Schizophrenia

Assume the medical workup was never done - Over half of these patients carry significant medical comorbidity and cardiovascular disease is a leading cause of death, often with nothing on file. For an elective case get a 12-lead ECG, a metabolic panel with glucose, and a lipid panel. Antipsychotic-driven weight gain, type 2 diabetes and metabolic syndrome are common and frequently untreated.

QT prolongation is a class effect - Both generations prolong QTc. Intravenous haloperidol and doses higher than recommended carry the greatest risk of torsades and sudden death, and the risk climbs with hypokalemia, hypomagnesemia, hypothyroidism, structural heart disease and a familial long QT. Check the preoperative ECG plus potassium and magnesium before stacking another QT drug on top. In neuroleptic toxicity with a QTc over 500 ms, magnesium 2 to 4 g IV over 10 minutes is the treatment.

Expect an exaggerated hypotension on induction - Alpha-1 blockade is a class effect and is strongest with clozapine, risperidone, olanzapine, quetiapine and aripiprazole. It shows up as orthostatic hypotension with reflex tachycardia awake, and as a steeper drop with propofol or a neuraxial block. In haloperidol toxicity the guidance is explicit — use norepinephrine or phenylephrine, not epinephrine, which can lower the pressure further against a blocked alpha receptor.

Anticholinergic burden is already high - The low-potency first-generation agents chlorpromazine and thioridazine, and clozapine, olanzapine and quetiapine among the atypicals, are potent antimuscarinics. That means baseline tachycardia, dry mucous membranes, dry skin and impaired heat loss, decreased bowel sounds, urinary retention and a real delirium risk. Be sparing with atropine, scopolamine and diphenhydramine layered on top.

Acute dystonic reaction - Involuntary spasm of the face, neck, tongue or larynx after a dopamine blocker; laryngeal dystonia can obstruct the airway outright, and dysphonia or a complaint of throat tightness is the early sign. Mental status and vital signs stay normal, which is what separates it from neuroleptic malignant syndrome. Treat with diphenhydramine 50 mg IV or benztropine 1 to 2 mg IV; symptoms break within 10 to 30 minutes. It shows up in about 6.8% of adults on antipsychotics.

Plan for it to come back in PACU - Antipsychotic half-lives outlast a single dose of diphenhydramine or benztropine, so redosing is expected. Continue oral diphenhydramine every 6 hours for 1 to 2 days, or benztropine 1 to 2 mg twice daily for up to 7 days. Observe 12 to 24 hours after resolution if there were any respiratory symptoms. Second-line if anticholinergics fall short is lorazepam 0.05 to 0.10 mg/kg IV or diazepam 0.1 mg/kg IV.

Your antiemetic is a dopamine blocker - Metoclopramide and prochlorperazine cause extrapyramidal reactions in their own right — roughly 1 in 500 for metoclopramide — and both have precipitated neuroleptic malignant syndrome. Reach for ondansetron or dexamethasone instead, keeping the QT in mind.

Droperidol is not the fallback here - Per current FDA labeling, QT prolongation and torsades have been reported at doses at or below the recommended dose, in patients with no known risk factors, and some cases were fatal. The label reserves droperidol for patients who have failed other adequate treatments and calls for a 12-lead ECG in all patients before administration. In a patient already on a QT-prolonging antipsychotic, that is a hard sell for routine PONV.

Clozapine - agranulocytosis - About 1% of patients, dose-independent, concentrated in the first six weeks to six months. Look up the current ANC in the REMS record: under 1500/mm³ is neutropenia, under 500/mm³ is agranulocytosis. If the count is low, treat them as immunocompromised for line and airway technique and for any postoperative fever.

Clozapine - myocarditis - Under 3% of patients but lethal, dose-independent, and clustered in the first four weeks of therapy, with rapid titration and concurrent SSRIs as risk factors. It can be entirely asymptomatic, which is why the fatality rate is high. In a recently started patient the workup is troponin I or T, BNP, CRP and echocardiography — a flu-like illness with a new tachycardia is not a benign preoperative finding.

