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Preoperative assessment and management of

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/STRU^NI RAD
Preoperative assessment and management of patient
with psychiatric comorbidity
........
.................................
Miodrag Milenovi}1, Nevena Kalezi}1,2, Duica Simi}2,3, Draga
Dimitrijevi} 4, Dejan Markovi}1, Ivan Dimitrijevi}2,5
1
Center for Anesthesia, Clinical Center of Serbia, Belgrade,
2
University of Belgrade, School of Medicine, Belgrade,
3
University Childrens Hospital, Belgrade
4
Special hospital for psychiatric diseases "Dr Laza Lazarevic",
Belgrade, Serbia
5
Clinic for Psychiatry, Clinical Center of Serbia, Belgrade, Serbia
rezime
This article explains the most frequent psychiatric
disorders such as co-morbidity in the acute surgi-
cal treatment, along with its position and importa-
nce for the surgical procedure. Besides basic fea-
tures of these disorders, epidemiology and clinical
expression, this article holds the latest therapeutic
approach, side effects, toxicity and drug interac-
tions, during the surgical procedure.
Frequent postoperative problems, delirium, and post-
operative cognitive disorders are noted in these pati-
ents. To avoid these complications, it is recommended
to use a mini-mental score examination to re-evaluate
the decision and indication for high risk surgery pa-
tient.
Key words: preoperative assessment, psychiatric
diseases, comorbidity
INTRODUCTION
P sychiatric illnesses and personality cognitive disorders
have a significant influence on peoples lives and ac-
tivities. Recent population studies from the countries
with highly developed medical systems show joined and
concomitant mental disorders as significant throughout
all areas of the health system. Mental disorders and the
treatment efficacy, being a great burden to National health
systems, became a topic of a great interest.1 The role of
mental disorder exceeds psychiatry itself and become
more visible in area of general and primary medical prac-
tise, emergency medicine, surgery as well as in pain ther-
apy.2
Management of patients with mental disorder is of great
importance in preoperative evaluation of patients with
previous physical and mental trauma, cognitive and men-
tally induced pain disorders, related to surgical proce-
dures. It is important that doctors recognise patients with
mental disorder during preoperative assessment, because
some symptoms, even somatic disorders could be related
UDK 616.89-008-085-036
DOI:10.2298/ACI1102143M
to this.3 To prevent and treat it, some psychotropic medi-
cations are used: antidepressants, anxiolytics, antipsycho-
tics (neuroleptics), sedatives, anticonvulsants etc. In the
last decade there has been more use of sedatives, neu-
roleptics and antidepressants in populations of much you-
nger patients, prescribed by psychiatrists and general pra-
ctitioners.
In preanesthetic and presurgical evaluations, the points
of interests are neurochemical, behavioral, cognitive and
emotional factors. All this is of great importance to peri-
operative management and pain therapy of patients, and
makes it much more complex and challenging to obtain
personal agreement necessary for any surgical or invasive
procedure. Patients with mental disorders who hardly co-
mmunicate can give inadequate anamnesis and details of
their illness, symptoms and medications.4 Often, they re-
fuse any cooperation. In postoperative periods they often
develop changes in behaviour, psychomotor agitation, de-
lirium and a whole range of cognitive disorders. If it stays
as permanent, these complications make the surgical re-
covery harder, and challenge if not minimise the result of
complete medical treatment.5 This is the reason why our
goal is to obtain valid preoperative assessment of patients
mental status and undoubted informed consent process.
We also need to obtain details of psychiatric therapeutic
regimen, so we can avoid drug interactions during periop-
erative period. Because of higher risk of developing intra
and postoperative complications, such as postoperative
cognitive dysfunction (POCD) and delirium in these pa-
tients, preoperative evaluation is of great importance.
