Is preoperative Haloperidol (haloperidol) recommended for anesthesia-induced ballism in patients with existing choreoathetosis (involuntary movement disorder)?

Preoperative Haloperidol for Anesthesia-Induced Ballism in Patients with Existing Choreoathetosis

Preoperative haloperidol is recommended for patients with existing choreoathetosis who are at risk for anesthesia-induced ballism, as it can effectively control worsening of involuntary movements during the perioperative period.

Rationale for Preoperative Haloperidol Use

• Haloperidol has an established track record in suppressing choreic and ballistic movements, making it a first-line agent for acute treatment of ballism 1
• For patients with pre-existing choreoathetosis, anesthesia emergence can trigger exacerbation of movement disorders, similar to how febrile illnesses can trigger ballismus episodes in patients with choreoathetoid conditions 2
• Severe ballistic movements can lead to exhaustion, injury, and metabolic disorders if not properly controlled during the perioperative period 1

Dosing and Administration Considerations

• Start with low doses of haloperidol and titrate as tolerated until movements are controlled 1
• For preoperative administration, haloperidol can be given as a slow IV bolus at an initial dose of 0.5-2 mg 3
• Careful monitoring is required as haloperidol is associated with extrapyramidal side effects and QT prolongation 3

Important Considerations and Precautions

• Perform QT interval assessment before administration, especially in patients with cardiac risk factors or those on other QT-prolonging medications 4
• Use with caution in elderly patients, as they may be more susceptible to adverse effects 5
• Consider alternative agents such as sulpiride in older patients due to its reduced side effect profile 5

Management Algorithm

1. Preoperative Assessment:

   • Confirm diagnosis of pre-existing choreoathetosis 3
   • Document baseline severity of movement disorder 3
   • Assess cardiac status including QT interval 4

2. Preoperative Administration:

   • For adults: Administer haloperidol 0.5-2 mg IV as a slow bolus 30-60 minutes before anesthesia induction 3
   • For elderly patients: Consider starting at lower dose (0.5 mg) or using sulpiride as an alternative 5

3. Intraoperative Management:

   • Consider depth of anesthesia monitoring to facilitate smoother emergence 4
   • Avoid extremely low BIS values and burst suppression of EEG to reduce risk of postoperative complications 4

4. Postoperative Monitoring:

   • Continue monitoring for movement disorders in recovery 3
   • Be prepared to administer additional doses if ballism recurs during emergence 1

Special Considerations

• While guidelines generally do not support routine preoperative administration of antipsychotics for prevention of emergence phenomena 4, this recommendation is specifically for patients with pre-existing choreoathetosis at risk for anesthesia-induced ballism
• Unlike delirium prevention where haloperidol is not recommended prophylactically 3, the use of haloperidol for controlling existing movement disorders has established efficacy 1, 2
• In cases of severe, persistent ballism that is refractory to medication, consider consultation with a neurologist for potential adjustment of the patient's regular movement disorder medications 3

Common Pitfalls to Avoid

• Failing to distinguish between emergence delirium (which should not be treated prophylactically with haloperidol) and anesthesia-induced ballism in patients with pre-existing movement disorders 3, 4
• Administering excessive doses that may lead to extrapyramidal side effects or excessive sedation 3
• Not monitoring for QT prolongation, which can lead to dangerous cardiac arrhythmias 4