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Case Report

Successful use of regional anesthesia in an elderly with

Parkinson’s disease
Ramyavel Thangavelu
Department of Anaesthesiology, Pondicherry Institute of Medical Sciences, Puducherry, India

Abstract Parkinson’s disease (PD) is a relatively common neurological disorder which an anesthesiologist often
encounters, especially with an increasing elderly surgical population. PD is associated with certain
physiological aberrancies in the cardiovascular, respiratory, autonomic, and neurological systems that can
have profound anesthetic implications. Drugs used in anesthesia may also interact with antiparkinsonian
medications. There is controversy about the optimal anesthetic management of patients with PD. However,
both general and regional anesthesia have been successfully used and described in these patients. We
describe a case of a 65‑year‑old male with recently diagnosed PD posted for rectopexy. The patient
underwent regional anesthesia successfully, and the perioperative period was uneventful. Hence, anesthetic
management of patients with PD involves comprehensive evaluation, careful consideration, and meticulous
planning to prevent and manage the complications that arise perioperatively.

Keywords: Autonomic system, Parkinson’s disease, postural hypotension, saddle anesthesia

Address for correspondence: Dr. Ramyavel Thangavelu, Department of Anaesthesiology, Pondicherry Institute of Medical Sciences, Kalathumettupathai,
Ganapathichettikulam, Village 20, Kalapet, Puducherry, India.
E‑mail: ramyavel1988@gmail.com
Received: 20.03.2019, Accepted: 18.04.2019

INTRODUCTION CASE REPORT

Parkinson’s disease  (PD) is among the most disabling
neurological diseases caused by dopamine–acetylcholine
imbalance in the nigrostriatal pathway.[1]
The involvement of various systems in PD, namely
respiratory, cardiovascular, autonomic, and neurological
systems along with the interaction of common anesthetics
with the drug therapy of the patient presents an anesthetic
challenge and directly influences the perioperative
morbidity and mortality.[1,2] In this case report, we present
the successful anesthetic management of a patient with
PD posted for rectopexy.
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A sixty year old male with rectal prolapse was posted for
rectopexy. He had a history of tremors of the upper limbs
and body from the past 5 years. On further eliciting history,
he had features of increased sweating, increased salivation,
alternating diarrhea, and constipation with giddiness
on standing upright. He also complained of hoarseness
of voice and cough with expectoration. There was no
history of any previous surgeries. On general physical
examination, he was noted to have resting tremors of the
upper limbs and the body along with typical short stepping
gait. The patient had a stooping posture with masklike
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DOI: How to cite this article: Thangavelu R. Successful use of regional

10.4103/jcrsm.jcrsm_10_19 anesthesia in an elderly with Parkinson's disease. J Curr Res Sci Med
2019;5:68-70.

68 © 2019 Journal of Current Research in Scientific Medicine | Published by Wolters Kluwer ‑ Medknow

