Anesthesia for patients with psychiatric illnesses: a narrative review with emphasis on preoperative assessment and postoperative recovery and pain

The physical and psychological fragility of patients with psychiatric illness poses critical importance in the preoperative assessment, evaluation, and choice of premedication, which includes regular therapy, as well as concerns about polypharmacy with possible interactions of anesthetics, analgesics, and psychiatric medications. A considerable effort is to reduce risks for exacerbations or relapses of imminent illness in the postoperative period. In this narrative review, the goal was also set towards the use of proper tools for the preoperative assessment of anxiety and management of postoperative pain. Indeed anxiety can be a manifestation of primary comorbidity within the spectrum of a major psychiatric condition and affects dramatically the presentations of other symptoms as well evolution. Pain perception is changed in patients with psychiatric illness; therefore, the postoperative bundle of measures including assessment of pain using tools adjusted to the patient's cognitive state and regular nonopioid analgesics is important aiming to minimize opioid use. Ketamine, esketamine, xenon, nitrous oxide, dexmedetomidine, and propofol seem to have a novel role and benefit the management of certain types of psychiatric illness during the perioperative period. Psychiatrist involvement is necessary throughout the perioperative period, starting preoperatively and continuing after discharge. Clinical pharmacologists should be part of the team during the management of critically ill patients when polypharmacy can cause undesirable effects. Psychosocial wellbeing of surgical patients with psychiatric co-morbidity depends deeply on the collaboration of medical staff, family, and friends and international guidelines aim to establish standards, including but not limited to postoperative management.