EPIDEMIOLOGY OF MENTAL DISORDERS
During last two decade, major research efforts have de-
fined incidence and prevalence of serious mental illne-
sses. According to data of the US Epidemiologic Catch-
ment Area Study from 1980 - 1985, among more than
20,000 patients above 18 years, 15.7% had mental disor-
144 M. Milenovi} et al.
ders or addiction. Revaluating the results, Burdoun et al.
confirmed that in any six month interval during the study,
19.5% of the adult population, or one in every five, had at
least one (or multiple) mental disorder.6 The other investi-
gation with a US Congressional mandate, the National
Comorbidity Study (NCS), in population from 15 - 45 ye-
ars old, in 48 US states from 1990 - 1992, showed that
50% of people included reported chronic psychiatric ill-
ness and 30% developed it in the last 12 months. The
most frequent disorders were depression, alcoholic addic-
tion and phobias.7 The ageing, ethnic density and gen-
der8,9, socioeconomic status and geographic distribution
had a prevalence trend influence. There is significant
trend in affective and anxiety bipolar disorders in women
population as well as, substance abuse and asocial behavi-
our among men. Large number of individuals with psychi-
atric disorders did not ask or received professional medi-
cal help, which means that most of them are not in the da-
tabase of medical health system.
DELIRIUM
According to the International Statistical Classification
of Diseases and Related Health Problems-10th Revision
(ICD 10), delirium is a nonspecific organic cerebral syn-
drome characterized by simultaneous disturbances of con-
ciousness and attention, perception, thinking, memory,
emotion, psychomotor behaviour and the sleep-wake
phase. It is manifestation of alcoholic abstinence in alco-
hol abusers, as delirium tremens. Also it can be an acute
confusion state, observed in more than 30% of surgical
patients. It is related to the elderly, traumatised, orthopae-
dic patients, mostly because of pre-existing cognitive dis-
orders, co-morbidity and dementia.
Postoperative delirium predisposing and precipitating
factors are:
Demographic characteristics - age >65 years and male
Cognitive dysfunction or depression
Functional disorder
Sensitive disorder (visual or auditive)
Lower oral intake
Some medication - psychoactive substances, seda-
tives, narcotics, anticholinergics and alcohol
Co-morbidity - major internal medicine and neurology
diseases and disorder
Some surgery types - high risk surgery
ICU admission
Pain
Sleep deprivation
Immobility - bead physical condition
The delirium risk assessment model shows, that the mo-
re predisposing factors and co-morbidity are involved, the
lower ranked stress is enough to trigger it.10 The most im-
portant are visual problems, major illnesses, cognitive dis-
orders and dehydration. Older patients risk assessment
model was checked and introduced to patients who un-
dergo hip replacement surgery. The study confirms that if
many predisposing factors exist, there is a higher risk to
ACI Vol. LVIII
develop postoperative delirium.11 To recognise predispos-
ing and precipitating factors on time and to start treatment
of postoperative delirium is of great importance. Using
standardised protocol when predisposing factors are pre-
sent significantly reduces the nu-mber of delirium epi-
sodes in hospitalised older patients12
POSTOPERATIVE COGNITIVE DYSFUNCTION
(POCD)
POCD is deterioration of intellectual functions expre-
ssed by loss of memory and concentration. Damage is in
the area of perception and information processing mecha-
nisms that allow people to use their knowledge and solve
the problems. Manifestation is inability in performing si-
mple tasks, followed by confusion, hallucination and deli-
rium, if illness is more severe. Incidence of POCD is in
the wide range of 10-80%. This disorders may be transi-
tional (up to 7 days), persistent (3-5 months) or longer.
The risk factors for POCD are connected to the age and
patients co-morbidity: psychiatric and neurological co-
morbidity; addiction, illness and disease; substance absti-
nence; and illnesses followed with higher intracranial
pressure. It is related to the type of surgery and choice of
anaesthesia (cardiovascular, major abdominal, orthopae-
dic surgery and urology; ketamine and anticholinergic
drug). Estimation of the risk of POCD can be done by
testing the high risk patients in preoperative period includ-
ing psychiatric high risk patients. Several tests can be
used in evaluation of cognitive function. One of the oldest
(1982.) and still in use is the Cognitive Failures Question-
naire (CFQ).13 The most often used are Abbreviated Men-
tal Test Score (AMTS)14 and Mini Mental State Examina-
tion (MMSE). Test results depend mostly on intelligence,
education and cognitive possibilities.15 It is shown that
patients with pre-existing cognitive impairment in preop-
erative periods have a greater risk of developing POCD.
