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Table of Contents
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 122-124

Perioperative care in a patient with acute psychosis: Challenges and management

1 Department of Anesthesiology, Ganga Medical Centre and Hospitals Pvt Ltd., Coimbatore, Tamil Nadu, India
2 Department of Anesthesiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
3 Department of Psychiatry, Krishna Nursing Home, Centre for Medical Psychology, Counselling and De-addiction, Coimbatore, Tamil Nadu, India

Date of Submission17-Mar-2020
Date of Decision18-Apr-2020
Date of Acceptance02-May-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Dr. Tuhin Mistry
G-304, Jainam Planet, Tatibandh, Raipur - 492 099, Chhattisgarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_24_20

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Providing perioperative care for patients with acute psychosis poses a unique challenge to the anesthesiologist. These patients are usually uncooperative, difficult to communicate with, and present with aggressive behavior. Such patients often have a history of substance abuse or chronic psychiatric illness and are on antipsychotic drugs. We report the successful perioperative management of a patient with acute psychosis, scheduled for open reduction and internal fixation of right humerus and clavicle fractures under regional anesthesia and conscious sedation.

Keywords: Acute psychosis, antipsychotic drugs, conscious sedation, perioperative care, regional anesthesia, substance abuse

How to cite this article:
Balavenkatasubhramanian J, Mistry T, Gurumoorthi P, Shankar BR. Perioperative care in a patient with acute psychosis: Challenges and management. Bali J Anaesthesiol 2020;4:122-4

How to cite this URL:
Balavenkatasubhramanian J, Mistry T, Gurumoorthi P, Shankar BR. Perioperative care in a patient with acute psychosis: Challenges and management. Bali J Anaesthesiol [serial online] 2020 [cited 2021 Mar 9];4:122-4. Available from: https://www.bjoaonline.com/text.asp?2020/4/3/122/290088

  Introduction Top

Acute psychosis refers to a symptom complex that includes disturbance of thought process and behavior. Patients with a new onset or recurrent psychotic episode have a varied presentation. It becomes apparent because of their psychiatric state or the complications of substance misuse.[1] Childhood trauma and re-traumatization are also considered as triggering factors for acute psychosis. Delusions along with hallucinations, incoherent speech, or grossly disorganized behavior, can lead to physical injury in the form of suicidal attempts or traffic accident and polytrauma.[2] Exposure to cannabis produces euphoria, sedation, anxiolysis, dysphoria, flashbacks, perceptual changes, impairment of the psychomotor performance, seizures, transient ischemic attack or ischemic stroke, acute psychosis, and increase the risk of aggression and violence in schizophrenia patients.[3],[4]

Perioperative management of patients with acute psychosis is challenging to the anesthesiologist. It is difficult to communicate with the patient to elicit proper history, to expect cooperation for examination, and to obtain informed consent for anesthesia and surgery. Hence, treatment of acute psychotic state is necessary before hurrying for the surgery, whenever possible. Management includes balanced pharmacotherapy and psychosocial therapy with the aim to decrease the symptoms, improve cognitive abilities, reduce the side effects of medication, prevent relapse, and enhance the quality of life.

The choice of anesthetic technique is still a subject of debate. It depends on the overall clinical presentation of the patient, psychological status, presence of risk factors, and the individual response to the anesthetic drugs.[5] This case report discusses the anesthetic management of a patient of acute psychosis leading to trauma along with a review of the pertinent literature.

  Case Report Top

A 22-year-old female, weighing 48 kg with a height of 165 cm, was brought to the emergency room with alleged history of road traffic accident. She had sustained an injury to the right shoulder and arm, with no history of head injury, nausea, vomiting and bleeding from ear, nose, or mouth.

On examination, she was conscious, talking irrelevantly, agitated, and uncooperative. Her fasting status was unknown and airway could not be assessed properly. Her baseline hemodynamic parameters were as follows: heart rate: 116 bpm, noninvasive blood pressure: 110/68 mmHg, temperature: 98.7°F, and oxygen saturation: 97% on room air. Local examination of the right shoulder and arm revealed swelling, tenderness, and crepitus over the right clavicle and upper part of the right arm with no distal neurovascular deficit. Abrasions were noted over the right chin and dorsum of the left hand. Her non-contrast computed tomography of brain was within normal limits. The rest of the systemic physical examination was unremarkable.

An X-ray of the right shoulder and arm revealed a fracture at the lateral-third of the right clavicle and proximal-third of the right humerus. Open reduction and internal fixation with plating was planned, and a plaster with arm sling was applied to immobilize the injured limb.

