Parkinson's Disease
Background
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Central dopamine deficiency leading to rigidity, tremors & late dementia
Considerations
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Elderly with associated co-morbidities
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Potential difficult airway (temporomandibular joint & cervical spine rigidity)
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↑ risk of peri-operative complications:
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Airway: airway obstruction
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Pulmonary: aspiration (secondary to bulbar dysfunction, esophageal dysfunction & gastroparesis) & restrictive lung disease (secondary to chest wall rigidity)
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Cardiac: autonomic instability
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Neurologic: worsening of neurologic symptoms & risk of postoperative delerium
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Management of medications (see paragraph below for further details):
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Ensure perioperative use of anti-parkinson's medications
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Avoid medications which exacerbate/precipitate parkinsonism
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Avoid meperidine in patients on selegiline
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Goals
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Safe airway management:
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Aspiration prophylaxis
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Modified RSI
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Avoid clinical exacerbation:
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Continue anti-parkinson medications perioperatively
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Avoid anti-dopaminergic medications: droperidol, metoclopramide, methotrimeprazine
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Maximize respiratory function
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Prevent delirium
Conflicts
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Aspiration risk vs autonomic instability/difficult airway
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Regional anesthesia with tremulous patient vs risks of GA
Medications & Parkinson's
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Avoid drugs that precipitate or exacerbate Parkinson's disease (ie. dopamine antagonists):
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Metoclopramide
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Butyrophenones (droperidol, haloperidol)
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Phenothiazines (chlorpromazine, methotrimeprazine)
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Selegiline (type B MAO inhibitor):
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Used to prevent central breakdown of dopamine to improve parkinson's symptoms
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Usually safe as is not a type A MAO inhibitor
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Avoid meperidine in patients taking selegiline (case reports of hyperthermia, agitation, muscle rigidity & seizures)
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Opioids:
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May have ↑ muscle rigidity with fentanyl & morphine
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Dystonic reactions associated with use of alfentanil & fentanyl
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