Results of the 1st International Study of Postoperative
Cognitive Dysfunction, on 1218 patients tested preopera-
tively, detected cognitive impairment in 74 patients. Fur-
ther testing has been performed after 7 days when all 74
patients experienced worsening of cognitive impairment,
but not uniformly for all tests (the biggest deterioration
showed by Letter-Digit Coding Test). Cognitive impair-
ment persisted after 3 month in all 74 patients, detected
with all tests.16 Steinmetz J, associates and ISPOCD
Group followed 701 surviving patients with POCD per-
sistence after 7 days and 3 month, who underwent surgery
in 1994 - 2000. All patients were followed up to August
2007, for an ave-rage of 8.5 years (5.3 - 11.4 years). Re-
sults of the study show statistically significant higher
mortality in groups with persistent POCD after 3 months
versus groups with transient ore without POCD.17
DEMENTIA
According to the Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition (DSM-IV) dementia is mul-
tiple cognitive deficits development, including memory
impairment. It always goes along with at least one of the
Br. 2 Preoperative assessment and management of patient
with psychiatric comorbidity
following cognitive impairments: aphasia, apraxia, agno-
sia, or a disturbance in executive functions. Classification
of dementia often includes some disease in ethiology ori-
gin (Alzheimer type, vascular type, head trauma, Parkin-
son disease, Huntingtons disease etc.). Lack of cognition
or self-criticism about memory loss, or other abilities, wo-
uld be usual.18 Deterioration of motor skills, frequent
falls, deterioration of personal hygiene, and loss of per-
sonal belongings, behavioural disinhibition and neglect of
duty, often correlate with dementia in different stages.
Everything already said can be of great importance in pe-
rioperative period. Insufficient information and misinter-
pretation of symptoms or illness in patients, memory or
speech impairment, or even inability to communicate are
of great importance. Under those circumstances a clini-
cian depends on heteroanamnesis from significant indi-
viduals, family members as well as on existing medical
records.
Patients with early signs of dementia can already be me-
dicated with cholinesterase inhibitor, which makes the ef-
fect of depolarizing muscle relaxant deeper and longer.
Cholinesterase inhibitors can induce vagotonic and choli-
nomimetic effect.19
Searching for the drug which can have perioperative ne-
uroprotective effect, some studies identified lidocaine as
potentially neuroprotective, if infusion starts before induc-
tion in anaesthesia and proceeds the next 48 hours.20 Re-
cently performed randomised, double-blind, placebo con-
trolled trials, did not confirmed that effect.21
DEPRESSION
Depression is a frequent psychiatric disorder in popula-
tions, among 10 - 20%. It should be recognised separately
and distinct from sadness and sorrow, by the quality and
the duration of mood changes. Some of the patients may
experience dramatic mood swings from depressive to ma-
nic episode, named bipolar disorder. There is family his-
tory and the highest incidence in the late twenties or early
thirties. Womens are affected twice as often. About 15%
of them with major depression, ineffectively treated, com-
mit suicide. Neurotransmission pathway abnormalities
can be detected, and probably are the main pathophysiol-
ogy mechanism of depression, but are still insufficiently
investigated.
Diagnosis of depression is based on the constant presen-
ce of at least five of the following symptoms: constant,
daily repeated depressed mood (sadness or empty feeling,
irritability in children and adolescents), significantly re-
duced interest or pleasure in any activity, unintentional
noticeable weight or appetite change, sleep disturbances
(insomnia or excessive sleeping), restlessness, exhausted-
ness and lethargy, guilty or worthless feeling, concentra-
tion problem and the suicidal ideas. Organic based or
mood disturbance as a reaction to death of beloved ones
are excluded.22,23Therapy recommendation includes anti-
depressants, selective serotonin reuptake inhibitors, antip-
sychotics and lithium.
