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Email this article Filed under: Departments, Clinical, Key Clinical Question

How should Parkinsons disease be

managed perioperatively?From:The Hospitalist, June 2010

by Swati G. Patel, MD, Chad R. Stickrath, MD, Mel Anderson, MD, andOlga Klepitskaya, MD, University of Colorado DenverCase

A 67-year-old female with moderately advanced Parkinsons disease

(PD) had a mechanical fall in her home, which resulted in a humeral

fracture. The fall occurred in the morning before she was able to take her

medications and was related to her difficulty in initiating movements.

On her current regimen, her PD symptoms are controlled. She is able to

perform daily living activities independently and ambulates without

assistance. She also performs more complex tasks (e.g., cooking and

managing her finances). She has not exhibited any symptoms consistent

with dementia. She occasionally experiences dyspnea on exertion and

dysphagia, but she has not been evaluated for these complaints. She

takes carbidopa/levodopa (CD/LD) 25 mg/100 mg four times a day,

amantadine 100 mg twice daily, and ropinirole 3 mg three times a day.

She is scheduled for open reduction internal fixation of her fracture; the

orthopedic surgeon has requested a perioperative risk assessment and

recommendations concerning her medications. How should PD be

managed perioperatively?
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Overview

Advances in surgical and anesthetic techniques, in combination with an

aging population, have contributed to an increasing number of geriatric

patients undergoing surgery. As many as 50% of Americans older than

65 will undergo a surgical procedure; hospitalists will comanage many ofthese patients in the perioperative period.1

Although cardiopulmonary disorders receive a great deal of attention

with regard to perioperative risk assessment, other comorbid conditions

also contribute to perioperative risknamely, disorders specific to the
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elderly population. Parkinsons disease is one such condition that

deserves attention.

PD is a progressive, neurodegenerative condition associated with loss of

dopaminergic neurons and the presence of Lewy bodies within thesubstantia nigra and other areas of the brain and peripheral autonomic

nervous system.2 Cardinal clinical features include rigidity,

bradykinesia, and resting tremor. A supportive feature is a consistent

response to levodopa. Postural instability, cognitive impairment, and

autonomic dysfunction usually occur later in the disease.3,4

As the population ages, Parkinsons disease is becoming more prevalent,

affecting approximately 1% of individuals older than 60.5 These patients

pose a specific challenge to the hospitalist, not only because themultiorgan system manifestations of PD can raise surgical risk, but also

due to the direct effects of dopaminergic medications used to treat PD,

lack of a parenteral route for these medications in NPO patients, and the

risks associated with abrupt withdrawal of these medications.

Although surgical risk in PD patients has received intermittent attention

in surgical, anesthesia, and neurology literature, there is no broad

consensus statement or treatment guideline for the perioperative

approach.

Literature ReviewKEY POINTS

Hospitalists are often asked to comanage or consult on hospitalized patients with Parkinsons disease (PD) inthe perioperative setting.

The various organ-system manifestations and treatments place PD patients at increased risk of complicationsduring the perioperative period.

PD patients in the perioperative period are at risk for developing Parkinsonism-hyperpyrexia syndrome(PHS), which carries a substantial degree of morbidity and mortality if not prevented or treated in its early

stages.

By minimizing interruptions in the administration of PD medications, many of the perioperativecomplications related to PD can be prevented or diminished.


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PD patients who are undergoing long procedures, undergoing procedures involving the gastrointestinal tract,or are utilizing deep-brain-stimulation treatment typically require more complex perioperative care and

might benefit from neurological consultation.

Additional Reading

Pepper PV, Goldstein MK. Postoperative complications in Parkinsons disease. J Am Geriatr Soc.1999;47(8):967-972.

Glvez-Jimnez N, Lang AE. The perioperative management of Parkinsons disease revisited. Neurol Clin.2004;22(2):367-377.

