Parkinsonism and Anesthesia R2 Guo Shu-lin 2002.12.5 2018/11/22 Parkinsonism and Anesthesia

Two Challenge to Anesthetist Manage elderly patients lesser pulmonary reserve poorer cardiovascular function Acute disturbances of motor control during or after anesthesia rigid chest wall motion poor cooperation to region anesthesia 2018/11/22 Parkinsonism and Anesthesia

Parkinsonism and Anesthesia Pathophysiology Loss of pigmented cells in the substantia nigra. A deficiency of dopamine leads to a dopamine/ acetylcholine imbalance Sub-clinical phase: decreased pigmented cells can compensate the effect of loss neurons 2018/11/22 Parkinsonism and Anesthesia

Clinical Presentation Hypokinesia: difficulty in initiating and slowness in executing movement Rigidity: throughout the whole range of movement of a joint Tremor: most pronounced at rest and a frequency of 4-8 Hz 2018/11/22 Parkinsonism and Anesthesia

Parkinsonism and Anesthesia 2018/11/22 Parkinsonism and Anesthesia

Parkinsonism and Anesthesia Current Treatment Dopamine precursor: Levodopa (L-dopa) Peripheral decarboxylase inhibitor: Carbidopa Anti-cholinergic drug: benztropine Mono-amine oxidase inhibitor-B (MAOI-B): Selegiline Dopamine agonist: Bromocriptine 2018/11/22 Parkinsonism and Anesthesia

Parkinsonism and Anesthesia 2018/11/22 Parkinsonism and Anesthesia

Anesthetic Considerations Pre-operative assessments Anti-parkinsonism drugs using principles Anesthetic decisions Peri-operative management Post-operative management 2018/11/22 Parkinsonism and Anesthesia

Parkinsonism and Anesthesia 2018/11/22 Parkinsonism and Anesthesia

Parkinsonism and Anesthesia Drug using principles Recommend that L-dopa uses just 20 min po before operation begins Recheck the last time of taking medicine MAOI drug should be hold to prevent hypertension crisis, but MAOI-B can use before operation Continuation of therapy perioperatively to avoid laryngospasm, aspiration pneumonia, hallucinations and violent tremors 2018/11/22 Parkinsonism and Anesthesia

Parkinsonism and Anesthesia Anesthetic Decision Discussion with surgeon about the length of time and the strength of anesthesia L-dopa half-life is short about 1-3 hrs Only L-dopa (no carbidopa) iv form is available 2018/11/22 Parkinsonism and Anesthesia

Parkinsonism and Anesthesia Anesthetic Decision Regional anesthesia Subjective feeling of Parkinsonism attack Drug given by po Difficultly apply on the patients with violent tremor or severe rigidty 2018/11/22 Parkinsonism and Anesthesia

Parkinsonism and Anesthesia Anesthetic Decision General anesthesia Provide a good surgical condition Inhalation agent may affect dopamine activity Muscle relaxants mask the myopotential Difficult maintain anti-parkinsonism drugs Severe nausea and vomiting in these patients after general anesthesia 2018/11/22 Parkinsonism and Anesthesia

Peri-operative management Opioid-induced muscle rigidity Patients with Parkinsonism with three fold more incidence than normal geriatric population Opioid can inhibit the release of dopamine in CNS Infusion of fentanyl 300μg/min or total dose of 50 μg/kg resulted in difficulty with ventilation 2018/11/22 Parkinsonism and Anesthesia

Peri-operative management Inhalational agents Increase extracellular dopamine concentration in brain Block the dopamine transport by synaptosomes Decreased dopaminergic transmission, inhibit the dopamine reuptake, and then accumulation of extracellular dopamine 2018/11/22 Parkinsonism and Anesthesia

Peri-operative management Other drugs known to exacerbate extrapyramidal stimulation Dopaminergic antagonist: droperiadol Antihistamine drugs: phenothiazine Mixed dopamine blocker: metoclopramide Sympathetic blocker: reserpine 2018/11/22 Parkinsonism and Anesthesia

Post-operative management If the patient is on “off ”stage, chest stiffness, laryngospasm and facial violent tremor will result in delaying the extubation GI dysfunction is common esp. lapa and presents with dysphagia and sialorrhea. That will increase the risk of aspiration pneumonia More likely to develop confusion and hallucianation 2018/11/22 Parkinsonism and Anesthesia

Parkinsonism and Anesthesia Any Question ? 2018/11/22 Parkinsonism and Anesthesia