145
SCHIZOPHRENIA
Disintegration of thinking process and emotional hype-
rsensitivity is the shortest definition of serious mental dis-
order named schizophrenia. Typical manifestations are:
acoustic illusion, obsessed or weird delusions, confused
verbal communication and thinking, followed by social
and professional deterioration. A child with family (par-
ent) schizophrenia history has approximately a 10%
chance to develop schizophrenia. That risk is about one
percent in the general population. The peak incidence is in
the late teenage period.22,23
Schizophrenia patients are the high risk surgical patients
and can developed severe hypotension and hypothermia
during anaesthesia. More often they can develop postop-
erative mental confusion, pneumonia and ileus. Elevation
of the cortizol, noradrenaline and cytokines can add to de-
velopment of ileus.24 Pulmonary thromboembolism, ir-
regular ventricular rhythm, anasarca and rabdomiolisis are
seldom but still more often than in general population.
Complications go along with main surgical illness wors-
ening, use of antipsychotic drugs, drug interactions and
patients risky life behaviour.
Ketamine, propofol and fentanil used for anaesthesia in-
duction lowers the postoperative confusion level in schi-
zophrenic patient. The choice of other anaesthesia tech-
niques, not the general, can reduce the level of complica-
tions. Epidural anaesthesia and the local anesthetic infil-
tration in abdominal surgery also can reduce the level of
postoperative ileus.25To reduce the level of postoperative
mental complications, antipsychotic drugs should be con-
tinued.
ANXIETY DISORDER
Anxiety is a frequent feeling, present and persisting in
the preoperative period. Often, it is possible to relieve the
patient of that feeling with just talking, explanations of the
procedures to follow and reassurances. Finally, premedi-
cation and intravenous sedation (eg. midazolam 2mg IV),
can be induced.
Anxiety disorder can be acute or chronic, with similar
symptoms presented. Moreover, it can be part of other,
major psychiatric disorder symptoms: depression, somati-
zation and pain attacks. These symptoms, especially pain
attack in panic fear can be associated with symptoms si-
milar to myocardial infarction. Dose two illnesses can be
presented with diaphoresis (excessive swathing), tachyp-
nea and dispnea, palpitation, presyncope and existential
fear. Great numbers of panic fear attacks patients, in ana-
mnesis already has detailed cardiology and gastroenterol-
ogy examinations, without significant results.
PSYCHOTROPIC DRUGS AND ANESTHESIA
There is certain perioperative risks related to patients
using psychiatric therapy. If oral therapy has to be
stopped and there is no adequate IV substitute, worsening
of chronic psychiatric disorders can occur. Moreover,
there is a possibility of drug interaction between antipsy-
chotics and anesthetics in the preoperative period.26
146 M. Milenovi} et al.
Patients with lithium, monoamine oxidase inhibitors, tri-
cyclic antidepressants as chronic therapies are at higher
risk of drug interactions, worsening of the mental illness
and abstinence crisis. This is the reason why these pa-
tients are classified according to American Society of An-
esthesiologists as ASA 3.27
Patients mentally and physically stable, treated with se-
lective serotonin reuptake inhibitors (SSRI), classified as
ASA 2, should be treated without disruption and risks ha-
ve to be reconsidered, but probably accepted.28 Patients
on a double antipsychotic and antidepressant therapy are
also at higher risk. Those patients are classified as ASA 2.
If therapy withdrawal and related risks are a concern, a
psychiatrist has to be consulted.
Tricyclic antidepressant (TCA)
Fewer numbers of side effects and over dosage are the
main reasons of SSRIs to replace TCAs. Amitriptyline,
nortriptyline and imipramine are the most used TCAs in
therapy of chronic pain and enuresis nocturna (involun-
tary urination while asleep). Synaptic cleft amine reuptake
and transferring protein competition is the mechanism of
TCAs action. For the fool effect of medication, 2-4 wee-
ks are needed. The most common side effects are similar
to atropine effects: dry mouth, unclear vision, urine reten-
tion, constipation, sedation, and postural hypotension.