Kalenka A, SchwarzA. Anaesthesia and Parkinsons disease: how to manage with new therapies? Curr OpinAnesthesiol. 2009;22(3):419-424.

Nicholson G, Pereira AC, Hall GM. Parkinsons disease and anesthesia. Br J Anaesthesia. 2002;89(6):904-916.

A retrospective cohort of 51 PD patients undergoing various types ofsurgery revealed that PD patients have a longer hospital stay than

matched cohorts.6 Pepper et al studied a cohort of 234 PD patients in the

Veterans Administration population who were undergoing a variety of

surgeries.7 They found that patients with PD had a longer acute hospital

stay and had higher in-hospital mortality.7 The multisystem

manifestations of PD might account for this global increase in

perioperative risk.

The following are reviews of organ-system manifestations of PD andtheir relevance to the perioperative period.

Motor: The motor symptoms of PD place patients at increased risk for

falls and might impair their ability to participate in rehabilitation.

Mueller et al demonstrated that there was a significantly increased risk

of postoperative falls and a higher need for inpatient rehabilitation due

to motor difficulties in the PD cohort.6

Pulmonary: PD patients have increased risk of abnormal pulmonary

function secondary to rigidity and akinesia. Increased airway resistanceand decreased lung elastic recoil lead to obstructive lung disease.8,9

Rigidity of voluntary chest wall and upper airway muscles leads to a

restrictive lung disease pattern.8,10 Furthermore, respiratory dyskinesia

is a common side effect of levodopa, which can result in restrictive and

dyskinetic ventilation.11 As a consequence of disordered respiratory


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mechanics (especially in combination with disordered swallow

mechanics), PD patients are at increased risk of lower respiratory

infections. In fact, pneumonia remains the leading cause of mortality

among PD patients.11

Not surprisingly, several cohorts have suggested that PD patientsundergoing surgical procedures are at higher risk for atelectasis,

pneumonia, and postoperative respiratory failure.7,12 Postoperative VTE

rates are not statistically different between PD patients and matched

cohorts.

Gastrointestinal: Abnor-malities in muscles of the mouth, pharynx,

and esophagus account for the dysphagia commonly noted in PD.13

Barium swallow tests are abnormal in 80% or more of PD patients.14

Dysphagia can lead to aspiration, as well as inadequate oral intake,resulting in pneumonia and malnutrition, respectively.15 Dysfunction of

the myenteric plexus (evidenced by Lewy Body deposition) accounts for

gastrointestinal dysmotility manifested as gastroparesis, ileus, and slow

colonic transit, which results in constipation.16

PD patients in the postoperative period are at risk for swallowing

difficulties, which increases the risk of aspiration and might delay

initiation of oral medications. Gastroparesis threatens appropriate

delivery of oral medications for adequate absorption. In addition,postoperative ileus and constipation can pose challenges.

Cardiovascular: Such cardiac sympathetic abnormalities as orthostatic

hypotension, postprandial or exercise-induced hypotension, impaired

heart rate variability, and dysrhythmias are common in PD.17 Pepper et

al found a trend toward increased risk of hypotension and acute

myocardial infarction (MI) in PD patients undergoing surgery.7

Genitourinary: Urinary complaints (e.g., nocturia, frequency, urgency,

and urge incontinence) are common in PD patients.18 These clinicalcomplaints correspond to involuntary detrusor contractions (detrusor

hyperreflexia).19 Pepper et al found an increased risk of postoperative

urinary tract infection in PD patients.7


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The four primary symptoms of Parkinsons disease are trembling in hands, arms, legs, jaw, andface; rigidity, or stiffness of the limbs and trunk; bradykinesia, or slowness of movement; andpostural instability, or impaired balance and coordination.

