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How should Parkinson’s disease be managed perioperatively?
From: The Hospitalist, June 2010 by Swati G. Patel, MD, Chad R. Stickrath, MD, Mel Anderson, MD, and Olga Klepitskaya, MD, University of Colorado Denver Case A 67-year-old female with moderately advanced Parkinson’s disease (PD) had a mechanical fall in her home, which resulted in a humeral fracture. The fall occurred in the morning before she was able to take her medications and was related to her difficulty in initiating movements.
On her current regimen, her PD symptoms are controlled. She is able to perform daily living activities independently and ambulates without assistance. She also performs more complex tasks (e.g., cooking and managing her finances). She has not exhibited any symptoms consistent with dementia. She occasionally experiences dyspnea on exertion and dysphagia, but she has not been evaluated for these complaints. She takes carbidopa/levodopa (CD/LD) 25 mg/100 mg four times a day, amantadine 100 mg twice daily, and ropinirole 3 mg three times a day. She is scheduled for open reduction internal fixation of her fracture; the orthopedic surgeon has requested a perioperative risk assessment and recommendations concerning her medications. How should PD be managed perioperatively?

in combination with an aging population.click for large version Overview Advances in surgical and anesthetic techniques.1 Although cardiopulmonary disorders receive a great deal of attention with regard to perioperative risk assessment. disorders specific to the . other comorbid conditions also contribute to perioperative risk—namely. hospitalists will comanage many of these patients in the perioperative period. have contributed to an increasing number of geriatric patients undergoing surgery. As many as 50% of Americans older than 65 will undergo a surgical procedure.

A supportive feature is a consistent response to levodopa.3. affecting approximately 1% of individuals older than 60. there is no broad consensus statement or treatment guideline for the perioperative approach.  By minimizing interruptions in the administration of PD medications.5 These patients pose a specific challenge to the hospitalist. Postural instability. and neurology literature. lack of a parenteral route for these medications in NPO patients.elderly population. Although surgical risk in PD patients has received intermittent attention in surgical. PD is a progressive. and the risks associated with abrupt withdrawal of these medications. which carries a substantial degree of morbidity and mortality if not prevented or treated in its early stages. The various organ-system manifestations and treatments place PD patients at increased risk of complications during the perioperative period. but also due to the direct effects of dopaminergic medications used to treat PD. and resting tremor. cognitive impairment. neurodegenerative condition associated with loss of dopaminergic neurons and the presence of Lewy bodies within the substantia nigra and other areas of the brain and peripheral autonomic nervous system. Literature Review KEY POINTS    Hospitalists are often asked to comanage or consult on hospitalized patients with Parkinson’s disease (PD) in the perioperative setting. Parkinson’s disease is one such condition that deserves attention. anesthesia. many of the perioperative complications related to PD can be prevented or diminished. Parkinson’s disease is becoming more prevalent. and autonomic dysfunction usually occur later in the disease.4 As the population ages.2 Cardinal clinical features include rigidity. PD patients in the perioperative period are at risk for developing Parkinsonism-hyperpyrexia syndrome (PHS). not only because the multiorgan system manifestations of PD can raise surgical risk. bradykinesia. .

Br J Anaesthesia. or are utilizing deep-brain-stimulation treatment typically require more complex perioperative care and might benefit from neurological consultation.89(6):904916. Increased airway resistance and decreased lung elastic recoil lead to obstructive lung disease.7 The multisystem manifestations of PD might account for this global increase in perioperative risk. Postoperative complications in Parkinson’s disease. Hall GM.6 Pepper et al studied a cohort of 234 PD patients in the Veterans Administration population who were undergoing a variety of surgeries.7 They found that patients with PD had a longer acute hospital stay and had higher in-hospital mortality. Kalenka A.10 Furthermore. Neurol Clin.8. 2004.11 As a consequence of disordered respiratory . Schwarz A. J Am Geriatr Soc. 2009. Motor: The motor symptoms of PD place patients at increased risk for falls and might impair their ability to participate in rehabilitation.8. 1999.22(3):419-424.6 Pulmonary: PD patients have increased risk of abnormal pulmonary function secondary to rigidity and akinesia. Mueller et al demonstrated that there was a significantly increased risk of postoperative falls and a higher need for inpatient rehabilitation due to motor difficulties in the PD cohort. Pereira AC. which can result in restrictive and dyskinetic ventilation. Anaesthesia and Parkinson’s disease: how to manage with new therapies? Curr Opin Anesthesiol. The following are reviews of organ-system manifestations of PD and their relevance to the perioperative period. Nicholson G.47(8):967-972.22(2):367-377. 2002. Goldstein MK. The perioperative management of Parkinson’s disease revisited. A retrospective cohort of 51 PD patients undergoing various types of surgery revealed that PD patients have a longer hospital stay than matched cohorts.9 Rigidity of voluntary chest wall and upper airway muscles leads to a restrictive lung disease pattern. PD patients who are undergoing long procedures. Lang AE. Parkinson’s disease and anesthesia. undergoing procedures involving the gastrointestinal tract. Additional Reading     Pepper PV. Gálvez-Jiménez N. respiratory dyskinesia is a common side effect of levodopa.

