Movement disorder emergencies in the perioperative period

Deep Brain Stimulation Emergencies: How the New Technologies Could Modify the Current Scenario

After 25 years of deep brain stimulation (DBS) for the treatment of Parkinson's disease, it has become increasingly recognized that a range of postoperative urgent situations and emergencies may occur. In this review we describe the possible scenarios of DBS-related emergencies: perioperative (intraoperative and early postoperative) and postoperative settings and issues from suboptimal control of motor and nonmotor symptoms in the early programming phase and during long-term follow-up. We also outline potential advantages in the management of these emergencies offered by the newest devices, emerging technologies, and new possibilities in programming.

Tourette syndrome and procedures related to dental treatment: a systematic review

PURPOSE

Dental treatment of patients with Tourette syndrome (TS) may present special challenges to the dentist. The aim was to systematically review the literature regarding perioperative procedures including sedation and general anaesthesia (GA) of patients with TS.

MATERIALS AND METHODS

Literature searches were performed in PubMed and Embase to identify papers concerning TS in combination with dental treatment, sedation, and/or GA in order to study outcomes regarding co-morbidity, perioperative complications, and drug interactions.

RESULTS

The literature search identified six publications (case reports or series) which addressed the topic. No unexpected adverse effects or drug interactions in relation to sedation or GA in TS patients and no perioperative complications were reported.

CONCLUSIONS

The literature on TS is scarce and the evidence level is low. Therefore, guidelines regarding the dental treatment of patients with TS cannot be formulated at the present time.

Effects of rotigotine on Parkinson's disease-related sleep disturbances

INTRODUCTION

Sleep abnormalities are a frequent non-motor symptom and a prominent cause of disability in patients with Parkinson's disease (PD).

AREAS COVERED

This review discusses what is currently known about the characteristics of sleep disturbances in PD patients and attempts to clarify the role of dopaminergic pathways in their pathogenesis as well as the beneficial effect of dopaminergic agents in their treatment. In particular, this review will focus on the effects of transdermal rotigotine on improving PD-related sleep disorders.

EXPERT OPINION

Sleep disturbances are common in PD, and these disturbances can be reduced or resolved, in large part, by preventing or attenuating nocturnal and early morning motor and non-motor symptoms of PD. The studies discussed within this review suggest that sleep disorders are not just a consequence of motor impairment and dopaminergic therapy but are an integral part of the neurodegenerative process of PD. This is supported by the appearance of specific sleep disturbances, which are related to degeneration of the brainstem areas involved in the regulation of sleep/wake states in advance of typical PD symptoms. Development of more detailed diagnostic tools aimed at detecting sleep disturbances and at defining the main causative factors of sleep disturbances in PD will lead to improved treatment of these disturbances.

The development of the rotigotine transdermal patch: a historical perspective

The rotigotine transdermal system is a dopamine receptor agonist delivered over a 24-hour period. It is approved for the treatment of idiopathic Parkinson's disease (PD). This article reviews the development of the rotigotine transdermal system, including rotigotine's receptor profile, steady-state pharmacokinetics, and metabolism. Preclinical studies of rotigotine in animal models of PD and proof-of-concept studies in patients with PD are reviewed. These preclinical and clinical studies established this system as an effective method for providing continuous rotigotine delivery across the skin providing the basis for continued clinical development of rotigotine for the treatment of early and advanced PD.

[Perioperative management of Parkinson's disease]

One of the particular characteristics of Parkinson's disease (PD) is the wide clinical variation as regards the treatment that can be found in the same patient. This occurs with specific treatment for PD, as well as with other drug groups that can make motor function worse. For this reason, the perioperative management of PD requires experience and above all appropriate planning. In this article, the peculiarities of PD and its treatment are reviewed, and a strategy is set out for the perioperative management of these patients.

[Perioperative management of Parkinson's disease]

One of the particular characteristics of Parkinson's disease (PD) is the wide clinical variation as regards the treatment that can be found in the same patient. This occurs with specific treatment for PD, as well as with other drug groups that can make motor function worse. For this reason, the perioperative management of PD requires experience and above all appropriate planning. In this article, the peculiarities of PD and its treatment are reviewed, and a strategy is set out for the perioperative management of these patients.

