During surgeries requiring blood-vessel cauterization, DBS should be temporarily turned off. This can be done with the patient’s handheld device or, preferably, by a trained technician usually available through 24/7 technical support services provided by the manufacturer.
Summary of recommendations: There are no clear treatment guidelines regarding the optimal perioperative management of PD patients. The following measures are based on available data and are extensions of routine perioperative management; however, there is no evidence to demonstrate their efficacy in decreasing complication rates among patients with PD:
- A thorough preoperative history and physical examination should include Parkinsonian signs and symptoms, precise medication regimen with doses and timing of intake, effects of medication withdrawal or missed doses, type of surgery planned, and comorbid conditions;
- Depending on symptoms mentioned in the history, consider further testing for dysphagia (preoperative swallow evaluation) and dyspnea (preoperative pulmonary function tests);
- The major goal of medication management in the perioperative period is to continue administration of dopamine replacement therapy as close to the outpatient regimen as possible.
- Titrate down dose of anti-Parkinsonian medications to lowest possible dose prior to surgery if prolonged NPO status is anticipated;
- Ensure medications are administered immediately prior to surgery;
- For short, nonenteric procedures, resume outpatient medication doses and timing of administration as soon as possible postoperatively. For longer, nonenteric surgeries, consider placement of nasogastric tube for medication delivery during procedure and immediately postoperatively;
- If the major limitation of oral medication intake is dysphagia, the use of orally disintegrated formulation CD/LD (parcopa) is helpful;
- For longer enteric surgeries in which patient must be on bowel rest, recommend consultation with neurologist specialized in movement disorders to guide use of intravenous or subcutaneous agents. Transdermal delivery systems of the dopamine agonist rotigotine are in the process of being approved in the U.S. market and might be helpful for this purpose;
- Initiation of tube feeding, when co-administered with levodopa, might result in sudden changes in medication absorption and potential worsening of PD symptoms; feeding should be started slowly and preferably at night when the body’s dopamine requirements are lower;
- Consider use of promotility agents;
- If apomorphine or intravenous LD are not available, consider trial of intravenous anticholinergics or antihistamines, carefully observing for potential cognitive and behavioral side effects;
- Avoid such dopamine antagonists as droperidol, haloperidol, risperidone, metaclopramide, prochlorperazine, or promethazine, as these medications can worsen Parkinsonian symptoms; and
- If patient was on MAO-B inhibitors (selegiline, rasagiline) before surgery, be aware of multiple potential interactions with various medications that are commonly used in perioperative period, including anesthesia agents and certain analgesics, specifically meperidine. These interactions include serotonin syndrome, and can be life-threatening.34
- Psychiatric considerations: delirium precautions;
- Motor considerations: early PT/OT, early referral to inpatient rehabilitation; fall precautions;
- Pulmonary considerations: institute aggressive incentive spirometry, postural drainage, management of respiratory secretions, and breathing exercises; VTE prophylaxis;
- Gastrointestinal considerations: aspiration precautions and prompt speech therapy to evaluate for aspiration and to teach appropriate swallow techniques (chin tuck); institute aggressive bowel regimen; maximize fluids, electrolytes, and avoid narcotics to prevent precipitating or exacerbating ileus;
- Cardiovascular considerations: monitor orthostatic vital signs; fall precautions to avoid syncopal falls; and
- Genitourinary considerations: early urinary catheter removal; vigilance in monitoring for urinary tract infection.
Back to the Case
The patient underwent repair of her fracture, was extubated, and recovered from general anesthesia without incident. She was evaluated in the postanesthesia care unit, at which time she had a slight tremor and mild rigidity. She was immediately given a dose of her CD/LD, and her evening doses of amantadine and ropinirole were resumed. The patient had no significant flare of her Parkinsonian symptoms and did not exhibit any evidence of PHS.
A postoperative consultation was placed for speech therapy, physical therapy, and occupational therapy. She was given low-molecular-weight heparin for VTE prophylaxis and asked to use incentive spirometry. On postoperative day one, she complained of urinary frequency. A urinalysis was consistent with possible infection. She was discharged home on her previous medication regimen, in addition to antibiotics for cystitis.