Perioperative management of patients with Parkinson's disease

Perioperative Use of Intravenous Levodopa as an Anti-Parkinsonian Drug: A Propensity Score Analysis

Background

Perioperative discontinuation of oral anti-parkinsonian medication can negatively impact the prognosis of abdominal surgery in patients with Parkinson's disease. Although intravenous levodopa may be an alternative, its efficacy has not yet been investigated.

Objectives

To determine the efficacy of intravenous levodopa as an alternative to oral anti-Parkinsonian drugs during gastric or colorectal cancer surgery.

Methods

We identified patients with Parkinson's disease who underwent surgery for gastric or colorectal cancer between April 2010 and March 2020, using the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan. Patients were divided into two groups: those who received intravenous levodopa during the perioperative period and those who did not. We compared in-hospital mortalities, major complications, and postoperative length of stay between the groups after adjusting for background characteristics with overlap weights based on propensity scores.

Results

We identified 648 patients who received intravenous levodopa and 1207 who did not receive levodopa during the perioperative period. In the adjusted cohort, the mean postoperative length of stay was 24.7 and 29.0 days (percent difference, -7.7%; 95% confidence interval, -13.1 to -1.5); in-hospital death was 3.2% and 3.3% (adjusted odds ratio, 0.95; 95% CI: 0.54-1.67); and incidence of major complications were 21.4% and 19.3% (adjusted odds ratio, 0.89; 95% confidence interval, 0.70-1.13) in those with and without intravenous levodopa, respectively.

Conclusions

Intravenous levodopa was associated with a shorter postoperative length of stay, but not with mortality or morbidity. Intravenous levodopa may improve perioperative care in patients with Parkinson's disease.

Minimally Invasive Spine Surgery for Kyphoscoliosis in a Patient With Parkinson's Disease: A Case Report

The surgical treatment for severe deformity correction in patients with Parkinson's disease (PD) is usually challenging, requiring lengthy fusions, and with a high risk of postoperative complications. We present a patient with severe kyphoscoliosis and medical history of PD undergoing minimally invasive surgical deformity correction. A 75-year-old female with a 10-year history of medically controlled PD presented at our hospital's outpatient reporting progressive postural changes during the last two years and a half. On clinical examination, we recognized severe kyphoscoliosis associated with Pisa deformity, in the absence of any neurological manifestations. On the initial x-rays, the coronal angulation was 56° in the lumbar area with a significant lateral shift of the trunk, while the right ribs were close to the iliac crest. The patient underwent deformity correction with percutaneous pedicle screws from T5 to S1, a percutaneous transverse process hooks at T5, and transforaminal lumbar interbody fusion at L5-S1. The total duration of the operation was seven hours, and the estimated blood loss was approximately 300 mL. Clinically, the patient's posture improved significantly, alleviating any preoperative compensatory mechanisms such as knee flexion. The postoperative x-rays revealed a very satisfying correction in both the coronal and sagittal planes (20.1 degrees and 26.6 degrees, respectively). Our current case report showed that MIS constitutes a viable alternative for deformity correction in selected patients with PD as part of a multidisciplinary approach. Proper patient selection requires a detailed medical history and a complete neurological and musculoskeletal examination by a dedicated healthcare provider.

Toxin Induced Parkinsonism and Hospitalization Related Adverse Outcome Mitigation for Parkinson's Disease: A Comprehensive Review

Patients with Parkinson's disease admitted to the hospital have unique presentations. This unique subset of patients requires a multidisciplinary approach with a knowledge-based care team that can demonstrate awareness of complications specific to Parkinson's disease to reduce critical care admissions, morbidity, and mortality. Early recognition of toxic exposures, medication withdrawals, or medication-induced symptoms can reduce morbidity and mortality. This review can assist in the critical assessment of new or exacerbating Parkinson's disease symptoms.

Degenerative Spine Surgery in Patients with Parkinson Disease: A Systematic Review

BACKGROUND

Parkinson disease (PD) has been recognized as responsible for concurrent spinal disorders. Surgical correction may be necessary, but the complexity of such fragile patients may require specific considerations. We systematically reviewed the literature on degenerative spine surgery in patients with PD.

