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

2. 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

3. 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

4. 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

5. Parkinsonism and Anesthesia
2018/11/22
Parkinsonism and Anesthesia

6. 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

7. Parkinsonism and Anesthesia
2018/11/22
Parkinsonism and Anesthesia

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

9. Parkinsonism and Anesthesia
2018/11/22
Parkinsonism and Anesthesia

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

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