aware of its possibility and able to judge and manage it promptly.

Pediatric Anticholinergic Toxidrome and Treatment with Physostigmine

Background and Hypothesis: Physostigmine is the antidote to anticholinergic poisoning. Widely used in the 1970s, 2 cases published in 1980 associated use of physostigmine with significant adverse cardiotoxic events. This caused widespread opposition to the use of physostigmine. More recently, the safety profile has been re-examined, and it has been shown to have a more favorable safety profile than was previously believed. Current literature focuses on adult populations, and the available pediatric data does not comprehensively evaluate treatment plans for anticholinergic toxicity in pediatrics. We sought to establish the prevalence of pediatric anticholinergic toxicity as well as determine the prevalence of exposure types associated with physostigmine administration. We then looked at the difference in outcomes, including mortality, for those treated with physostigmine versus those treated with benzodiazepines. Project Methods: We retrospectively analyzed data from the National Poison Data System (NPDS), a database collected from poison centers nationwide. We queried for all poison center exposure cases for ages 2-18 to selected anticholinergic agents or any cases that received physostigmine from January 1, 2013 – December 31, 2017. Results: The NPDS had a total of 109,833 patients exposed to one of the selected anticholinergic agents or plants. Only 0.27% of cases were treated with physostigmine (n=298), versus 3.3% that were treated with benzodiazepines (n=3626). The most prevalent exposure was diphenhydramine. The most likely pediatric patients to be treated with physostigmine are those that are adolescents, exposed to diphenhydramine, or ingested the substance intentionally with suspected suicidal intent. Conclusion and Potential Impact: Despite a good safety profile and superior efficacy to benzodiazepines, physostigmine is still under-utilized by physicians to treat patients with an anticholinergic toxidrome. Further study can also be carried out on the potential of physostigmine to reduce resource utilization in treating the anticholinergic toxidrome.