Clozapine - the rest of the list - It lowers the seizure threshold in 1 to 6% of patients, worse with rapid titration. Sialorrhea and dysphagia raise aspiration risk. Constipation affects 15 to 60% and can progress to ileus, obstruction and bowel ischemia. It is the one antipsychotic shown to increase platelet adhesion and aggregation, with pulmonary embolism reported. Tobacco induces CYP1A2, so an enforced hospital smoking stop pushes clozapine levels up.

Catatonia is not uncooperativeness - Between 7.6% and 25% of hospitalized patients with schizophrenia have catatonic features: immobility, staring, posturing, negativism, waxy flexibility, echolalia. Score it with the Bush-Francis Catatonia Rating Scale. Lorazepam 2 mg IV or PO typically produces a visible response within 10 minutes, and the antipsychotic should be stopped because it may be contributing. These patients arrive dehydrated, malnourished, and at real risk of aspiration, pressure injury and thromboembolism.

Neuroleptic malignant syndrome - Altered mental status, muscular rigidity, hyperthermia and autonomic instability, developing over 1 to 3 days, with 5% to 20% mortality and most deaths from complications of rigidity. Stop the causative agent, resuscitate and cool, and give dantrolene 0.25 to 2 mg/kg IV every 6 to 12 hours to a maximum of 10 mg/kg/day, or bromocriptine 2.5 mg PO every 6 to 8 hours to a maximum of 40 mg/day. Expect elevated CPK, myoglobinuria and acute renal failure. See the neuroleptic malignant syndrome entry.

Continue the antipsychotic through the case - Abrupt withdrawal risks relapse, and in a patient on a long-acting depot there is no quick route back. Take the morning dose. Note that no atypical antipsychotic is available intravenously, so if you need one intraoperatively the options are limited to what can be given IM.

Sedation stacks - Quetiapine, clozapine, olanzapine and aripiprazole cause significant sedation through histamine blockade, as do the low-potency phenothiazines. Titrate your anesthetic to effect rather than to the usual dose, and expect a slower, foggier emergence.

Ask specifically about alcohol and smoking - Substance misuse is common in schizophrenia and worsens both positive and negative symptoms. Schizophrenia is itself a listed non-alcoholic cause of thiamine deficiency, so in a malnourished patient give thiamine before any glucose-containing fluid. See the Wernicke-Korsakoff syndrome and alcohol substance abuse entries.

Move them carefully - Up to 65% of patients on chronic antipsychotics have osteopenia and hip fracture risk runs about 1.6 times baseline, driven by antipsychotic-induced hyperprolactinemia. Somnolence, motor instability and orthostatic hypotension add fall risk on both ends of the case. Pad deliberately and transfer with help.

Consent is a capacity question, not a rapport question - Insight is often limited at presentation and patients frequently do not seek care for psychotic symptoms themselves. Establish who holds decision-making authority before the day of surgery. Keeping the preoperative environment quiet and explaining each step plainly helps cooperation, but it does not substitute for settling the legal question.

Schizophrenia is a chronic psychotic disorder — hallucinations, delusions and disorganized thought on the positive side, anhedonia, poverty of speech and loss of motivation on the negative side. It affects roughly 1% of adults. The prevailing model is neurochemical: excess D2 activation in the mesolimbic pathway produces the positive symptoms, low mesocortical dopamine the negative ones, with glutamatergic hypoactivity and serotonergic hyperactivity also implicated.

Perioperatively the psychosis is rarely the problem. The diagnosis carries a 20% reduction in life expectancy, over half of patients have significant medical or psychiatric comorbidity, and a large share die of cardiovascular disease — much of it unworked-up. On top of that, nearly every patient is on a dopamine-blocking drug whose cardiac, autonomic, extrapyramidal and hematologic effects follow them onto the table.