METHODS

PubMed, Scopus, Web of Science, and Cochrane were searched according to the PRISMA guidelines to include studies reporting clinical data of patients with PD undergoing degenerative spine surgery. Clinical characteristics, treatment protocols, and outcomes were analyzed.

RESULTS

We included 22 articles comprising 442 patients (61.5% female). Mean age was 66.9 ± 3.5 years (range, 41-83 years). Mean PD duration and modified Hoehn and Yahr stage were 4.46 ± 2.39 years and 2.3 ± 0.8, respectively. Operation types included fusion (55.3%) and decompression (41.6%). Mean operated spine levels were 6.0 ± 5.08. A total of 377 postoperative complications occurred in 34.6% patients, categorized into mechanical failure (58.0%), infection (15.1%), or neurologic (10.7%). Of patients, 31.8% required surgical revisions, with an average of 1.88 ± 1.03 revisions per patient. The average normalized presurgery, postsurgery, and final aggregate numeric patient outcome scores were 0.37 ± 0.13, 0.63 ± 0.18, and 0.61 ± 0.19, respectively, with a score of 0 and 1 representing the worst and best possible score.

CONCLUSIONS

Degenerative spine surgery in patients with PD is challenging, with complications and revisions occurring in up to a third of treated patients. Surgery should be offered when other treatment options have proved ineffective and is typically reserved for patients with myelopathy or significant disability. Successful outcomes depend on strong interdisciplinary support to control the movement disorder before and after surgery.

Preoperative Management of Medications for Neurologic Diseases: Society for Perioperative Assessment and Quality Improvement Consensus Statement

Neurologic diseases are prevalent in patients undergoing invasive procedures; yet, no societal guidelines exist as to best practice in management of perioperative medications prescribed to treat these disorders. The Society for Perioperative Assessment and Quality Improvement tasked experts in internal medicine, anesthesiology, perioperative medicine, and neurology to provide evidence-based recommendations for preoperative management of these medications. The aim of this review is not only to provide consensus recommendations for preoperative management of patients on medications for neurologic disorders, but also to serve as an educational guide to perioperative clinicians. While, in general, medications for neurologic disorders should be continued preoperatively, an individualized approach may be needed in certain situations (eg, holding anticonvulsants on day of surgery if electroencephalographic mapping is planned during epilepsy surgery). Pertinent interactions with commonly used drugs in anesthesia practice, as well as considerations for targeted laboratory testing or perioperative drug substitutions, are addressed as well.

Do we really improve life quality after total knee arthroplasty in patients with Parkinson's disease?

INTRODUCTION

The knee in Parkinson's disease (PD) patients is a problematic joint due to pain, stiffness and gait instability. The aim of this study is to evaluate the functional outcome and degree of pain relief achieved after total knee arthroplasty (TKA) in PD patients.

MATERIALS AND METHODS

This is a retrospective review of 26 PD patients (32 knees) with osteoarthritis who underwent a TKA between 1994 and 2013. Comorbidities, anesthetic procedures and complications were recorded. Patient functional status was assessed with the Knee Society Function Score (KFS) and the Knee Society Score (KSS). PD stage was classified with the Hoehn and Yahr Scale.

RESULTS

The mean follow-up was 3.5 years (range 2-9). The mean age was 71 years (range 61-83) with a mean time since PD diagnosis of 11.8 years (range 4-24). PD severity on the Hoehn and Yahr Scale was 1.5 points before surgery and 2 points postoperatively. Pain on the visual analogic scale improved from 8 points preoperatively to 5 points at 1-year follow-up; function improved from 32 (range 20-45) to 71 (range 50-81) and from 34 (range 28-52) to 59 (range 25-76) on the KSS and KFS, respectively. The mean postoperative hospital stay was 9.8 days (range 5-21). Confusion and flexion contracture were the most frequent perioperative complications.

CONCLUSION

TKA successfully provided pain relief in PD patients. However, the functional outcome is related to disease progression and, therefore, variable. Perioperative complications are difficult to avoid and manage.

