Parkinson's Disease 

 

 

Background

 

  • Central dopamine deficiency leading to rigidity, tremors & late dementia

 

 

Considerations 

 

  • Elderly with associated co-morbidities

  • Potential difficult airway (temporomandibular joint & cervical spine rigidity)

  • ↑ risk of peri-operative complications:

    • Airway: airway obstruction

    • Pulmonary: aspiration (secondary to bulbar dysfunction, esophageal dysfunction & gastroparesis) & restrictive lung disease (secondary to chest wall rigidity)

    • Cardiac: autonomic instability

    • Neurologic: worsening of neurologic symptoms & risk of postoperative delerium

  • Management of medications (see paragraph below for further details):

    • Ensure perioperative use of anti-parkinson's medications

    • Avoid medications which exacerbate/precipitate parkinsonism

    • Avoid meperidine in patients on selegiline

 

 

Goals 

 

  • Safe airway management:

    • Aspiration prophylaxis

    • Modified RSI

  • Avoid clinical exacerbation:

    • Continue anti-parkinson medications perioperatively

    • Avoid anti-dopaminergic medications: droperidol, metoclopramide, methotrimeprazine

  • Maximize respiratory function

  • Prevent delirium

 

 

Conflicts 

 

  • Aspiration risk vs autonomic instability/difficult airway

  • Regional anesthesia with tremulous patient vs risks of GA

 

 

Medications & Parkinson's 

 

  • Avoid drugs that precipitate or exacerbate Parkinson's disease (ie. dopamine antagonists):

    • Metoclopramide

    • Butyrophenones (droperidol, haloperidol)

    • Phenothiazines (chlorpromazine, methotrimeprazine)

  • Selegiline (type B MAO inhibitor):

    • Used to prevent central breakdown of dopamine to improve parkinson's symptoms

    • Usually safe as is not a type A MAO inhibitor

    • Avoid meperidine in patients taking selegiline (case reports of hyperthermia, agitation, muscle rigidity & seizures)  

  • Opioids:

    • May have ↑ muscle rigidity with fentanyl & morphine

    • Dystonic reactions associated with use of alfentanil & fentanyl

 All rights reserved 2017 © anesthesiaconsiderations.com

 Feedback & inquiries: