Successful Perioperative Management Of A Patient With Parkinson’s Disease By Enteral Levodopa Administration Under Propofol Anesthesia
Ryousuke Furuya, Akiko Hirai, Tomio Andoh, Ichidai Kudoh, Fukuichiro Okumura Successful Perioperative Management of a Patient with Parkinson’s Disease by Enteral Levodopa Administration under Propofol Anesthesia . Anesthesiology 1998 89:261263 doi:
PARKINSON’S disease is a relatively common neurologic disorder. Many drugs currently used for the treatment of PD may have significant interactions with anesthetic and cardiovascular drugs. Even brief interruption of anti-PD drugs during surgery may result in exacerbation of Parkinson’s symptoms. However, safe and effective ways to administer anti-PD drugs during surgery are not widely known.
We used the enteral administration of levodopa in a patient with PD who had experienced exacerbation of PD during emergence from general anesthesia in two previous operations. This method of LD administration successfully prevented the exacerbation of the symptoms in this patient.
The Management Of Medical And Surgical Problems In Parkinson’s Disease
Patients with Parkinson’s disease live for a long time and many develop concurrent problems requiring medical or surgical intervention. The drugs used to treat Parkinson’s disease are powerful and have side effects. They are compatible with most other drugs but should be taken into account when initiating treatment for other conditions. If surgery is needed, the patient’s drug regimen and symptom severity need to be considered throughout the perioperative period. Cooperation between the prescribing physician and other medical and surgical specialists is essential to ensure the best outcome for patients with Parkinson’s disease. This paper reviews the literature and includes the personal observations of the authors.
Physicians are seeing an increasingly aging population with PD, often with concurrent acute or chronic medical and surgical problems. Patients often have well-controlled PD, and an aggressive approach can have a rewarding outcome.
Introduction
Patients with PD do not die as a direct result of their PD but are more likely to succumb to complications associated with immobility or other conditions.
Increased risk of death from pneumonia or influenza is understandable because patients with advanced PD are immobile, rigid, and debilitated. These patients have reduced lung function and are also at increased risk for fractures, most often of the hip.
Medical problems
Hypertension
Heart disease
Osteoarthritis and gout
Anesthetic Drugs May Interact With Medications Used For Parkinsons Disease
Lorri A. Lee, MD Tricia A. Meyer, PharmD, MS, FASHP
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An estimated one million people in the United States have been diagnosed with Parkinsons Disease making it one of the most common neurological disorders in patients. This number is estimated to double in the next 30 years as PD is associated with increasing age. PD patients have a deficiency of dopamine in their brain and many of their medications are used to increase this neurotransmitter. They are frequently very sensitive to missing even one dose of their Parkinson medications and may exhibit increased rigidity, loss of balance, agitation, and confusion if their dosing schedule is delayed. Neuroleptic malignant syndrome or parkinsonism-hyperpyrexia syndrome can develop if their medications are held too long or as a result of serious infection.1 Many drugs used in the perioperative period, such as metoclopramide, butyrophenones , and phenothiazines have anti-dopaminergic activity that can worsen the symptoms of PD.
PD patients may be prescribed selective MAOI-B medications such as selegiline and rasagiline that inhibit metabolism of dopamine. Though caution is still advised, several studies have demonstrated that the risk of serotonin syndrome with these selective MAOI-B drugs is extremely low, even in combination with serotonergic antidepressants.
The authors have no conflicts of interest to declare for this article.
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Pathophysiology Diagnosis And Clinical Features
The pathophysiology of PD is a loss of dopaminergic neurones in the pars compacta region of the substantia nigra, leading to the classical motor symptoms of parkinsonism: bradykinesia, muscle rigidity, and asymmetric resting tremor. There is considerable dopaminergic neuronal reservesymptoms are often not seen until around 6080% of dopaminergic neurones have degenerated. While the precise mechanism responsible for this cell death is unknown, age is the single most consistent risk factor. Patients with PD are therefore typically older and, as patients may live with PD for 20 yr or more, the prevalence in those aged over 65 is 1%.
There is no specific diagnostic test for PDthe diagnosis is essentially clinical, using the UK Parkinson’s Society Brain Bank Criteria, although brain imaging may be useful to exclude structural lesions or to demonstrate features supportive of other neurodegenerative disorders. A number of other rarer neurodegenerative conditions also present with parkinsonism, and are collectively referred to as Parkinson-plus syndromes.
Patients And Study Design
Fourteen patients with idiopathic PD from six German trial sites were enrolled in this prospective, open-label, multicenter trial approved by the respective local institutional review boards and conducted according to the Declaration of Helsinki and Good Clinical Practice. Only patients who required PD medication, who were scheduled for an operation under general anesthesia, and who had a physical status classification according to the American Society of Anesthesiologists of stage II or III were included in the trial. All patients gave written informed consent.
Following a pretreatment visit and baseline assessments on the day before surgery, patients received transdermal 24-h rotigotine patches at approximately 7 p.m. on the evening before surgery, replacing their regular PD medication . The last administration of previous PD medication was at noon of the preoperative day for most PD medications, i.e., cabergoline was stopped upon baseline assessment and the last levodopa-containing preparations were administered in the evening of the pre-operative day. Rotigotine dose determination was at the discretion of the neurologist general guidance regarding target doses was given according to published literature . After surgery, previous PD medication was to be resumed in the evening of the operative day if required, rotigotine could be applied for up to 2 weeks following surgery. The trial was completed by a safety follow-up 2 weeks after discharge from the hospital.
