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Preparing patients with Parkinson’s Disease for surgery by Dr Paul Siberstein

May 31, 2018

I am often asked by my patients with Parkinson’s disease (PD) who have upcoming elective surgery as to whether there is anything that their treating surgical teams need to take into particular consideration given the presence of their PD.

PD is complex neuropsychiatric slowly progressive degenerative neurologic syndrome which can affect movement (tremor, rigidity, bradykinesia, gait disturbance), mental state (mood, anxiety, behaviour & - in later disease - cognition) and autonomic function (swallow, sphincter function, temperature and blood pressure regulation).  Not surprisingly, patients with PD are at increased risk of perioperative surgical complications, prolonged hospital stay and delayed recovery.

Perioperative recommendations need to take into account each individual’s particular circumstances and comorbidities.  There are however, a number of general strategies that can help mitigate the risk of peri-operative complications:

Pre-operative management:

• Maintenance of usual anti-Parkinsonian drug regime on admission to hospital including dose timing
• Many anaesthetists now allow patients to take their usual medications with a sip of water even in the pre-op NBM (nil by mouth period) and patients are encouraged to discuss this with the treating team prior to/ on admission to hospital.

 Operative considerations:

• If muscle relaxation (paralysis) is required as part of the anaesthetic regimen, use of the novel muscle relaxant reversal agent Sugammadex is recommended.This agent does not have cholinergic effects and consequently is less likely to be a trigger/ contributor to post operative confusion.
• Patients with Deep Brain Stimulation devices require particularly considerations with respect to whether or not the device needs to be switched off for the surgery, diathermy use and placement and prophylactic antibiotics.Requirements vary by device manufacturer and involvement of device company representatives is recommended.

Post operative management:

• NBM period should be as short as practical to allow reinstitution of usual oral anti-Parkinsonian medication regime. If a prolonged NBM is anticipated eg after bowel resection, pre-operative planning by a Neurologist or peri-operative physician is recommended.
• Symptomatic treatment considerations – medication side effects and interactions need to be taken into account when prescribing symptomatic treatments post operatively.This is particularly important with respect to prescription of anti-emetics and antipsychotics which have dopamine receptor blocking activity.For nausea, metoclopramide and prochlorperazine should be avoided if at all possible.Ondansetron and other 5HT3 receptor antagonists do not commonly cause extrapyramidal side effects (but are associated with a risk Serotonin syndrome when used concomitantly with SSRI’s).Domperidone is an alternative anti-emetic which does not commonly cause extrapyramidal side effects (but may prolong the QTc)
• Post discharge: Patients with PD may be at increased risk of DVT and constipation due to motor impairment.Early mobilisation is important in minimising the risk of these post- operative complications.

Refs:

Shimotohata et al. Perioperative management of Parkinson’s disease. Brain Nerve 2015 Feb;67(2):205-11.

Katus & Shtilbans. Perioperative management of patients with Parkinson’s disease. American Journal of Medicine 2014 Apr; 127(4): 275-80.