as well as inadequate oral intake.16 PD patients in the postoperative period are at risk for swallowing difficulties. Cardiovascular: Such cardiac sympathetic abnormalities as orthostatic hypotension. nocturia.mechanics (especially in combination with disordered swallow mechanics). and slow colonic transit. In fact. In addition. and urge incontinence) are common in PD patients. and esophagus account for the dysphagia commonly noted in PD. which increases the risk of aspiration and might delay initiation of oral medications.19 Pepper et al found an increased risk of postoperative urinary tract infection in PD patients. PD patients are at increased risk of lower respiratory infections. pneumonia. frequency. urgency. postprandial or exercise-induced hypotension. respectively. resulting in pneumonia and malnutrition.12 Postoperative VTE rates are not statistically different between PD patients and matched cohorts.7 . postoperative ileus and constipation can pose challenges.g. pneumonia remains the leading cause of mortality among PD patients. pharynx. and postoperative respiratory failure.18 These clinical complaints correspond to involuntary detrusor contractions (detrusor hyperreflexia).14 Dysphagia can lead to aspiration. Gastroparesis threatens appropriate delivery of oral medications for adequate absorption.17 Pepper et al found a trend toward increased risk of hypotension and acute myocardial infarction (MI) in PD patients undergoing surgery. which results in constipation.11 Not surprisingly..15 Dysfunction of the myenteric plexus (evidenced by Lewy Body deposition) accounts for gastrointestinal dysmotility manifested as gastroparesis. and dysrhythmias are common in PD. Gastrointestinal: Abnor-malities in muscles of the mouth. ileus.7. impaired heart rate variability.13 Barium swallow tests are abnormal in 80% or more of PD patients.7 Genitourinary: Urinary complaints (e. several cohorts have suggested that PD patients undergoing surgical procedures are at higher risk for atelectasis.

20 Pepper et al noted a trend toward increased incidence of postoperative delirium in their cohort of 234 PD patients undergoing surgery. legs.21 PHS is characterized by very high fever. disseminated intravascular coagulation. abrupt withdrawal of these medications can lead to a potentially lethal condition called Parkinsonism-hyperpyrexia syndrome (PHS). or stiffness of the limbs and trunk. rigidity. and multiple severe systemic complications (e. bradykinesia. and face. acute renal failure. altered consciousness. and infections).22-24 As many as 30% of patients who survive a PHS episode have worsening of their PD symptoms and never return to their pre-PHS baseline. PHS occurs in up to 4% of PD patients. PD with dementia has been associated with shortened survival. arms. mortality is reported to be from 4% for treated to 20% for untreated episodes. and postural instability. autonomic failure. which is clinically similar to neuroleptic malignant syndrome. impaired quality of life. jaw. extreme muscle rigidity.. autonomic instability. or slowness of movement. aspiration pneumonia. Studies estimate the prevalence of dementia in cohorts of PD patients is from 28% to 44%. Cognitive: A recognized feature of advanced PD is cognitive impairment.7 Medication: Management of anti-Parkinsonian medications in the perioperative period poses unique challenges.g.The four primary symptoms of Parkinson’s disease are trembling in hands. or impaired balance and coordination. At the same time. These medications’ prodopaminergic effects can lead to hemodynamic compromise and are potentially arrhythmogenic. PHS prevention in hospitalized patients by uninterrupted administration of . and increased caregiver distress.

