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Parkinsonism and Anesthesia

Parkinsonism and Anesthesia. R2 Guo Shu-lin 2002.12.5. Two Challenge to Anesthetist. Manage elderly patients lesser pulmonary reserve poorer cardiovascular function Acute disturbances of motor control during or after anesthesia rigid chest wall motion poor cooperation to region anesthesia.

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Parkinsonism and Anesthesia

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  1. Parkinsonism and Anesthesia R2 Guo Shu-lin 2002.12.5 Parkinsonism and Anesthesia

  2. Two Challenge to Anesthetist • Manage elderly patients • lesser pulmonary reserve • poorer cardiovascular function • Acute disturbances of motor control during or after anesthesia • rigid chest wall motion • poor cooperation to region anesthesia Parkinsonism and Anesthesia

  3. Pathophysiology • Loss of pigmented cells in the substantia nigra. • A deficiency of dopamine leads to a dopamine/ acetylcholine imbalance • Sub-clinical phase:decreased pigmented cells can compensate the effect of loss neurons Parkinsonism and Anesthesia

  4. Clinical Presentation • Hypokinesia:difficulty in initiating and slowness in executing movement • Rigidity:throughout the whole range of movement of a joint • Tremor:most pronounced at rest and a frequency of 4-8 Hz Parkinsonism and Anesthesia

  5. Parkinsonism and Anesthesia

  6. Current Treatment • Dopamine precursor:Levodopa (L-dopa) • Peripheral decarboxylase inhibitor:Carbidopa • Anti-cholinergic drug:benztropine • Mono-amine oxidase inhibitor-B (MAOI-B):Selegiline • Dopamine agonist:Bromocriptine Parkinsonism and Anesthesia

  7. Parkinsonism and Anesthesia

  8. Anesthetic Considerations • Pre-operative assessments • Anti-parkinsonism drugs using principles • Anesthetic decisions • Peri-operative management • Post-operative management Parkinsonism and Anesthesia

  9. Parkinsonism and Anesthesia

  10. Drug using principles • Recommend that L-dopa uses just 20 min po before operation begins • Recheck the last time of taking medicine • MAOI drug should be hold to prevent hypertension crisis, but MAOI-B can use before operation • Continuation of therapy perioperatively to avoid laryngospasm, aspiration pneumonia, hallucinations and violent tremors Parkinsonism and Anesthesia

  11. Anesthetic Decision • Discussion with surgeon about the length of time and the strength of anesthesia • L-dopa half-life is short about 1-3 hrs • Only L-dopa (no carbidopa) iv form is available Parkinsonism and Anesthesia

  12. Anesthetic Decision • Regional anesthesia • Subjective feeling of Parkinsonism attack • Drug given by po • Difficultly apply on the patients with violent tremor or severe rigidty Parkinsonism and Anesthesia

  13. Anesthetic Decision • General anesthesia • Provide a good surgical condition • Inhalation agent may affect dopamine activity • Muscle relaxants mask the myopotential • Difficult maintain anti-parkinsonism drugs • Severe nausea and vomiting in these patients after general anesthesia Parkinsonism and Anesthesia

  14. Peri-operative management • Opioid-induced muscle rigidity • Patients with Parkinsonism with three fold more incidence than normal geriatric population • Opioid can inhibit the release of dopamine in CNS • Infusion of fentanyl 300μg/min or total dose of 50 μg/kg resulted in difficulty with ventilation Parkinsonism and Anesthesia

  15. Peri-operative management • Inhalational agents • Increase extracellular dopamine concentration in brain • Block the dopamine transport by synaptosomes • Decreased dopaminergic transmission, inhibit the dopamine reuptake, and then accumulation of extracellular dopamine Parkinsonism and Anesthesia

  16. Peri-operative management • Other drugs known to exacerbate extrapyramidal stimulation • Dopaminergic antagonist: droperiadol • Antihistamine drugs: phenothiazine • Mixed dopamine blocker: metoclopramide • Sympathetic blocker: reserpine Parkinsonism and Anesthesia

  17. Post-operative management • If the patient is on “off ”stage, chest stiffness, laryngospasm and facial violent tremor will result in delaying the extubation • GI dysfunction is common esp. lapa and presents with dysphagia and sialorrhea. That will increase the risk of aspiration pneumonia • More likely to develop confusion and hallucianation Parkinsonism and Anesthesia

  18. Any Question ? Parkinsonism and Anesthesia

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