Anaesthetic Management of a Patient With Severe Bipolar Disorder: A Case Report

Bipolar disorder is a chronic psychiatric illness that presents unique anaesthetic challenges due to potential drug interactions, mood instability, and perioperative complications. Lithium, a mainstay of treatment, has a narrow therapeutic window and can interact with anaesthetic agents, leading to toxicity, arrhythmias, and prolonged neuromuscular blockade. We report the case of a 45-year-old man weighing 72 kg, with a 10-year history of bipolar I disorder, managed on lithium 400 mg twice daily and olanzapine 10 mg at night, who presented for elective laparoscopic cholecystectomy. Medication adherence was poor, and no preoperative psychiatric review was conducted due to limited access to liaison psychiatry services. Lithium was held for 24 hours preoperatively based on the Royal College of Psychiatrists' guidelines, while olanzapine was continued. Preoperative laboratory findings revealed low lithium levels, deranged urea and electrolytes (U&Es), leucocytosis with neutrophilia, and normal haemoglobin. General anaesthesia was induced with propofol 2.5 mg/kg and rocuronium 0.6 mg/kg and maintained with sevoflurane in oxygen/air. Fentanyl 1 mcg/kg and morphine 0.1 mg/kg were used for analgesia. Intraoperatively, the patient developed haemodynamic instability and supraventricular tachycardia. Emergence was complicated by agitation. Postoperatively, he experienced nausea, vomiting, and delirium, with mood disturbance requiring psychiatric review. He was discharged on postoperative day five. This case highlights the critical importance of preoperative psychiatric assessment, lithium level monitoring, and electrolyte optimisation in bipolar patients presenting for surgery. Multidisciplinary collaboration between anaesthetists, psychiatrists, and surgeons is essential to mitigate risks and optimise outcomes.