A Systematic Review of Total Knee Arthroplasty in Neurologic Conditions: Survivorship, Complications, and Surgical Considerations

BACKGROUND

Patients with neurologic disorders present a unique set of challenges for knee surgeons because of contractures, muscle weakness, spasticity, and ligament instability. The primary purpose of this review was to report the outcomes of total knee arthroplasty (TKA) in these patients, including survivorship, complications, and surgical considerations.

METHODS

We performed a systematic review of articles using PubMed, Cochrane Central, EMBASE, and Google Scholar. All studies reporting outcomes of TKA in patients with Parkinson disease, multiple sclerosis, poliomyelitis, Charcot joint, spina bifida, stroke, and cerebral palsy were included.

RESULTS

In total 38 studies were included: 22 studies (461 patients) reported patient-reported outcome measures and 24 studies (510 patients) reported survivorship. All 38 studies reported complication rates. TKA resulted in an improvement in functional outcome in all series. Complication rate was higher in patients with neurologic conditions. Of studies reporting survivorship, mean follow-up ranged from 1 to 12 years with survivorship from 66% to 100%. All levels of implant constraint were reported without consensus. Limited rehabilitative data exist.

CONCLUSION

TKA in patients with neurologic disorders improves symptoms and function but carries significant risk. This review helps surgeons preoperatively counsel their patients in an informed manner. Careful planning, perioperative care, and appropriate implant selection may mitigate risk of complication.

Nurses' knowledge about perioperative care of patients with neurological diseases

This study investigated the level of nurses' knowledge regarding the perioperative care of neurological patients. An author-developed questionnaire of 20 items was used in a sample of 94 hospital nurses serving in the neurology, surgery and anesthesiology departments and the intensive care unit. The average percentage of participants with correct answers was 49.2%. The mean value of participants' score was 9.8 ±3.4. Preexisting experience in the care of cases with multiple sclerosis and Parkinson's disease was positively related to the level of knowledge (p = 0.001 and 0.014 respectively). The ascertained level of nurses' knowledge regarding the perioperative care of neurological patients was moderate, questioning their adequacy to handle such cases. Previous experience in the care of particular diseases had significantly positive impact on knowledge, suggesting potential improvement strategies through targeted education and specialization of nurses. In conclusion, nurse's knowledge regarding perioperative care of neurological patients was insufficient, requiring appropriate improvement interventions.

Management of Spinal Conditions in Patients With Parkinson Disease

Parkinson disease (PD) is increasingly prevalent in the aging population. Spine disorders in patients with PD may be degenerative in nature or may arise secondary to motor effects related to the parkinsonian disease process. Physicians providing care for patients with PD and spine pathologies must be aware of several factors that affect treatment, including the patterns of spinal deformity, complex drug interactions, and PD-associated osteoporosis. Following spine surgery, complication rates are higher in patients with PD than in those without the disease. Literature on spine surgery in this patient population is limited by small cohort size, the heterogeneous patient population, and variable treatment protocols. However, most studies emphasize the need for preoperative optimization of motor control with appropriate medications and deep brain stimulation, as well as consultation with a movement disorder specialist. Future studies must control for confounding variables, such as the type of surgery and PD severity, to improve understanding of spinal pathology and treatment options in this patient population.

The need for non-oral therapy in Parkinson's disease; a potential role for apomorphine

In the course of Parkinson's disease (PD), oral medication may lose its effectiveness due to several reasons, like dysphagia, impaired absorption from the gastro-intestinal tract and delayed emptying of the stomach. If these problems occur, a non-oral therapy should be considered. Examples of non-oral therapies are transdermal patches, (e.g. rotigotine) which may overcome motor and nonmotor nighttime problems, and may serve as well to treat daytime response-fluctuations, if oral therapies fail to do so. Other options are injections with apomorphine to treat early morning dystonia and random off-periods during daytime, as well as continuously infused subcutaneous apomorphine for random fluctuations in PD patients. Low-dose apomorphine infusions also may be useful in the peri-operative phase, when PD patients may not be able to swallow oral medication. Finally, levodopa-carbidopa intestinal gel (LCIG) infusions or DBS have shown to be effective non-oral options to treat PD patients adequately, if they are not properly controlled by oral options.

Management of Spinal Deformity in Adult Patients With Neuromuscular Disease

A wide range of neuromuscular diseases, including Parkinson disease, cerebral palsy, multiple sclerosis, and myopathy, are associated with spinal deformities. The most common postural deformities include anterocollis, Pisa syndrome (pleurothotonus), scoliosis, and camptocormia. Nonsurgical management of spinal deformity in patients with neuromuscular disease centers on maximizing the medical management of the underlying neurodegenerative pathology before surgical intervention is contemplated. Surgical management can include decompression alone, or decompression and fusion with short or long fusion constructs. Patients with neuromuscular disease are susceptible to postoperative medical complications, such as delirium, epidural hematomas, pulmonary emboli, and cardiac events. Compared with outcomes in the typical patient with spinal deformity, postoperative outcomes in patients with neuromuscular disease have higher rates of surgical complications, such as instrumentation failure, proximal junctional kyphosis, loss of correction, and the need for revision surgery, regardless of the magnitude of surgical treatment.

Outcomes After Non-neurological Surgery in Patients With Parkinson's Disease: A Nationwide Matched Cohort Study

Patients with Parkinson disease (PD) were known to have increased risk of complications during hospitalization. The purpose of this study is to validate the global features of postoperative adverse outcomes for patients with PD.Using reimbursement claims from Taiwan's National Health Insurance Research Database, we conducted a nationwide retrospective cohort study of 6455 patients with preoperative PD receiving major surgery during 2008 to 2012. With a propensity score matching procedure, 12,910 surgical patients without PD were selected for comparison. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for 9 major postoperative complications and 30-day postoperative mortality associated with preoperative PD were calculated in the multivariate logistic regressions.Patients with PD had increased risk of postoperative pulmonary embolism (OR 2.72, 95% CI 1.45-5.10), stroke (OR 1.77, 95% CI 1.53-2.05), pneumonia (OR 1.98, 95% CI 1.70-2.31), urinary tract infection (OR 1.52, 95% CI 1.35-1.70), septicemia (OR 1.54, 95% CI 1.37-1.73), acute renal failure (OR 1.36, 95% CI 1.07-1.73), and mortality (OR 1.45, 95% CI 1.06-1.98). The association between preoperative PD and postoperative adverse events was significant in both sexes and every age group. Low income, ≥65 years of age, surgery not in medical center, highest quartile of PD medication users, and more medical conditions worsen the risk of postoperative adverse events in patients with PD.This study showed increased postoperative complications and mortality in patients with PD. Our findings suggest that revision of postoperative care protocols for this population is urgently needed.

Postanesthesia Care for the Elderly Patient

PURPOSE

As the general population lives longer, the perioperative physician is more likely to encounter disease states that increase in incidence in an aging population. This review focuses on anesthetic considerations for rational drug choices during the perioperative care of elderly patients. The primary aim of the review was to identify intraoperative and postanesthetic considerations for diseases associated with advancing age; it includes highlights of the commonly impaired major organs (eg, cardiovascular, pulmonary, neurologic, renal, hepatic systems). We also outline an approach to frequent issues that arise in the immediate postsurgical period while caring for these patients.

METHODS

A systematic review was performed on aspects of the perioperative and postoperative periods that relate to the elderly. A list of pertinent key words was derived from the authors, and a PubMed database search was performed.

FINDINGS

The anesthesiologist must account for changes in various organ systems that affect perioperative care, including the cardiovascular, pulmonary, renal, hepatic, and central nervous systems. The pharmacokinetic principles frequently differ and are often unpredictable because of anatomic changes and decreased renal and hepatic function. The most important pharmacodynamic consideration is that elderly patients tend to exhibit an exaggerated hypoactivity after anesthesia.

IMPLICATIONS

Before surgery, it is essential to identify those patients at risk for delirium and other commonly encountered postanesthesia scenarios. Failure to manage these conditions appropriately can lead to an escalation of care and prolonged hospitalization.

