Parkinson's Disease

Question 1

A 68-year-old male patient is listed for an elective anterior resection. He was diagnosed with Parkinson’s disease 2 years ago and is an ex-smoker. You are asked to review him in the preoperative assessment clinic.
What is Parkinsonism?

Answer 1

• Triad of symptoms: resting tremor, rigidity and bradykinesia.
• There are numerous causes of Parkinsonism that lead to an imbalance between dopamine and acetylcholine levels in the basal ganglia, including:
• Parkinson’s disease.
• Infective causes.
• Trauma.
• Drugs.

Question 2

What are the perioperative risks in patients with Parkinson’s disease?

Answer 2

Patients with Parkinson’s disease have:

• An overall increase in morbidity and mortality.
• A higher likelihood of falls.
• An increased incidence of a difficult airway and aspiration pneumonitis.
• A higher risk of developing postoperative pulmonary complications.
• An increased likelihood of venous thromboembolism due to peri-operative immobility.
• An increased length of stay in intensive care and hospital, with its associated complications.
• More chance of developing postoperative delirium and cognitive decline.
• Potential for adverse effects of missed doses of anti-Parkinson’s medications.

Question 3

What are the key concerns when assessing this patient preoperatively?

Answer 3

1) General
2) Systemic symptoms of PD
3) Medication

Question 4

What are the key concerns when assessing this patient preoperatively?

General?

Answer 4

• High-risk patient undergoing major abdominal surgery. The patient should be discussed with the MDT including the surgical team, a consultant anaesthetist and a neurologist, as well as the ICU team for consideration of postoperative level 2/3 care.
• Given that the patient is being assessed in the preoperative clinic, there is adequate time available for optimisation of the patient prior to the procedure.
• Carry out a thorough anaesthetic assessment including the patient’s comorbidities, regular medication, a social history and the airway.

Question 5

What are the key concerns when assessing this patient preoperatively?

Systemic symptoms of Parkinson’s disease?

Answer 5

• The patient may demonstrate signs of a difficult airway due to a fixed flexion neck deformity, rigidity and poor upper airway muscle function causing increased secretions and a higher risk of aspiration. In addition, the patient may have delayed gastric emptying secondary to the side effects of anti-Parkinsonian agents and dysphagia.
• A restrictive pulmonary deficit and obstructive sleep apnoea are common in patients with Parkinson’s disease, making ventilation challenging. LFT’s and a CXR may be indicated.
• Postural hypotension and arrhythmias are common in patients with severe Parkinson’s disease and may lead to intra-operative haemodynamic instability, particularly on induction of anaesthesia.

Question 6

What are the key concerns when assessing this patient preoperatively?

Medication?

Answer 6

• The dosage and timing of Parkinson’s medication should be noted and discussed with a disease specialist.
• The medication may interact with anaesthetic and analgesic agents with potential for worsening of symptoms.
• Ensure a return to oral intake as soon as possible through adequate hydration, analgesia and enhanced recovery where possible.
• Consider a nasogastric tube for medication postoperatively after discussing with the surgeon and neurologist.

Question 7

What is your plan for analgesia in this patient?

Answer 7

• Continue medication that the patient may be on for chronic pain, or convert to an intravenous dose if the patient is unable to take medication orally.
• Use regional nerve blockade or local anaesthetic infiltration where possible to minimise the use of opioid-based drugs.
• Assess the patient’s dexterity (and therefore their ability to use a PCA) prior to prescribing analgesic regimens.
• Avoid pethidine and high-dose fentanyl, which may lead to increased rigidity during the peri-operative period.

Question 8

What is your plan for anti-emesis in this patient?

Answer 8

• Anti-emetic medications that act as dopamine receptor antagonists should be avoided as they may lead to extra-pyramidal side efects or intensify pre-existing Parkinsonian symptoms.
• Drugs that can be used safely include domperidone (a dopamine receptor antagonist that does not cross the blood brain barrier), ondansetron and cyclizine.
• However, other methods of minimising nausea and vomiting should be favoured including hydration, reassurance, avoidance of opiates where possible and effective analgesia.