Clinical problems in the hospitalized Parkinson's disease patient: systematic review

The problems Parkinson's disease (PD) patients encounter when admitted to a hospital, are known to be numerous and serious. These problems have been inventoried through a systematic review of literature on reasons for emergency and hospital admissions in PD patients, problems encountered during hospitalization, and possible solutions for the encountered problems using the Pubmed database. PD patients are hospitalized in frequencies ranging from 7 to 28% per year. PD/parkinsonism patients are approximately one and a half times more frequently and generally 2 to 14 days longer hospitalized than non-PD patients. Acute events occurring during hospitalization were mainly urinary infection, confusion, and pressure ulcers. Medication errors were also frequent adverse events. During and after surgery PD patients had an increased incidence of infections, confusion, falls, and decubitus, and 31% of patients was dissatisfied in the way their PD was managed. There are only two studies on medication continuation during surgery and one analyzing the effect of an early postoperative neurologic consultation, and numerous case reports, and opinionated views and reviews including other substitutes for dopaminergic medication intraoperatively. In conclusion, most studies were retrospective on small numbers of patients. The major clinical problems are injuries, infections, poor control of PD, and complications of PD treatment. There are many (un-researched) proposals for improvement. A substantial number of PD patients' admissions might be prevented. There should be guidelines concerning the hospitalized PD patients, with accent on early neurological consultation and team work between different specialities, and incorporating nonoral dopaminergic replacement therapy when necessary.

Transdermal rotigotine for the perioperative management of Parkinson's disease

Continuous delivery of antiparkinsonian medication during a perioperative period is desirable to avoid ‘off’-symptom complications in surgical patients with concomitant Parkinson’s disease (PD). Fourteen PD patients undergoing surgery under general anesthesia were switched from oral dopaminergic medication to transdermally delivered 24-h rotigotine (median dose 12 mg/24 h) for the perioperative period. Rotigotine treatment was considered feasible by patients, their anesthesiologists and neurologists with good control of PD symptoms and easy switching and re-switching of PD medication.

Identification and management of deep brain stimulation intra- and postoperative urgencies and emergencies

Deep brain stimulation (DBS) has been increasingly utilized for the therapeutic treatment of movement disorders, and with the advent of this therapy more postoperative urgencies and emergencies have emerged. In this paper, we will review, identify, and suggest management strategies for both intra- and postoperative urgencies and emergencies. We have separated the scenarios into 1--surgery/procedure related, 2--hardware related, 3--stimulation-induced difficulties, and 4--others. We have included ten illustrative (and actual) case vignettes to augment the discussion of each issue.

Anesthetic management of patients with Huntington disease

BACKGROUND

Huntington disease (HD) is a rare autosomal dominant disease with symptoms of chorea, dystonia, incoordination, cognitive decline, and behavioral difficulties. Abnormal responses to anesthesia have been reported in case reports and raised concerns regarding the safety of anesthesia in this patient population.

METHODS

We performed a computerized search of the Mayo Clinic medical records database searching for patients with HD who underwent general anesthesia. Medical records were reviewed for anesthetic technique, medications used, and postoperative complications.

RESULTS

We identified 11 patients with genetically confirmed HD who underwent 17 general anesthetics. Psychiatric medication use was common, with 6 patients using antipsychotics, 7 patients using antidepressants, and 3 patients using benzodiazepines. Succinylcholine was used in 7 anesthetics, and nondepolarizing neuromuscular blocking drugs in 11 anesthetics, all without adverse effects. Patients had normal responses to induction and maintenance of anesthesia without adverse effects. Serious postoperative complications did not occur.

CONCLUSION

Contrary to previous case reports, we found that patients with HD have normal responses to general anesthesia. However, the anesthesiologist should be aware of interactions between anesthetics and psychiatric medications frequently used by these patients. Measures should also be taken to minimize the risk of pulmonary aspiration because bulbar dysfunction may be a manifestation of this disease.

Rotigotine transdermal system for perioperative administration

We present a series of patients participating in clinical trials with the rotigotine transdermal system. All patients were scheduled for surgery with general anaesthesia unrelated to the trial procedure or to rotigotine. Perioperative administration of rotigotine appeared to be feasible and efficacious. No safety issues emerged from these observations.