TCAs efficacy can be increased by using competing me-
dication (aspirin, warfarin, digoxin etc.). Overdosed, these
drugs are very toxic, followed by agitation, delirium, res-
piratory depression and coma. Also, cardiac arrhytmias
with prolonged duration of the QRS complex and QT in-
terval are often detected. Refractory hypotension can oc-
cur. There is no need to withdraw TCAs preoperatively.
Moreover, it can be dangerous to do so.29
Using of sympathomimetic drugs (adrenaline, noradre-
naline) can provoke cardiovascular effects of TCAs toxic-
ity. Use of indirect sympathomimetic drugs (ephedrine,
amphetamine) can deliberate noradrenaline from the vesi-
cles and provoke hypertensive crisis. Atropine and other
anticholinergic drugs can induce postoperative confusion.
Tramadol increses risc of CNS toxicity: agitation, delir-
ium, respiratory depression and coma. High level of vola-
tile anesthetics can induce ventricular arrhythmias. There
is no specific antidote. The raising pH (alkalisation) of
plasma can increase protein affinity and lowering the free
drug fraction.29 It is important to know that TCAs delay
gastric emptying.
Selective serotonin reuptake inhibitors (SSRIs)
SSRIs are frequently prescribed antidepressant in obses-
sive-compulsive disorder, panic attack etc. Drug intake
disruption can provoke acute withdrawal syndrome.
Mechanism of action is selective presynaptic inhibition
of serotonin reuptake. Level of toxicity is much lower
than TCAs. Typical side effects are gastrointestinal: nau-
sea, vomiting, diarrhoea, and CNS: insomnia, agitation,
tremor, sexual disorder and headache. Bradycardia is pos-
sible but not so often cardiovascular disorder. Coronary
ACI Vol. LVIII
vasoconstriction can happen to patients with ischemic
heart disease. Older patients can experience antidiuretic
hormone disorder and hyponatremia. High dosage of
SSRIs can induce permanently damage and reduction of
the platelet aggregability. SSRIs overdose accumulates
high serotonin level in synaptic cleft of pons and medulla.
It is much more often in drags combination among TCAs,
MAOIs, pethidine and tramadol. Toxic crisis is the mani-
festation named "Serotonin syndrome". Agitation and
confusion are the behaviour change; rigidity, myoclonus
and hyperreflexia are the characteristic motor activity;
pyrexia, diarrhea, tachycardia and unstable blood pressure
are the consequences of autonomic instability etc.29
Often, ICU admission is needed for complete treatment of
such patients in the next 24 hours. SSRIs are the inhibitors
of p450 enzyme so prolong or increase the effect of some
other drugs. It is related to: warfarin, teofilin, phenytoin,
carbamazepine, tolbutamide and benzodiazepine (diaze-
pam, midazolam), antiarrhythmic drugs typ 1c (flecaini-
de), TCAs and nonsteroidal anti-inflammatory drugs
(NSAID). Special precaution is suggested with ben-
zodiazepine, because of prolonged duration of action.
Coagulation disorder should be monitored and cor-
rected, if needed. Serum electrolytes have to be measured
in older patients, to avoid hiponatremia.
Monoamine oxidase inhibitors (MAOIs)
MAO enzyme is located in mitochondrial membrane. Its
function is to inactivate (deaminates) monoamino neuro-
transmitter in the cytoplasm. There are two isoenzymes: A
and B. Serotonin, noradrenaline and adrenaline are meta-
bolized predominantly in CNS by enzyme MAO-A.
MAO-B enzyme from non neural cells of liver and lung,
metabolise aromatic amino acid phenylethylamine i
methylhistamine. MAO-B takes 75% of all MAO enzyme
activities. Tyramine and dopamine are the substrates for
both isoenzymes (A and B).30
Indirect sympathomimetic drugs metabolized by MAO
can enhance its activities and provoke fatal hypertensive
crisis. Irreversible MAOIs was used previously, and for
recovering this enzyme function 2-3 weeks where needed.