Cognitive: A recognized feature of advanced PD is cognitive

impairment. Studies estimate the prevalence of dementia in cohorts of

PD patients is from 28% to 44%. PD with dementia has been associated

with shortened survival, impaired quality of life, and increased caregiver

distress.20 Pepper et al noted a trend toward increased incidence of

postoperative delirium in their cohort of 234 PD patients undergoing

surgery.7

Medication: Management of anti-Parkinsonian medications in the

perioperative period poses unique challenges. These medicationsprodopaminergic effects can lead to hemodynamic compromise and are

potentially arrhythmogenic. At the same time, abrupt withdrawal of

these medications can lead to a potentially lethal condition called

Parkinsonism-hyperpyrexia syndrome (PHS), which is clinically similar

to neuroleptic malignant syndrome.21 PHS is characterized by very high

fever, extreme muscle rigidity, autonomic instability, altered

consciousness, and multiple severe systemic complications (e.g., acute

renal failure, disseminated intravascular coagulation, autonomic failure,

aspiration pneumonia, and infections). PHS occurs in up to 4% of PD

patients; mortality is reported to be from 4% for treated to 20% for

untreated episodes.22-24

As many as 30% of patients who survive a PHS episode have worsening

of their PD symptoms and never return to their pre-PHS baseline. PHS

prevention in hospitalized patients by uninterrupted administration of


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PD medications should be the goal. Early recognition and aggressive

treatment is key to successful recovery.

Furthermore, even brief interruption of medications can lead to

decompensation of Parkinsonian symptoms, which not only delaysrecovery from surgery, but also increases the risk for multisystem

complications as discussed above.25 Traditional anti-Parkinsonian

medications can only be delivered orally, presenting significant

challenges for NPO patients, especially those undergoing enteric surgery

requiring bowel rest.

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Case reports describe various approaches to medication management in

the perioperative period, but no single consensus statement (or

treatment guideline) exists. The most common clinical scenarios are:
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Patient undergoes short surgery and is able to take oral medication immediately after the procedure (e.g.,orthopedic, eye);

Patient undergoes more lengthy surgery and will be able to take enteric medications perioperatively (e.g., longerorthopedic surgeries, genitourinary); and

Patient undergoes lengthy procedure in which they will be required to adhere to bowel rest (e.g., bowelresection).

Depending on the category, the approach to medication management

might differ.

Furuya et al describe a 70-year-old male with PD who had previously

experienced perioperative complications associated with his medication

management, including postoperative rigidity, dysphagia, and difficulty

maintaining respiratory secretions.26 These symptoms were reversed

with intravenous levodopa. However, the patient experiencedhypotension and premature ventricular contractions as side effects of

this therapy. This patient was scheduled to undergo hepatic lobectomy.

Given his previous complications, Furuya et al provided enteral

administration of CD/LD via nasogastric tube every two hours during the

surgery, with placement of a duodenostomy for postoperative

administration of CD/LD. The patient maintained hemodynamic

stability throughout the perioperative period and emerged from

anesthesia smoothly with no muscle rigidity or postoperativecomplications.26

Fujii et al described three cases of PD patients undergoing

gastrointestinal surgery. They suggested that the dose of medication

required to control symptoms should be minimized before surgery to

avoid withdrawal symptoms. They also described the use of intravenous

levodopa immediately, postoperatively, while the patient was unable to

tolerate enteric medications, and suggested the use of prokinetics to

prevent ileus and maximize drug absorption.27

Glvez-Jimnez et al discuss the limitations of intravenous levodopa,

including hemodynamic compromise, need for escalating doses, frequent

adjustments to maintain effect, and large amount of fluids required.

They propose the use of subcutaneous apomorphine, which is a potent

D1/D2 dopamine agonist in conjunction with rectal domeperidone, a D2


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antagonist with poor blood-brain-barrier penetration, to counteract the

peripheral dopaminergic side effects. The main limitation to this

approach is that domeperidone is not available in the U.S.28

Intravenous antihistamines and anticholinergics are readily available.However, they show limited efficacy in halting Parkinsonian symptoms

and carry multiple side effects (e.g., confusion, delay in gastrointestinal

recovery, and urinary retention).28

Various anesthesiologists agree with administering anti-PD medications

immediately, preoperatively, and restarting medications as soon as

possible postoperatively. However, they do not provide uniform

treatment guidelines regarding specific medication management.29,30

Deep-brain-stimulation (DBS) management: DBS is an effective

treatment for advanced PD. There are more than 60,000 patients around

the world who have DBS for various conditions, mostly for PD.