While being treated in the trauma unit, she was found overfamiliar, talkative with a pressure of speech, elated mood, and delusional for control and grandeur. She was describing herself as flimsy as a butterfly. She felt like floating in the air and rambled on how she could teleport to the past to prevent her accident. She intellectualized and rationalized using cannabis, and she would like to spread the health benefits of cannabis among people. Her social judgment was impaired, and her insight was partial.

Her family members disclosed the history of her self-isolation, solitary confinement, and decreased socialization for the past 6 months. She also had history of poor intake of food, and disturbed sleep. On further inquiry, her father revealed that she was very agitated, restless, and had fought with the family members and left her house on a two-wheeler before meeting the accident.

She reported regular use of cannabis for the past one year and also used lysergic acid diethylamide occasionally. She had a history of complex partial seizure with poor compliance with anti-epileptic medication. She was diagnosed to have acute psychosis with polymorphic symptoms following cannabis abuse by the consultant psychiatrist (BRS). Tablets olanzapine (12.5 mg/day in divided doses), divalproex sodium (250 mg twice daily in an extended-release tablet), and lorazepam (1 mg twice daily) were started. Five days after the therapy, she became tranquil, quiet and started following commands. We then decided to schedule her for surgery. Her preoperative blood investigations and electrocardiogram were unremarkable. Airway assessment revealed a modified Mallampati Class I airway with adequate thyromental distance and a full range of neck flexion and extension. Anesthesia plan was discussed with her in presence of her parents, and informed written consent was taken.

In the preoperative room, standard monitors were attached, and one 18G intravenous line was secured over the dorsum of the left hand. An oxygen mask was attached with 4 L/min oxygen flow. Intravenous 1 mg midazolam and 100 μg fentanyl were administered for anxiolysis, analgesia, and sedation. Under all aseptic precautions, ultrasound-guided right-sided interscalene brachial plexus block and superficial cervical plexus block were performed. Additional local anesthetic infiltration over the area supplied by the intercostobrachial nerve (T2) and ultrasound-guided periosteal infiltration over medial 1/3rd of the clavicle was performed. The total volume of local anesthetics used was as follows: 10 ml 2% lignocaine and adrenaline, 20 ml of 0.5% bupivacaine, and 8 mg dexamethasone.

Once she was wheeled into the theater, intravenous dexmedetomidine (0.5 μg/kg/h) infusion was started. During the course of surgery, her vitals and end-tidal carbon dioxide were within normal limits. A fluid warmer and hot air blower was used to maintain normothermia. The estimated blood loss during the surgery was approximately 200 ml. Intravenous paracetamol and ketorolac were administered as a part of multimodal analgesia. The entire surgery lasted for 2 h, with no intraoperative untoward events.

In the postoperative recovery room, she was comfortable, and her vital signs were stable. Oxygen was provided with Hudson's mask at 4 L/min. For postoperative pain management, we prescribed intravenous paracetamol 1 g every 6 h, ketorolac 30 mg every 8 h, and a transdermal 10 mg buprenorphine patch. She was in the recovery room for 3 h for observation. The patient was discharged and referred to the consultant psychiatrist for further care.

  Discussion Top

Perioperative management of acute psychosis in cannabis abuser needs a thorough understanding of various aspects of the disease process. The most potent psychoactive agents are δ9-tetrahydrocannabinol (THC) and its two metabolites, cannabidiol and cannabinol. They are highly fat soluble, and the tissue elimination half-life of THC is approximately 7 days and the total elimination of a single dose may take up to 30 days.[6] However, we did not measure the serum levels in this patient.

Recent use of cannabis increases the heart rate and myocardial oxygen demand and results in systemic hypotension due to vasodilatation, increased incidence of arrhythmia (atrial fibrillation and ventricular tachycardia), and acute coronary events in young persons.[7] Hence, drugs such as glycopyrrolate, atropine, ketamine, and epinephrine are better to be avoided. Chronic use of cannabis can cause depression of calcium-dependent ATPase activity in the cardiac muscle, which may appear in electrocardiogram as bradycardia, premature ventricular contractions, arrhythmias with flattening of the T-wave, and inversion or a decrease in voltage of the P-wave. It augments the effects of drugs that cause cardiac depression. The inhalational anesthetics which sensitize the myocardium to the catecholamines may have a more profound response due to the increased level of epinephrine.