New generations of MAO-A inhibitors drugs are reversi-
ble and selective. Antibiotic Linezolid (oxazolidinone) is
a non-selective but reversible MAOI. The anti-Parkinso-
nian drug selegiline is a MAO-B inhibitor.31Patients using
MAOIs can undergo general anaesthesia with precaution-
ary measures to reduce the possible risk.31 The most dan-
gerous interactions can happen with indirect sym-
pathomimetic drugs: ephedrine, metaraminol, amphe-
tamine, cocaine, tyramine and some opioides. The use of
these drugs (and pethidine) can provoke fatal hypertensive
crisis, so it is absolutely contraindicated to use them toge-
ther with MAOIs.32
Neuroleptics
Neuroleptics are drugs for use in treatment of psychosis
like schizophrenia and mania. The indications are in treat-
ment of acute hallucinations and false ideas, such as para-
Br. 2 Preoperative assessment and management of patient
with psychiatric comorbidity
noia and delusions. The main effect of this drug is to anta-
gonize dopamine (D2) receptors in CNS.33 Great number
of other antipsychotic drugs antagonizing other receptors
as well: histamine (H1), serotonin (5HT2), muscarinic
acetylcholine (mAChR) and a-adrenergic receptors.28
Side effects in chronic neuroleptics use are: sedation,
extrapyramidal symptoms and tardive dyskinesia (uninte-
ntional movements of the tongue, lips, face, trunk, and ex-
tremities). Seldom, some of the following side effects are
present: weight gain, ginekomastia, postural hypotension,
constipation, obstructive icterus and agranulocytosis.
Paralytic ileus can occur in surgical patients. Chlorpro-
mazine, haloperidol and trifluoperazine are the typical an-
tipsychotic drugs with the highest number of extrapyra-
midal side effects. Clozapine, olanzapine and amisulpri-
de are the representatives of atypical antipsychotic drugs
without tendency of extrapyramidal side effects, but can
evoke neutropenia (clozapine).34
Neuroleptic malignant syndrome (NMS)
Neuroleptic malignant syndrome is a rare reaction to an-
tipsychotic drugs, and manifested by symptoms similar to
malignant hyperthermia. Patients are usually young males
with symptoms of: hyperthermia, tachycardia, extrapyra-
midal disorders (rigidity, dystonia) and disorders of auto-
nomic regulation (sweating, unstable blood pressure, sa-
livation, urinary incontinence).36 In the case of neurolep-
tic malignant syndrome, patients should be transferred to
ICU. Mortality is about 20%.36
Therapy recommendation for NMS syndrome
Early recognition is of extreme importance to reduce
mortality. Immediately withdraw the neuroleptic triggers
of the NMS. 100% oxygen is recommended. Intravenous
Dantrolene 2-3 mg/kg doses until symptoms subside (total
of 10 mg/kg/day). Supportive, intensive therapy should
follow laboratory control, adequate hydration, electrolyte
stabilization, temperature reduction with cooling devices
and ventilatory assistance.37,38,39
Abrupt withdrawal of antipsychotic drugs is undesirable
and potentially dangerous for the patients. Antipsychotic
drugs potentiate the sedative and hypotensive effects of
anesthetics, including opioids. These drugs have a signifi-
cant antiemetic effect.
Lithium
Lithium is used for treatment of bipolar affective disor-
der, one of the worst forms of mood disorders, with alter-
nating phases of depression and mania.
Characteristic is a narrow therapeutic range with con-
centration in plasma of 0.6 - 1.0mmol / l. Lithium mimics
sodium in excitative tissues. It contributes to partial open-
ing of ion channels and accumulates in the cell interior,
leading to a smaller loss of intracellular potassium, partial
depolarization and reduces the release of neurotransmit-
ters.40Chronic lithium treatment leads to increased body
weight, renal insufficiency and hypothyroidism. Side ef-
147
fects of lithium can occurs in increased concentration in
plasma, above 1mmol/l.
