Psychiatry Pre-Operative Clearance Note

• Known case of seizure disorder - Tab Levetiracetam 500 mg PO BD x 1 year, maintained well
• Known case of anxiety disorder - Tab Sertraline 100 mg PO BD x 8 years, maintained well
• Planned procedure: Hemicolectomy (note: "helicolectomy" appears to be a transcription of hemicolectomy)

I. Psychiatric Assessment

• Both conditions are stable and well-controlled on current regimens
• No recent psychiatric decompensation, no breakthrough seizures, no exacerbation of anxiety
• Patient is compliant with medications for a prolonged duration (8 years on sertraline, 1 year on levetiracetam)
• No active psychiatric contraindication to surgery

II. Recommendations Regarding Current Medications

A. Tab Levetiracetam 500 mg PO BD

• Levetiracetam (Keppra) has an IV formulation available, which is a significant advantage perioperatively
• Continue the patient's regular schedule; administer the morning dose with a small sip of water on the day of surgery
• If the patient is NPO postoperatively for >24 hours, switch to IV levetiracetam at the same dose and frequency - this avoids any risk of breakthrough seizure due to missed oral dosing
• Abrupt discontinuation risks breakthrough seizures, which would be a serious intraoperative/postoperative complication
• Levetiracetam does not require serum level monitoring in a stable patient, and no routine preoperative level is needed given the well-controlled status
• Levetiracetam may interact with neuromuscular blocking agents (NMBAs) used during anesthesia - the anesthesiologist should be informed; it has been reported to increase or decrease metabolism of some anesthetic agents. Levetiracetam is also not associated with hypotension during IV administration, unlike phenytoin
• Epilepsy patients have a modestly increased risk of postoperative complications; the surgical and anesthesia teams should be made aware of the seizure history

B. Tab Sertraline 100 mg PO BD

• SSRIs including sertraline deplete platelet serotonin stores by blocking the serotonin transporter (SERT) on platelets, impairing platelet aggregation and hemostatic function
• This may increase the risk of perioperative bleeding; hemicolectomy is a major abdominal surgery with moderate bleeding risk
• The evidence for SSRI-associated bleeding in abdominal/GI surgery is moderate; epidemiological data show a modest increase in odds of bleeding (AOR ~1.09) and 30-day mortality with perioperative SSRI use
• Given that this patient has been on sertraline 8 years for anxiety, abrupt discontinuation is strongly discouraged - it can precipitate SSRI discontinuation syndrome (dizziness, nausea, "brain zaps," rebound anxiety, emotional lability) and decompensation of the underlying anxiety disorder
• If bleeding risk is deemed high by the surgical team, taper over several weeks BEFORE elective surgery, in consultation with psychiatry. For a moderate-risk procedure like hemicolectomy without ongoing antiplatelet therapy, the general consensus is to continue the SSRI
• Avoid concomitant NSAIDs perioperatively, as they significantly amplify SSRI-related bleeding risk
• Avoid antiplatelet agents if not absolutely indicated

• Sertraline + certain perioperative opioids (especially tramadol, fentanyl, pethidine/meperidine) can precipitate serotonin syndrome
• Tramadol and pethidine/meperidine are contraindicated with sertraline due to high serotonin syndrome risk
• Fentanyl and oxycodone carry a lower but real risk - use with caution; morphine is generally preferred as it has the least serotonergic activity
• The anesthesiologist and pain management team must be informed of sertraline use to select appropriate analgesics
• Ondansetron (a 5-HT3 antagonist commonly used as an antiemetic) also has theoretical interactions; it generally does not cause serotonin syndrome but may reduce sertraline efficacy - use with clinical judgment

• SSRIs can cause SIADH, risking hyponatremia, particularly in the postoperative period (when ADH is already elevated due to surgical stress)
• Monitor serum electrolytes (sodium) preoperatively and in the postoperative period

• Sertraline is a moderate inhibitor of CYP2D6; this may affect metabolism of certain opioids (e.g., codeine - avoid, as it relies on CYP2D6 for activation)
• Sertraline does not interact as strongly with CYP2D6 as fluoxetine or paroxetine, so its overall interaction profile is relatively favorable among SSRIs

• Sertraline at higher doses may modestly prolong QT interval
• A baseline ECG is advisable; avoid other QT-prolonging agents in the perioperative setting

III. Summary of Perioperative Drug Instructions

IV. Specific Intraoperative/Anesthesia Alerts

1. Patient is on an AED (levetiracetam) - IV alternative available; avoid drug interactions with NMBAs
2. Patient is on sertraline (SSRI) - avoid tramadol, pethidine/meperidine for analgesia; use morphine preferentially; fentanyl may be used cautiously with monitoring
3. Serotonin syndrome precaution: Monitor for hyperthermia, tachycardia, myoclonus, agitation, hyperreflexia, diaphoresis postoperatively
4. Perioperative bleeding risk: Avoid NSAIDs; maintain hemostatic vigilance
5. Monitor postoperative serum sodium (SIADH/hyponatremia risk from SSRI)
6. Codeine is contraindicated (CYP2D6 inhibition by sertraline impairs conversion to morphine)

V. Fitness for Surgery from Psychiatry Perspective

VI. Post-Operative Psychiatric Follow-Up

• Resume both medications as early as oral intake is possible postoperatively
• Monitor for signs of SSRI discontinuation syndrome if medications are delayed (nausea, dizziness, flu-like symptoms, rebound anxiety)
• Monitor for breakthrough seizures in the first 48-72 hours postoperatively (surgical stress, pain, sleep disruption all lower seizure threshold)
• Psychiatric follow-up within 2-4 weeks postoperatively to reassess mental status