What is the perioperative management of psychotropic medications?

Updated: Jan 09, 2018
  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: William A Schwer, MD  more...
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Psychotropic agents demand close attention in the perioperative period. Their complex effects on cardiovascular and autonomic nervous system function warrant careful consideration.

Patients treated with psychotropic drugs may have altered responses to other medications. With proper precautions, psychotropic drugs can be managed safely in surgical patients.

  • Antidepressants

    • No drug interactions between selective serotonin reuptake inhibitors and anesthetics are known.

    • Tricyclic antidepressants (TCAs) manifest a number of important drug interactions. TCAs should be administered until just before surgery and resumed when the patient is able to take oral fluids. In cases in which the drug is to be discontinued, tapering should occur over 1-2 weeks to minimize sleep disturbances.

    • Although rarely used, controversy exists with discontinuing monoamine oxidase inhibitors (MAOIs) before surgery and with the safety of using narcotic-based anesthesia in patients taking them. Use of meperidine in patients taking MAOIs is contraindicated because of a possible life-threatening reaction similar to neuroleptic malignant syndrome (characterized by fever, hallucinations, and rigidity).

  • Neuroleptic drugs

    • This group of drugs is used primarily to treat psychotic symptoms and constitutes a chemically heterogeneous group of major tranquilizers, such as the phenothiazines, butyrophenones, thioxanthenes, indolones, and dibenzoxazepines.

    • Most adverse effects of these drugs are easily managed. Given the complications associated with untreated psychosis in the perioperative period, continued treatment with antipsychotic drugs is warranted throughout the perioperative period.

  • Lithium

    • Lithium is used to treat bipolar affective disorders. It may potentiate the effect of depolarizing and competitive neuromuscular blocking agents. The clearance of lithium can be reduced and its toxicity increased by factors that cause negative fluid balance, negative sodium balance, and decreased glomerular filtration rate.

    • Lithium should be discontinued 2-3 days before major surgery and resumed when renal function and electrolyte levels are stable. If serum levels are not in a toxic range, renal function is normal, and fluid electrolyte status is stable, lithium can be continued before minor surgery.

  • Benzodiazepines

    • Benzodiazepines (BZs) are the most commonly prescribed class of anxiolytic drugs and play a major role in anesthesia. They can be used throughout the perioperative period to treat anxiety and agitation. They can also be used with opiates for premedication or analgesia.

    • Patients who have been on BZs for a long time develop tolerance and have an increased risk of serious withdrawal symptoms. Maintaining these patients on BZs in adequate doses and appropriate formulations at timely intervals is indicated to avert withdrawal in the perioperative period.

    • The use of phenothiazines, butyrophenones, and BZs can lead to problems with hypotension and myocardial depression in the perioperative period in patients with heart disease. The recommendation is to discontinue tranquilizing agents several days before surgery and resume as needed on the second or third postoperative day.

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