Although acute inhalation of cannabis smoke causes bronchodilatation, chronic exposure results in airway irritation, cough, wheeze, sinusitis, bronchitis, hoarseness of voice, increased early morning sputum production, emphysema, squamous metaplasia, decreased pulmonary function, and even upper airway edema, particularly uvular edema, can occur.[8],[9]

Hence, a thorough clinical examination of upper as well as lower respiratory tract during the preoperative assessment is necessary. Airway assessment may be challenging in acute psychotic state. Prophylactic use of dexamethasone may be helpful to decrease airway edema. Cannabinoids suppress hormonal and cell-mediated immunity, temperature regulatory mechanism and depletes the acetylcholine stores responsible for its anticholinergic effect. It increases the sleeping time of barbiturates and potentiates the nondepolarizing muscle relaxants. It is better to avoid general anesthesia(GA) whenever possible in those individuals who have used cannabis within the preceding 72 h.

Regional anesthesia (RA) is the preferred technique with special emphasis placed on maintaining the integrity of the respiratory and circulatory systems. Benzodiazepine premedication helps to avoid possible sympathetic stimulation. We used midazolam and fentanyl in our patient as premedication. Dexmedetomidine is a selective central α2-adrenoceptor agonist with sedative, analgesic properties and without any clinically significant respiratory depression. It has been used to treat delirium in cases refractory to haloperidol.[10] we used low-dose dexmedetomidine infusion intraoperatively for conscious sedation without any adverse cardiovascular effect.

Tolerance, dependence, and withdrawal symptoms can occur with cannabis, just like other illicit drugs. Repeated use induces considerable tolerance to both pharmacological and behavioral effects. Cross-tolerance between cannabis and alcohol, barbiturates, opioids, prostaglandins, and chlorpromazine are also reported.

The acute psychotic state of the patient could lead to implant failure, nonunion, and further damage of injured limb because of uncontrolled limb movements. Hence, we decided to treat the acute psychotic state first and optimize the patient before the proposed surgery. We preferred site-specific RA with conscious sedation and multimodal analgesia over GA to ensure optimal perioperative attenuation of surgical stress, better analgesia, and reduced opioid requirements. Avoidance of airway manipulation and inhalation agents probably helped in smooth recovery and shorter postoperative stay.

  Conclusion Top

The anesthesiologist aims to prevent perioperative morbidity, withdrawal problems, acute episode and/or relapse of psychiatric illness. A thorough preoperative optimization including stabilization of acute psychotic state, application of regional anesthesia with conscious sedation, and multimodal systemic analgesia help to provide better perioperative care.

Declaration of patient consent

The authors certify that they have obtained all appropriate consent from the parent(s) of the patient. In the form, the parent(s) has/have given his/her/their consent for his/her/their child's images and other clinical information to be reported in the journal. The parent(s) understand that their child's names and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Byrne P. Managing the acute psychotic episode. BMJ 2007;334:686-92.  Back to cited text no. 1
Ojha R. Suicide attempt and psychosis revealed after an apparent traffic accident: A case report. Prim Care Companion J Clin Psychiatry 2008;10:486.  Back to cited text no. 2
Hackam DG. Cannabis and stroke: Systematic appraisal of case reports. Stroke 2015;46:852-6.  Back to cited text no. 3
Kudoh A. Perioperative management for chronic schizophrenic patients. Anesth Analg 2005;101:1867-72.  Back to cited text no. 4
Attri JP, Bala N, Chatrath V. Psychiatric patient and anaesthesia. Indian J Anaesth 2012;56:8-13.  Back to cited text no. 5
[PUBMED]  [Full text]  
Ashton CH. Adverse effects of cannabis and cannabinoids. Br J Anaesth 1999;83:637-49.  Back to cited text no. 6
Goyal H, Awad HH, Ghali JK. Role of cannabis in cardiovascular disorders. J Thorac Dis 2017;9:2079-92.  Back to cited text no. 7
Ribeiro LI, Ind PW. Effect of cannabis smoking on lung function and respiratory symptoms: A structured literature review. NPJ Prim Care Respir Med 2016;26:16071.  Back to cited text no. 8
Karam K, Abbasi S, Khan FA. Anaesthetic consideration in a cannabis addict. J Coll Physicians Surg Pak 2015;25 Suppl 1:S2-3.  Back to cited text no. 9
Carrasco G, Baeza N, Cabré L, Portillo E, Gimeno G, Manzanedo D, et al. Dexmedetomidine for the treatment of hyperactive delirium refractory to haloperidol in nonintubated ICU patients: A nonrandomized controlled trial. Crit Care Med 2016;44:1295-306.  Back to cited text no. 10


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