25 Traditional anti-Parkinsonian medications can only be delivered orally. especially those undergoing enteric surgery requiring bowel rest. click for large version Case reports describe various approaches to medication management in the perioperative period. presenting significant challenges for NPO patients. even brief interruption of medications can lead to decompensation of Parkinsonian symptoms. The most common clinical scenarios are: . but no single consensus statement (or treatment guideline) exists. Furthermore.PD medications should be the goal. but also increases the risk for multisystem complications as discussed above. Early recognition and aggressive treatment is key to successful recovery. which not only delays recovery from surgery.

and Patient undergoes lengthy procedure in which they will be required to adhere to bowel rest (e. longer orthopedic surgeries. eye). postoperatively. need for escalating doses. Given his previous complications. Furuya et al describe a 70-year-old male with PD who had previously experienced perioperative complications associated with his medication management.g. They also described the use of intravenous levodopa immediately.. frequent adjustments to maintain effect. They propose the use of subcutaneous apomorphine. including postoperative rigidity. while the patient was unable to tolerate enteric medications. orthopedic. the approach to medication management might differ. genitourinary). Depending on the category.. including hemodynamic compromise. and difficulty maintaining respiratory secretions. This patient was scheduled to undergo hepatic lobectomy. the patient experienced hypotension and premature ventricular contractions as side effects of this therapy.26 Fujii et al described three cases of PD patients undergoing gastrointestinal surgery.26 These symptoms were reversed with intravenous levodopa. a D2 . The patient maintained hemodynamic stability throughout the perioperative period and emerged from anesthesia smoothly with no muscle rigidity or postoperative complications. Furuya et al provided enteral administration of CD/LD via nasogastric tube every two hours during the surgery.g. and large amount of fluids required. However.   Patient undergoes short surgery and is able to take oral medication immediately after the procedure (e. with placement of a duodenostomy for postoperative administration of CD/LD. dysphagia. Patient undergoes more lengthy surgery and will be able to take enteric medications perioperatively (e..g.27 Gálvez-Jiménez et al discuss the limitations of intravenous levodopa. bowel resection). and suggested the use of prokinetics to prevent ileus and maximize drug absorption. They suggested that the dose of medication required to control symptoms should be minimized before surgery to avoid withdrawal symptoms. which is a potent D1/D2 dopamine agonist in conjunction with rectal domeperidone.

cannot be stopped suddenly. Certain diagnostic tests (MRI) and treatment procedures (diathermy) are contraindicated.e.000 patients around the world who have DBS for various conditions. they do not provide uniform treatment guidelines regarding specific medication management.28 Various anesthesiologists agree with administering anti-PD medications immediately. There are more than 60. If there is any concern of the DBS system malfunctioning (i. fracture of the hardware during a fall). mostly for PD. The main limitation to this approach is that domeperidone is not available in the U..29. The following measures are based on available data and are extensions of routine perioperative management.S. It is important to recognize that stimulation. to counteract the peripheral dopaminergic side effects. Therefore.32. there is no evidence to . by a trained technician usually available through 24/7 technical support services provided by the manufacturer. and if done inappropriately. can result in permanent brain damage. preoperatively. This can be done with the patient’s handheld device or.30 Deep-brain-stimulation (DBS) management: DBS is an effective treatment for advanced PD.28 Intravenous antihistamines and anticholinergics are readily available. However.31. it is increasingly likely that hospitalists will encounter hospitalized patients with advanced PD who are treated both pharmacologically and with DBS. and urinary retention).33 During surgeries requiring blood-vessel cauterization. Summary of recommendations: There are no clear treatment guidelines regarding the optimal perioperative management of PD patients. delay in gastrointestinal recovery. just like PD medications.g.antagonist with poor blood-brain-barrier penetration. However. they show limited efficacy in halting Parkinsonian symptoms and carry multiple side effects (e. however.. the neurologist or neurosurgeon managing the DBS should be contacted immediately. and restarting medications as soon as possible postoperatively. DBS should be temporarily turned off. preferably. confusion.