Therefore, it is increasingly likely that hospitalists will encounter

hospitalized patients with advanced PD who are treated both

pharmacologically and with DBS. It is important to recognize that

stimulation, just like PD medications, cannot be stopped suddenly. If

there is any concern of the DBS system malfunctioning (i.e., fracture of

the hardware during a fall), the neurologist or neurosurgeon managingthe DBS should be contacted immediately. Certain diagnostic tests (MRI)

and treatment procedures (diathermy) are contraindicated, and if done

inappropriately, can result in permanent brain damage.31,32,33

During surgeries requiring blood-vessel cauterization, DBS should be

temporarily turned off. This can be done with the patients 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


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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 swallowevaluation) and dyspnea (preoperative pulmonary function tests);

The major goal of medication management in the perioperative period is to continue administration ofdopamine replacement therapy as close to the outpatient regimen as possible.

o Titrate down dose of anti-Parkinsonian medications to lowest possible dose prior tosurgery if prolonged NPO status is anticipated;

o Ensure medications are administered immediately prior to surgery;o 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;

o If the major limitation of oral medication intake is dysphagia, the use of orallydisintegrated formulation CD/LD (parcopa) is helpful;

o For longer enteric surgeries in which patient must be on bowel rest, recommendconsultation with neurologist specialized in movement disorders to guide use of

intravenous or subcutaneous agents. Transdermal delivery systems of the dopamineagonist rotigotine are in the process of being approved in the U.S. market and might

be helpful for this purpose;

o Initiation of tube feeding, when co-administered with levodopa, might result insudden changes in medication absorption and potential worsening of PD symptoms;

feeding should be started slowly and preferably at night when the bodys dopamine

requirements are lower;

o Consider use of promotility agents;o If apomorphine or intravenous LD are not available, consider trial of intravenous

anticholinergics or antihistamines, carefully observing for potential cognitive and

behavioral side effects;

o Avoid such dopamine antagonists as droperidol, haloperidol, risperidone,metaclopramide, prochlorperazine, or promethazine, as these medications can worsen

Parkinsonian symptoms; and


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o If patient was on MAO-B inhibitors (selegiline, rasagiline) before surgery, be aware ofmultiple 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 aspirationand 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 tractinfection.

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 notexhibit 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.

If the procedure had not been emergent, the patient might have

benefited from a preoperative swallow evaluation, given her dysphagia.

Consultation with a speech therapist would have ensured that the patient

was educated regarding aspiration precautions. Although this patient did

not have difficulty with extubation or experience postoperative


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respiratory failure, abnormal preoperative pulmonary function tests

might have prompted the anesthesiologists to consider alternative low-

risk techniques (e.g., a local nerve block).

Bottom LinePerioperative management of patients with Parkinsons disease requires

knowledge of the multisystem disease characteristics that raise

perioperative risk and the effects of the medications used to treat PD. To

date, no clear treatment guidelines exist for the optimal perioperative

management of PD patients.

However, vigilance in detecting possible complications and instituting

attentive perioperative care can aid a hospitalist consultant in improving

overall care for these patients. TH

Dr. Patel is a medical resident at the University of Colorado Denver. Dr.

Stickrath is a hospitalist at the Denver VA Medical Center and

instructor of medicine at the University of Colorado Denver. Dr.

Anderson is a hospitalist at the Denver VA Medical Center and assistant

professor of medicine at the University of Colorado Denver. Dr.

Klepitskaya is a neurologist and assistant professor of neurology at the

University of Colorado Denver.

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