A 57-year-old patient with COPD, HTN, traumatic foot amputation who is on phenelzine (MAOI), thiazide diuretic, and potassium; which anesthetic plan is most appropriate?

A 57-year-old patient with COPD, HTN, traumatic foot amputation who is on phenelzine (MAOI), thiazide diuretic, and potassium; which anesthetic plan is most appropriate?

• A. Spinal anesthetic with 0.5% hyperbaric bupivacaine
• B. Epidural anesthetic with 0.5% bupivacaine
• C. Local infiltration with lidocaine and epinephrine, sedation with propofol and meperidine
• D. General anesthesia with propofol, succinylcholine, nitrous oxide, fentanyl

Answer: (D)

When a patient is taking an MAOI like phenelzine, perioperative drug choices must avoid interactions that can trigger dangerous hypertension or serotonin syndrome. Meperidine is avoided with MAOIs because of serotonin syndrome risk, and epinephrine-containing local anesthetics can provoke severe hypertensive reactions. A regional block might seem appealing for COPD, but the combination of MAOI-related drug interactions and the need for careful hemodynamic control in a patient with multiple comorbidities makes a plan that ensures controlled airway management and stable cardiovascular status preferable. General anesthesia offers that control, allows reliable airway protection in a patient with COPD, and avoids problematic combinations such as meperidine and epinephrine with an MAOI. Propofol provides smooth induction, a short-acting muscle relaxant can facilitate intubation, and fentanyl complements analgesia without MAOI-related interactions. While there is always caution with techniques like succinylcholine in the setting of recent trauma due to potential hyperkalemia, within the context of this question this general anesthesia plan aligns best with safely managing the drug interactions and physiologic risks present.

When a patient is taking an MAOI like phenelzine, perioperative drug choices must avoid interactions that can trigger dangerous hypertension or serotonin syndrome. Meperidine is avoided with MAOIs because of serotonin syndrome risk, and epinephrine-containing local anesthetics can provoke severe hypertensive reactions. A regional block might seem appealing for COPD, but the combination of MAOI-related drug interactions and the need for careful hemodynamic control in a patient with multiple comorbidities makes a plan that ensures controlled airway management and stable cardiovascular status preferable. General anesthesia offers that control, allows reliable airway protection in a patient with COPD, and avoids problematic combinations such as meperidine and epinephrine with an MAOI. Propofol provides smooth induction, a short-acting muscle relaxant can facilitate intubation, and fentanyl complements analgesia without MAOI-related interactions. While there is always caution with techniques like succinylcholine in the setting of recent trauma due to potential hyperkalemia, within the context of this question this general anesthesia plan aligns best with safely managing the drug interactions and physiologic risks present.