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Preoperative Evaluation/Patient Issues/Should lithium be stopped before surgery?

QUESTION:

A woman has been on lithium for 10 years. Her mother states that she cannot be off it for more than 3 days, but her surgeon requests that she be off it for 2 weeks. What is the safe time frame to be off this medication before surgery?

-- From L.S., Louisiana

REPLY:

While the surgeon should be commended for taking a conservative course, this may a case of "mother knows best". Although some authorities recommend discontinuing lithium for 2 weeks before ECT because it may interfere with the therapeutic effectiveness of the ECT, and increase the incidence and severity of memory loss, I am aware of no literature which supports discontinuing the drug before elective surgery. Indeed, for the patient with a severe manic-depressive disorder, maintaining the drug may be critical in preventing life-threatening actions potentially associated with relapse into a manic state.

Nevertheless, there are several considerations which one must be aware of when providing anesthesia to patients receiving lithium therapy: potential prolongation of neuromuscular blockade (established for succinylcholine and pancuronium; not studied for the newer agents); possible potentiation of the action of sedative/hypnotics (established for barbiturates and diazepam; not studied for propofol, midazolam, or other newer agents); potential cardiac arrhythmias and conduction abnormalities (documented in lithium toxicity; one case report of atropine-resistant bradycardia during anesthesia with propofol and fentanyl); and the possibility of hypothyroidism and nephrogenic diabetes insipidus precipitated by the lithium therapy.

In the case described above, I would suggest that these anesthetic considerations be discussed with the mother so that she is aware of the importance of the situation, and then the mother's opinion of the maximum duration her daughter can have the lithium discontinued before surgery should be followed. (Manic-depressive patients themselves are notoriously unreliable in assessing their own need for therapy and should not be relied upon to make this decision).

-- From D.D., Houston, TX

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