2026 FSA Podium and Poster Abstracts

Introduction: Acute psychiatric symptoms presenting in the perioperative setting pose significant challenges for patient safety and ethical decision-making. While anesthesia providers routinely screen for psychiatric history, acute manic or paranoid presentations without prior diagnosis are rare and complicate risk assessment, informed consent, and procedural safety. WALANT (Wide Awake Local Anesthesia No Tourniquet) procedures are increasingly utilized for hand surgery due to physiologic advantages, but require patient cooperation throughout. This case examines the challenges of capacity assessment, suicide risk evaluation, and decision-making protocols when a patient exhibits acute psychiatric symptoms during an elective orthopedic procedure.

Methods: We report a case of a 39 y/o female, ASA II, 164 cm, 62 kg, with a history of psoriatic arthritis, who presented for WALANT tendon repair for a left middle finger flexor tendon laceration. The patient had three other procedures performed on her hand at an outside hospital; however, due to postoperative complications and significant scar formation, she required an additional procedure for definitive repair. The only medication the patient took was 800 mg ibuprofen daily. Preoperative risk assessment revealed no concerning medical, family, or psychosocial history, giving her a Revised Cardiac Risk Index score of 0. Preoperative labs were unremarkable, demonstrating WBC 6.2, Hgb 13.4, Hct 40%, platelets 248, Na 139, K 4.1, Cl 103, HCO3 24, BUN 14, Cr 0.8, and glucose 92. Urine pregnancy test was negative. EKG showed normal sinus rhythm.

Results: The procedure was completed successfully without physical complications; however, the course was marked by significant disruption. Following administration of 2 g cefazolin, local anesthesia with 1% lidocaine, and refusal of additional anxiolysis, the patient exhibited escalating agitation towards the CRNA for not correctly adjusting her pillow. The patient began to make repeated suicide threats and demonstrated paranoid ideation by insinuating that the anesthesia personnel were going to harm her. Notably, the patient maintained rapport with the surgical staff. Even after the surgery was complete, the patient had multiple episodes of crying due to the "neglect and persecution incurred from the anesthesiologist." Psychiatric consultation was offered but refused, triggering further suicidal statements. The patient did not meet involuntary examination criteria under Florida's Baker Act and was discharged on POD 2 in stable condition. 

Discussion/Conclusion: This case highlights critical gaps in perioperative protocols for managing unexpected acute psychiatric symptoms during conscious procedures. Key considerations include differentiation between organic causes (medication effects vs. primary psychiatric pathology), ruling out reversible medical etiologies (substance intoxication, metabolic derangements, neurologic pathology), and safety protocols balancing procedure completion against escalating psychiatric risk. We propose a framework including real-time capacity reassessment when psychiatric symptoms emerge, immediate consideration of primary and secondary etiologies, clear communication protocols between anesthesia and surgical teams regarding role-split behaviors, and established institutional guidelines for procedure termination thresholds. While this patient did not meet criteria for involuntary psychiatric hold, the case underscores the need for anesthesia providers to distinguish acute distress from genuine psychiatric crisis and document decision-making thoroughly. Future research should establish evidence-based algorithms for perioperative psychiatric emergency management.