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Thangavelu: Successful use of regional anaesthesia in Parkinson's disease
facies. Vitals showed a pulse rate of 98/min with a blood
pressure (BP) of 120/80 mmHg in the right upper limb
in lying position. BP rechecked after making the patient
stand for 3 min showed a BP of 100/60 mmHg suggesting
a probable postural hypotension. Neurology consultation
was sought, and he was diagnosed with PD and started on
tablet amantadine 200 mg hs. In view of voice hoarseness
and persistent cough, a diagnosis of laryngopharyngeal
reflux probably due to the laryngeal muscles’ involvement
in PD was entertained in consultation with the ENT team.
Furthermore, a nodular mass was detected on the chest
X‑ray in the left lung fields extending from the third to
fifth rib. Contrast‑enhanced computed tomography chest
revealed a calcified pericardial hydatid cyst. However, since
the patient was asymptomatic, there was no intervention
advised from the cardiothoracic team.
It was decided to go ahead with subarachnoid saddle
block for the rectopexy procedure. The usual night dose
of amantadine 200 mg was administered. Tablet ranitidine
150  mg and lorazepam 2 mg were given orally on the
morning of surgery. Metoclopramide was withheld due to
risk of drug‑induced parkinsonism. After shifting to the
operation theatre, American Society of Anesthesiologists
standard monitors were attached, and baseline parameters
were recorded. A heart rate (HR) of 90 beats/min with
a BP of 126/78 mmHg were recorded with a room air
saturation of 95%. After preloading the patient, spinal
anesthesia with 1.5 ml of 0.5% bupivacaine and 25 mcg of
fentanyl (a total volume of 2 ml) was administered to the
patient in sitting position. The patient was left in the sitting
position for 10 min to achieve a saddle block. However,
within 3 min of administration of spinal anesthesia, there
was a fall in BP to 86/57 with a HR of 86/min. Injection
ephedrine six mg was given intravenously, and the patient
was made to lie supine to facilitate venous return. Soon,
BP improved to 110/58 mmHg. Spinal level was checked,
and once the level was fixed at T 10, lithotomy position
was given and surgery was initiated. There was no further
disturbance in hemodynamics throughout the surgery.
The postoperative period was uneventful, and on the same
night, oral amantadine was resumed.
DISCUSSION
Apart from a routine history and physical examination,
patients with PD often require additional assessment.
Respiratory abnormalities along with cardiovascular and
neuropsychiatric involvement have been described in PD
making administration of anesthesia to these patients
challenging.[3]
Journal of Current Research in Scientific Medicine | Volume 5 | Issue 1 | January-June 2019 69
An upper airway dysfunction along with intrinsic laryngeal
muscle involvement leads to retained secretions, aspiration,
atelectasis, and respiratory infections. These factors
predispose patients to anesthesia complications including
aspiration pneumonia, postextubation laryngospasm,
and respiratory failure.[4] Furthermore, an exaggerated
hypotensive response to induction of anesthesia and
postoperative emergence reactions associated with tremors
and rigidity have been found in PD patients undergoing
anesthesia.[4]
Here, we had a patient with PD who was started on
medication just 2 days before surgery and had features
of autonomic dysfunction, thus placing the patient at
risk of exaggerated, hemodynamic disturbance with
regional anesthesia.[5] Administration of drugs during
spinal anesthesia as well as monitoring noninvasive BP
and electrocardiography was difficult due to the constant
tremors. Choosing general anesthesia (GA) on the other
hand was difficult due to poor preoperative respiratory
status of the patient. The patient had a room air saturation
of 93% with increased salivation and persistent cough,
signifying probable silent aspirations. Administering GA
would place the patient at increased risk of perioperative
aspiration pneumonia. Considering the risks and benefits
of spinal and GA, we proceeded with low‑dose spinal
anesthesia. Postspinal, there was a fall in BP which was
successfully treated with a small dose of sympathomimetic.
Regional anesthesia has been reported to have obvious
advantages in the form of better communication of
subjective feelings accompanying PD attacks. [2] The
interaction of general anaesthetics with anti parkinsonian
medications, the muscle rigidity exaggerating effects of
some opioids, arrythmogenic effect of inhalational agents
and postoperative nausea vomiting due to polypharmacy
are all avoided with the use of regional anaesthesia.[6] These
patients have better postoperative pain relief with less
incidence of perioperative chest infections when compared
with GA.[4] Successful management of our case matches
with few other case reports in the literature.
One of the case reports described a 77‑year‑old patient
posted for tibia fracture surgery. She successfully underwent
spinal anesthesia with levodopa continued till the morning
of surgery. Spinal anesthesia was preferred to avoid the risk
of perioperative aspiration pneumonia associated with GA.[2]
A significant number of cases under GA have also been
described. GA was administered to these patients with
adequate care taken to prevent PD exacerbations as well
as aspiration pneumonia perioperatively.[6,7]
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Thangavelu: Successful use of regional anaesthesia in Parkinson's disease

There are not adequate randomized control trials that REFERENCES

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basis would go a long way in achieving an uneventful
perioperative period and a smooth recovery in these
patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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