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Conflict Of Interest Statement
The study was sponsored by UCB Pharma GmbH. UW served as consultant and lecturer and on advisory boards for Boehringer-Ingelheim, Glaxo-SmithKline, Lifescience KG, Novartis Pharmaceuticals, Orion Pharma, Schering AG, Schwarz-Pharma, Teva, UCB Pharma and received grant/research funding from BMBF, DFG, NAF, Stiftung Doppelfeld, Stiftung Verum, dPV, MerckKgaA, Pharmacia & Upjohn. JK received honoraria for consultancy and lecturing from the sponsor and is a member of a local UCB advisory board. PO received consultancy fees from the sponsor. MS received lecture fees and is a member of a local UCB advisory board. MN has no conflict of interest. HJH and BB are employees of the study sponsor. HR received lecture fees and is part of a national and international UCB advisory board.
Deep Brain Stimulation For Parkinson’s Disease: Surgical Technique And Perioperative Management
Brian H. Kopell MD
Department of Neurosurgery, Medical College of Wisconsin and Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, USA
Robert E. Gross MD, PhD
Department of Neurology, Emory University, Atlanta, Georgia, USA
Brian H. Kopell MD
Department of Neurosurgery, Medical College of Wisconsin and Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, USA
Robert E. Gross MD, PhD
Department of Neurology, Emory University, Atlanta, Georgia, USA
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A Pragmatic Approach To The Perioperative Management Of Parkinsons Disease
Published online by Cambridge University Press: 22 September 2020
- Department of Neurology, Georgetown University Hospital, Washington, DC, USA
- Shivam Om Mittal
- Department of Neurology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
- Guillaume Lamotte
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Fernando Luis Pagan
- Department of Neurology, Georgetown University Hospital, Washington, DC, USA
- *
- Correspondence to: Dr. Abhishek Lenka MD, Ph.D., Department of Neurology, Georgetown University Hospital
Anesthesia In Parkinson Disease Requires Cautious Care
Parkinson disease affects an estimated 1 million people in the United States and 10 million individuals worldwide.1 PD develops in more than 80% of patients after the age of 60 years, and it is anticipated that the prevalence will increase as the elderly population continues to expand.2
PD has been linked with increased rates of perioperative morbidity and mortality, with one study finding more than twice the 3-month mortality rate among patients with PD compared with patients without PD after hip fracture surgery.3 Complications commonly arise from the impact of disease on the respiratory, cardiovascular, and neurological systems, with rates of postoperative aspiration pneumonia, bacterial infections, urinary tract infections, and falls significantly increased in this population, wrote the authors of a recent review published in the Journal of Clinical Neuroscience.4
The commonly used anesthetic drug propofol has been reported to demonstrate dyskinetic effects in individuals with and without movement disorders, including PD.5,6 Propofol increases striatal levels of gamma-aminobutyric acid , and increased concentrations of GABAA receptors have been observed postmortem in the globus pallidus internus of parkinsonian patients prone to dyskinesia, indicating that these patients may be more sensitive to the effects of GABA, according to the review.7
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Future Directions And Telemedicine
The rapid emergence of COVID-19 has overwhelmed global healthcare systems. Many procedures, including deep brain stimulator insertion, have been suspended and elective follow-ups postponed. As it is particularly important to prevent unnecessary COVID-19 exposure to this group of patients, telemedicine provides a new approach to ensure adequate care to patients with Parkinsons disease during this and possible future pandemics. Bloem et al. have written a viewpoint article on how the use of telemedicine in patients with chronic neurological disorders has expanded since the outbreak of COVID-19 . The American Academy of Neurology has published a position statement to support telemedicine . It is, therefore, apposite for anaesthetists to also embrace this technology in the preparation of patients with Parkinsons disease for surgery.
Ethics Approval And Consent To Participate
This study was reviewed and approved by the Institutional Board Review of King Abdullah University Hospital and Jordan University of Science and Technology. This study was conducted in accordance with the Declaration of Helsinki. The consent was waived due to the retrospective nature of the study. We confirm that the privacy of the participants was saved, and the data were anonymized and maintained with confidentiality.
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Anesthetic And Surgical Settings
ECG, non-invasive arterial blood pressure, heart rate, and peripheral blood oxygen saturation levels were all monitored while patients were in the operating theater. Just before the surgery, every patient received the required levodopa. On arrival to the operating theater, two intravenous access sites were secured. For all participants in the study, standard monitoring of blood pressure, three-lead electrocardiogram and oxygen saturation were conducted and continuously monitored during the intraoperative period in the operating theater and during the postoperative period in the post-anesthesia care unit.
SA was administered under aseptic conditions and with local lidocaine 5.9% 3cc, at the level of L3-L4 or L4-L5 in the lateral decubitus position due to the fractures. After assuring clear cerebrospinal fluid, SA was performed with 2.5 cc of 0.5% heavy bupivacaine using 25-gauge spinal needles 100% O2 was administered through a simple face mask with a flow of 4 L per minute.
Upon arrival to the operating theater, both groups received 750 mg of IV cefuroxime, IV 8 mg of dexamethasone, and IV 50 mg of ranitidine.
All the anesthetic procedures were performed by a single anesthesiologist. The orthopedic operations were done by consultant orthopedic surgeons who follow the same surgical guidelines. The diagnosis of PD was conducted by consultant neurologists in the same institution .
Limited statistical analysis tests were used due to the small sample size.