Poisoning occurs when lithium plasma levels exceed >
1.5mmol/l. Toxic effect is aggravated by hyponatremia,
diuretics and in patients with renal illness. Symptoms of
poisoning include: lethargy or agitation, nausea and vom-
iting, thirst, polyuria, trembling hands, muscle weakness,
kidney failure, ataxia, convulsions, coma and death.41
Lithium poisoning therapy is symptomatic, whereas we
need to correct the electrolyte disturbance and seizures.
Hemodialysis can be repeated successfully in renal fail-
ure, in order to remove lithium, which is gradually enter-
ing the circulation.
Lithium should not be withdrawn from treatment for
minor surgical interventions. Earlier, the practice was to
discontinue therapy 24 - 48 hours before major surgery.
We gave up that practice because of the much higher risk
of primary psychiatric illness exacerbation.42
The application of Lithium potentiates the effects of
neuromuscular blockade (depolarising and no-depolaris-
ing). Also lower doses of anesthetics may be required, be-
cause of decreased release of noradrenalin and dopamine
in the brain stem.43
Cardiovascular effects are rare, but it is possible to de-
tect changes in the ECG. T wave can be lower or inverted.
If there is discontinuity in lithium therapy, it should be
continued 24 hours after the surgery.
Drug interactions with lithium
Thiazide diuretics reduce lithium clearance. Loop diu-
retics have a similar but weaker effect.
Nonsteroidal anti-inflammatory drugs can increase se-
rum lithium to 40%. Due to the risk of worsening renal in-
sufficiency, and potentiated lithium toxicity, these drugs
should be used with caution.44
ACE inhibitors not only decrease the excretion of lith-
ium, but can provoke renal failure. Co-administration of
both drugs must be monitored closely.45
CONCLUSION
Patients with psychiatric comorbidity, schizophrenia,
depression, bipolar and other disorders are population
with increased risk of various complications. The preope-
rative treatment should pay particular attention to the
therapeutic regimen used in the treatment of comorbidity.
Chronic psychiatric treatment has to be continued. Abrupt
withdrawal of medications can lead to worsening (exacer-
bation) of illness. Regular prophylactic treatment also car-
ries risks of interaction and toxicity with anesthetics and
perioperative medication. These patients have an incre-
ased risk of developing postoperative cognitive deficits,
and postoperative delirium. Because of that it is suggested
to perform a preoperative evaluation of cognitive status.
The recommendation is to carry out a preoperative mini-
mental examination or some other valid test, and if the
score is lower than allowed, to re-evaluate decisions about
the indications for surgery, regarding the risks.
148 M. Milenovi} et al.
SUMMARY
PREOPERATIVNA EVALUACIJA I PRIPREMA BOLES-
NIKA SA PSIHIJATRIJSKIM KOMORBIDITETOM
U radu su prikazana naj~e}a psihijatrijska oboljenja, od
zna~aja u pripremi za hirurku intervenciju, kada ona pre-
dstavljaju komorbiditet, a akutno oboljenje zahteva hirur-
ko le~enje. Osim osnovnih karakteristika ovih bolesti,
njihove epidemiologije i klini~ke slike, u radu su prikaza-
ni i terapijski reimi, njihovi neeljeni efekti, toksi~nost i
interakcija sa medikamentima koji se intraoperativno pri-
menjuju.
Ukazano je i na naj~e}e postoperativne komplikacije
kod ovih bolesnika, postoperativni delirijum i postoperati-
vne kognitivne poreme}aje. U cilju izbegavanja ovih ko-
mplikacija preporuka je da se izvede mini-mental skor ex-
amination, kako bi se re-evaluirala odluka o indikacijama
za hirurko le~enje bolesnika sa povienim rizikom za
nastanak ovih komplikacija.
Klju~ne re~i: preoperativna priprema, psihijatrijske
bolesti, komorbiditet
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