risperidone.S. as these medications can worsen Parkinsonian symptoms. market and might be helpful for this purpose. the use of orally disintegrated formulation CD/LD (parcopa) is helpful. resume outpatient medication doses and timing of administration as soon as possible postoperatively. precise medication regimen with doses and timing of intake. feeding should be started slowly and preferably at night when the body’s dopamine requirements are lower. carefully observing for potential cognitive and behavioral side effects. The major goal of medication management in the perioperative period is to continue administration of dopamine replacement therapy as close to the outpatient regimen as possible. For longer. and . Ensure medications are administered immediately prior to surgery. effects of medication withdrawal or missed doses. o Titrate down dose of anti-Parkinsonian medications to lowest possible dose prior to surgery if prolonged NPO status is anticipated. might result in sudden changes in medication absorption and potential worsening of PD symptoms. haloperidol.   Depending on symptoms mentioned in the history. consider placement of nasogastric tube for medication delivery during procedure and immediately postoperatively. o o Consider use of promotility agents. nonenteric surgeries. o o o If the major limitation of oral medication intake is dysphagia. metaclopramide. consider further testing for dysphagia (preoperative swallow evaluation) and dyspnea (preoperative pulmonary function tests). If apomorphine or intravenous LD are not available. or promethazine. when co-administered with levodopa. For longer enteric surgeries in which patient must be on bowel rest. recommend consultation with neurologist specialized in movement disorders to guide use of intravenous or subcutaneous agents. For short. prochlorperazine. nonenteric procedures. Transdermal delivery systems of the dopamine agonist rotigotine are in the process of being approved in the U. and comorbid conditions. o Avoid such dopamine antagonists as droperidol. o o Initiation of tube feeding. consider trial of intravenous anticholinergics or antihistamines. type of surgery planned.demonstrate their efficacy in decreasing complication rates among patients with PD:  A thorough preoperative history and physical examination should include Parkinsonian signs and symptoms.

VTE prophylaxis. rasagiline) before surgery. fall precautions. physical therapy. She was immediately given a dose of her CD/LD. and can be lifethreatening. postural drainage. be aware of multiple potential interactions with various medications that are commonly used in perioperative period. Consultation with a speech therapist would have ensured that the patient was educated regarding aspiration precautions. A postoperative consultation was placed for speech therapy. institute aggressive bowel regimen. and Genitourinary considerations: early urinary catheter removal. Motor considerations: early PT/OT.   Cardiovascular considerations: monitor orthostatic vital signs. Pulmonary considerations: institute aggressive incentive spirometry. vigilance in monitoring for urinary tract infection. She was given low-molecular-weight heparin for VTE prophylaxis and asked to use incentive spirometry. electrolytes. and avoid narcotics to prevent precipitating or exacerbating ileus. If the procedure had not been emergent. Back to the Case The patient underwent repair of her fracture. A urinalysis was consistent with possible infection. at which time she had a slight tremor and mild rigidity. and occupational therapy. The patient had no significant flare of her Parkinsonian symptoms and did not exhibit any evidence of PHS. given her dysphagia. including anesthesia agents and certain analgesics. fall precautions to avoid syncopal falls. and her evening doses of amantadine and ropinirole were resumed. specifically meperidine. maximize fluids. in addition to antibiotics for cystitis. early referral to inpatient rehabilitation. On postoperative day one. and recovered from general anesthesia without incident.34     Psychiatric considerations: delirium precautions. She was evaluated in the postanesthesia care unit. She was discharged home on her previous medication regimen. she complained of urinary frequency.o If patient was on MAO-B inhibitors (selegiline. and breathing exercises. These interactions include serotonin syndrome. Although this patient did not have difficulty with extubation or experience postoperative . the patient might have benefited from a preoperative swallow evaluation. Gastrointestinal considerations: aspiration precautions and prompt speech therapy to evaluate for aspiration and to teach appropriate swallow techniques (chin tuck). was extubated. management of respiratory secretions.

Dr. However. abnormal preoperative pulmonary function tests might have prompted the anesthesiologists to consider alternative lowrisk techniques (e. Dr. Patel is a medical resident at the University of Colorado Denver. Bottom Line Perioperative management of patients with Parkinson’s disease requires knowledge of the multisystem disease characteristics that raise perioperative risk and the effects of the medications used to treat PD. Dr. Stickrath is a hospitalist at the Denver VA Medical Center and instructor of medicine at the University of Colorado Denver.g.. TH Dr. a local nerve block). vigilance in detecting possible complications and instituting attentive perioperative care can aid a hospitalist consultant in improving overall care for these patients. Anderson is a hospitalist at the Denver VA Medical Center and assistant professor of medicine at the University of Colorado Denver.respiratory failure. . To date. no clear treatment guidelines exist for the optimal perioperative management of PD patients. Klepitskaya is a neurologist and assistant professor of neurology at the University of Colorado Denver.