Parkinson's disease Overview

Agents used in anaesthesia

Choice of anaesthetic agent

Regional anaesthesia allows monitoring of Parkinson’s symptoms and should be considered in people who require very frequent dopaminergic medication; however, some motor symptoms of Parkinson’s disease (PD), such as severe dyskinesia, might make a general anaesthetic preferable.

Propofol can cause dyskinetic movements in all patients, including those with PD. However, it temporarily suppresses parkinsonian resting tremor and has an antiemetic action so is probably the best choice of induction agent in most situations.

Thiopental and ketamine have been used in PD patients without harm despite theoretical risks of exacerbation of parkinsonian symptoms and exaggerated sympathetic response respectively.

Neuromuscular blocking drugs (NMBDs)

NMBDs are safe to use in PD but it is essential to ensure adequate reversal of these agents as residual block can mask symptoms of PD. Neostigmine and glycopyrrolate reversal can thicken airway secretions1 but the benefits of reversal outweigh this effect. Alternatively consider using rocuronium, which can be reversed with sugammadex.

Anticholinergics

Centrally acting anticholinergics (e.g. atropine) may precipitate central anticholinergic syndrome causing confusion, somnolence and restlessness. If treatment of bradycardia is necessary glycopyrrolate, a peripherally acting agent, would be a safe alternative.

Analgesia

Large doses of fentanyl or alfentanil may result in muscle rigidity, which may exacerbate symptoms of PD.

Tremor and muscle rigidity may limit a patient using a patient-controlled analgesic (PCA) device.

Antiemetics

Avoid

Droperidol, haloperidol, metoclopramide and prochlorperazine should be avoided as their dopamine antagonist effects exacerbate PD.

Consider

Domperidone is a dopamine antagonist; however, it can safely be used in patients with PD as it does not cross the blood-brain barrier. In patients taking levodopa absorption may initially be increased due to stimulation of gastric emptying.

Cyclizine may decrease the absorption of levodopa; however, this is unlikely to be clinically significant, as cyclizine is generally considered useful in patients with PD.

Granisetron and ondansetron do not affect dopamine so are useful in patients with PD; however, cases of extrapyramidal adverse effects have been reported uncommonly with ondansetron. If patient is taking a Monoamine-oxidase B inhibitor there is a risk of serotonin syndrome (see Monoamine-oxidase B inhibitors drug records).

Delirium

Post-operative delirium is common in PD. Non-pharmacological treatments are preferable but if pharmacological treatment is absolutely necessary consider lorazepam. Avoid haloperidol as it can exacerbate PD symptoms.

NBM period and alternative routes

PD patients should ideally be placed first on the operation list to minimise the NBM period, reduce the risk of cancellation and ensure optimal early post-operative disease management. Even if patients are NBM they should still be advised to take medications at their usual time pre-operatively with a small sip of water.

If there is significant post-operative nausea and vomiting, post-operative ileus or concerns about enteral absorption, the oral route is likely to be unreliable and may lead to suboptimal treatment and potentially parkinsonism-hyperpyrexia syndrome (PHS) or Dopamine Agonist Withdrawal Syndrome (DAWS). Some treatments like amantadine, monoamine-oxidase B inhibitors and catechol-O-methyltransferase inhibitors can be safely omitted in these circumstances; however, it is not safe to omit levodopa or dopamine agonists and alternative treatment with transdermal rotigotine should be considered.

Guidance on dose conversions is available at http://parkinsonscalculator.com or refer to in-house guidelines if available. Due to the risk of delirium and other neuropsychiatric side effects (e.g. hallucinations), it may be prudent to decrease the initial rotigotine dose for acutely unwell or frail patients and then titrate accordingly. The rotigotine patch should be stopped and the patient’s usual treatment restarted when there are no longer concerns regarding enteral absorption. Rotigotine may not be sufficiently potent to provide adequate treatment for patients on higher dose treatment regimes. The only other parenteral option is subcutaneous apomorphine; however, this is highly emetogenic (requiring pre-treatment with domperidone) and should ONLY be initiated on advice of a specialist in PD.

Patients who do not rapidly regain the ability to take their usual PD medication should be seen by a PD specialist nurse or movement disorder consultant at the earliest opportunity.

References

Chambers DJ. Sebastian J. and Ahearn DJ. Parkinson’s disease. BJA Education. 2017; 17:145-149

Brennan KA & Genever RW. Managing Parkinson’s disease during surgery. BMJ. 2010; 341:c5718

Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 6th June 2019]

Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 6th June 2019]