1. 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

2. 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

3. Symptoms Central Peripheral Lowest age reported is 4

4. Central - Young patients

5. Central old patients

6. Central Agitation Amnesia Ataxia Asynergia Confusion,excitement Hallucinations Delirium Somnolence

7. Central Nausea Emotional instability Hyperpyrexia, Hyperalgesia Convulsions Muscle incoordination

8. Peripheral Dry mouth Dry skin Arrhythmias Mydriasis Blurred vision Micturition and bowel dysfunction Thirst

9. Almost no symptom is spared

10. Basic mechanism Cholinergic synapses necessary for memory and anticholinergics ?? Acetylcholine and anaesthetics GABA modifies Cholinergic synapses EEG behavioral dissociation

11. Incidence After GA, 9.4 % After RA with sedation 3.3 % Reported from 4 year child onwards From Immediate postop to first week

12. Old age- more incidence The decreased cholinergic reserve in older persons Other drugs

13. Drugs and CAS Antidepressants Anticholinergics Antipsychotics Antispamodics Halo,enflurane Morphine, pethidine Ketamine Antiparkinson drugs

14. 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.

15. Differential diagnosis Metabolic encephalopathy ABG, renal parameters,electrolytes Neurologic damage CT scan

16. How to conclude as CAS Method of exclusion Profile Physostigmine challenge 0.04 mg / kg IV or IM 5 – 15 minutes symptoms improve

17. Physostigmine A cholinesterase inhibitor Rapidly hydrolysed Raised BP and tachycardia !! No problem with neostigmine Analgesia Usually one dose is enough

18. Other drugs Galantamine hydrobromide 4 amino pyridine Tacrine But nonspecific

19. Delayed recovery naloxone and flumazenil, Usually the patients recover to go back to sleep In CAS, recovery after physostigmine is usually complete

20. How to avoid ?? Atropine Phenergan Physostigmine just before recovery

21. 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

22. Thank you all