Parkinson and Anesthesia
Overview:
- Degenerative disease of unknown origin
- Increasing age is the most important
risk factor loss of dopaminergic fibers in
basal ganglia --> depletion of regional
dopamine
- Dopamine --> inhibit neurons that
control EMS ==> Depletion of dopamine
results in diminished inhibition of these
neurons and unopposed stimulation by
acetylcholine
Classic triad:
Skeletal muscle tremor, rigidity, akinesia
Treatment:
Increase dopamine concentration in basal
ganglia
Decrease neuronal effects of
acetylcholine
Levodopa: the most effective treatment
SE: dyskinesias and psychiatric
disturbances, increased myocardial
contractility and HR (increased levels of
circulating dopamine converted from
levodopa). Orthostatic hypotension, GI SE
of levodopa therapy include nausea and
vomiting
Selegiline: type B monoamine oxidase
inhibitor (inhibiting the catabolism of
dopamine in CNS)
advantage over nonspecific MAOi
because it is not associated with
tyramine-related hypertensive crises
Surgery : implanted deep brain
stimulating device vs Pallidotomy
Management of Anesthesia:
IV access may prove challenging in an
extremity with a significant tremor
A variety of airway management devices
(e.g., fiberoptic, LMA) should be readily
available should airway compromise
become an issue intraoperatively (rigidity)
Choice of a muscle relaxant is not
influenced by presence of Parkinson's
Understanding of the treatment
1. Patients treated with Levodopa:
- Elimination t1/2 of Levodopa and the
dopamine it produces is brief, so
interruption of drug therapy for more
than 6 to 12 hours can result in an
abrupt loss of therapeutic effects + can
also lead to skeletal muscle rigidity
which can interfere with ventilation -->
levodopa must be continued
throughout the perioperative period
- Oral levodopa: 20 minutes before
induction, can be repeated intra-op and
post-op via OGT or NGT
- possibility of hypotension and cardiac
dysrhythmias must be considered, and
butyrophenones (e.g., droperidol,
haloperidol) must be available to
antagonize the effects of dopamine in
the basal ganglia
2. Opioids: Acute dystonic reactions
following alfentanil might indicate an
opioid induced decrease in central
dopaminergic transmission
3. Ketamine: controversial because of the
possible provocation of exaggerated
sympathetic responses
- It has been administered safely to
patients treated with levodopa
4. Patients undergoing deep brain
stimulator implantation may have been
told by surgeon to refrain from AM
dose of levodopa to facilitate the return
of tremors and enhance sensitivity in
detecting the efficacy of deep brain
stimulation during the procedure
- minimal sedation during lead
placement to prevent interference with
microelectrode recordings
- GABA: common neurotransmitter
normally found in basal ganglia -->
anesthetics with effects on GABA (eg
propofol, BZs) can alter the
characteristic microelectrode
recordings of specific nuclei and should
be avoided