Colorectal surgery in Parkinson's disease--outcomes and predictors of mortality

PURPOSE

Although diseases of the lower gastrointestinal tract are common in patients with Parkinson's disease, there is a paucity of data regarding postoperative outcomes after colorectal surgery.

METHODS

The Nationwide Inpatient Sample database (2007-2011) was utilized to analyze outcomes in patients with Parkinson's disease (PD) undergoing colorectal surgery. Main outcomes were risk-adjusted inpatient morbidity, mortality, hospital charge, and length of hospital stay.

RESULTS

A total of 6490 patients were identified. Utilization of laparoscopic surgery in Parkinson's patients has progressively increased in frequency over the latest 5 years analyzed. The most common diagnoses were colorectal malignancy (39 %) and intestinal obstruction (20 %). Right hemicolectomy (37 %) and sigmoidectomy (30 %) were the most common operations. Laparoscopy was used in 18 % of Parkinson's patients and most commonly in the elective setting. 54.3 % of Parkinson's patients had emergency surgery compared to 38.6 % in non-Parkinson's. Overall morbidity and mortality were significantly lower after laparoscopic surgery compared to open (20 vs. 25 % and 2.1 vs. 6.6 %, respectively). Length of stay was significantly shorter (OR -1.86; p < 0.01) for laparoscopic operations, but there were no significant differences in risk-adjusted outcomes between laparoscopic and open groups.

CONCLUSION

PD patients have high rates of morbidity and mortality after colorectal surgery; this may be because more than half of all patients in this population undergo emergent surgery. The laparoscopic approach appears to have short-term benefits in this patient population.

Decreased dopaminergic treatment of hospitalized Parkinson's disease patients during infectious diseases is associated with poor outcomes

A retrospective analysis of consecutive Parkinson's disease (PD) patients hospitalized in internal medicine wards during the years 2008 to 2013 due to infectious disease was performed. PD patients are prone to infections, often leading to hospitalization in internal medicine wards. We observed that during these hospitalizations, chronic anti-Parkinson's medications are frequently overlooked and withdrawn, their reintroduction is delayed and dosages are decreased. Only patients on chronic therapy with at least one anti-Parkinson's medication were included in this study. Multivariate analyses established the association between medication dose reductions on short-term clinical outcomes, including in-hospital mortality and change in discharge destination. Medical records from 528 PD patients were analyzed and 430 were excluded. Of the 98 included, 53 had pneumonia and 58 had urinary tract infections. The overall in-hospital mortality rate was 11.2%. 56.1% of patients' dopaminergic medications were decreased in dose upon admission (22.5% mean decrease in levodopa equivalent daily dose [LEDD]; p<0.001). Both absolute and relative LEDD reductions were associated with significantly increased in-hospital mortality (mean reduction of 394.5 mg versus 188.4 mg; p=0.035 by analysis of variance adjusted to age, sex and renal function) and was also associated with worse discharge destination relative to original place of arrival (mean reduction of 377.8 mg versus 150.7 mg; p=0.014). Decreased dopaminergic medication dosing upon admission of PD patients due to infection is widespread and potentially associated with worse clinical outcomes.

Low Norton Scale Score Predicts Worse Outcomes for Parkinson's Disease Patients Hospitalized Due to Infection

Background:Parkinson's disease (PD) patients are prone to infections leading to hospitalization. We used the Norton Scale score (NSS) as a prognostic tool for these patients. Method: Retrospective analysis of consecutive PD patients, all had NSS appreciation upon admission. Analyses were made to establish the association between NSS upon admission, short-term, and long-term clinical outcomes. Results: Five hundred twenty-eight PD patients' records were reviewed, of which 81 were eligible for analysis. Patients who died during hospitalization had a significantly lower NSS (10.0 vs. 13.1, p = .026). Among surviving patients, those who were discharged to more intensive care facilities relative to their original place of arrival also had a significantly lower NSS (10.38 vs. 13.63, p = .0002). Lower NSS was found to increase the risk for 1-year mortality (odds ratio = 1.3; 95% confidence interval = [1.09, 1.56], p = .003). Conclusion: Lower NSS upon admission of PD patients, suffering from infection is associated with worse clinical outcomes.