Does not holding lithium (lithium carbonate) before surgery increase the risk of prolonged paralysis?

Perioperative Management of Lithium and Risk of Prolonged Paralysis

Not holding lithium before surgery can increase the risk of prolonged paralysis due to potential interactions with anesthetic agents and complications from lithium-induced nephrogenic diabetes insipidus.

Mechanism and Risks

Lithium has several perioperative risks that can contribute to prolonged paralysis:

1. Nephrogenic Diabetes Insipidus (NDI)

   • Lithium causes NDI in many patients on chronic therapy
   • During surgery, this can lead to:
     • Dehydration from prolonged fasting
     • Electrolyte abnormalities, particularly hypernatremia
     • Hyperosmolar states that can affect neuromuscular function 1

2. Interactions with Anesthetic Agents

   • Lithium can potentiate the effects of neuromuscular blocking agents
   • May prolong recovery from anesthesia and muscle relaxants
   • Can increase risk of postoperative delirium 2

3. Fluid Balance Complications

   • Surgical stress combined with lithium-induced NDI can lead to significant fluid and electrolyte disturbances
   • These imbalances can affect neuromuscular function and recovery 3

Evidence-Based Recommendations

Preoperative Management

1. Discontinue lithium before elective surgery

   • Lithium should be discontinued preoperatively in all patients 2
   • If necessary, alternative psychiatric medications should be prescribed

2. Timing of discontinuation

   • For elective procedures, consider the half-life and monitoring requirements
   • Monitor serum lithium levels before surgery if recently discontinued

3. Special considerations

   • For patients with bipolar disorder, coordinate with psychiatry for alternative mood stabilization if needed
   • Temporarily suspending lithium during intercurrent illness or before procedures requiring NPO status is recommended to prevent toxicity 4

Intraoperative Management

1. Fluid management

   • Maintain near-zero fluid balance 5
   • Use balanced crystalloids rather than 0.9% saline to avoid hyperchloremic acidosis
   • Consider monitoring with appropriate devices to guide fluid therapy

2. Anesthetic considerations

   • Be vigilant about dosing of neuromuscular blocking agents
   • Consider shorter-acting agents when possible
   • Monitor neuromuscular function closely with train-of-four monitoring

Postoperative Management

1. Fluid and electrolyte monitoring

   • Close monitoring of serum sodium, osmolality, and fluid balance
   • Watch for signs of hypernatremia and dehydration
   • Regular monitoring of renal function 4

2. Restarting lithium

   • Only restart lithium after adequate oral intake is established
   • Monitor serum lithium levels after restarting 2
   • Ensure patient is hemodynamically stable before restarting

Potential Complications and Pitfalls

1. Lithium toxicity

   • Can occur postoperatively due to:
     • Dehydration
     • Reduced renal clearance
     • Drug interactions (NSAIDs, diuretics)
   • Symptoms include tremor, confusion, ataxia, and can progress to seizures and coma 6

2. Hyperosmolar states

   • Can develop rapidly in patients with lithium-induced NDI when fasting
   • Case reports describe hyperosmolar coma following standard perioperative management 1

3. Prolonged neuromuscular blockade

   • Monitor for incomplete reversal of neuromuscular blocking agents
   • Consider using quantitative train-of-four monitoring before extubation

Special Situations

1. Emergency surgery

   • If lithium cannot be discontinued in advance:
     • Check lithium levels preoperatively if possible
     • Be vigilant about fluid management
     • Consider reduced doses of neuromuscular blocking agents
     • Monitor for signs of lithium toxicity postoperatively

2. Patients with renal impairment

   • Higher risk of lithium toxicity and prolonged effects
   • May require more aggressive perioperative monitoring
   • Consider nephrology consultation

By following these guidelines, the risk of prolonged paralysis and other lithium-related perioperative complications can be significantly reduced.