Parkinson's disease and anaesthesia

Anesthetic Considerations for Cataract Surgery in Patients with Parkinson's Disease: A Narrative Review

Parkinson's disease (PD) is a chronic neurological degenerative disease affecting the central nervous system, which is responsible for progressive disorders such as slow movements, tremors, rigidity, and cognitive disorders. There are no specific recommendations and guidelines for anesthetic management of patients with PD undergoing ophthalmic procedures. This narrative review aims to summarise the anesthetic considerations in patients with PD presenting for cataract surgery.

[Anaesthesia and Perioperative Management for Patients with Parkinson's Disease]

Idiopathic Parkinson's syndrome is associated with the loss of dopaminergic cells. It is defined by the presence of akinesia together with one of the cardinal symptoms: rigor, tremor, or postural instability. As the perioperative management of these patients can be challenging and they have an increased perioperative risk, every anaesthesiologist should know some special features. If a patient with Parkinson's disease does not receive the required amount of dopa, akinetic crisis may occur. Moreover, the administration of dopamine-antagonistic drugs can trigger a malignant neuroleptic syndrome. These are life-threatening clinical pictures that require intensive medical treatment. Therefore, patients with Parkinson's disease should be enabled to keep the period without the intake of the specific medication as short as possible. General anaesthesia should be performed with short acting anaesthetics and a regional anaesthesia might be beneficial. Besides, all dopamine antagonists sometimes used for prophylaxis or therapy of delirium or PONV (haloperidol, metoclopramide) are contraindicated. Alternatives are short-acting benzodiazepines, atypical neuroleptics and domperidone.

Treatment paradigms in Parkinson's Disease and Covid-19

People with Parkinson's Disease (PwP) may be at higher risk for complications from the Coronavirus Disease 2019 (Covid-19) due to older age and to the multi-faceted nature of Parkinson's Disease (PD) per se, presenting with a variety of motor and non-motor symptoms. Those on advanced therapies may be particularly vulnerable. Taking the above into consideration, along with the potential multi-systemic impact of Covid-19 on affected patients and the complications of hospitalization, we are providing an evidence-based guidance to ensure a high standard of care for PwP affected by Covid-19 with varying severity of the condition. Adherence to the dopaminergic medication of PwP, without abrupt modifications in dosage and frequency, is of utmost importance, while potential interactions with newly introduced drugs should always be considered. Treating physicians should be cautious to acknowledge and timely address any potential complications, while consultation by a neurologist, preferably with special knowledge on movement disorders, is advised for patients admitted in non-neurological wards. Non-pharmacological approaches, including the patient's mobilization, falls prevention, good sleep hygiene, emotional support, and adequate nutritional and fluid intake, are essential and the role of telemedicine services should be strengthened and encouraged.

Bone cement implantation syndrome during hip replacement in a patient with pemphigus and Parkinson’s disease: A case report

BACKGROUND

Bone cement implantation syndrome (BCIS) is characterized by hypotension, arrhythmia, diffuse pulmonary microvascular embolism, shock, cardiac arrest, any combination of these factors, or even death following bone cement implantation.

CASE SUMMARY

An 80-year-old patient with pemphigus and Parkinson’s disease underwent total hip replacement under spinal subarachnoid block and developed acute pulmonary embolism after bone cement implantation. The patient received mask mechanical ventilation with a continuous intravenous infusion of adrenaline (2 μg/mL) at a rate of 30 mL/h. Subsequently, the symptoms of BCIS were markedly alleviated, and the infusion rate of adrenaline was gradually reduced until the infusion was completely stopped 45 min later. The patient was then transferred to the Department of Orthopedics, and anticoagulation therapy began at 12 h postoperatively. No other complications were observed.

CONCLUSION

This is a rare case of BCIS in a high-risk patient with pemphigus and Parkinson’s disease.

Total hip arthroplasty in Parkinson's disease - A systematic review of the current evidence

This systematic review assessed the efficacy, survivorship, and complications of Total Hip Replacement (THR) in Parkinson's Disease (PD). Databases were searched according to the Preferred Reporting Items for Systematic Reviews. PD patients had higher wound infections, dislocations, peri-prosthetic fractures, and revision surgery compared to their non-PD counterparts. They also had inferior functional outcomes, and longer and expensive hospital admissions. Dual-mobility (DM) implants had the lowest survival rate. THR in PD patients is associated with significant surgical complications and peri-operative challenges. Despite the use of DM implants to minimize instability, there is insufficient evidence on its effectiveness and long-term survivorship.

Preoperative Magnetic Resonance Image Quality in Motion Disorder Patients Scheduled for Deep Brain Stimulation Surgery

BACKGROUND

To obtain magnetic resonance (MR) images of good quality for accurate target localization in deep brain stimulation (DBS) surgery, sedation or anesthesia may be used, although their usefulness has not been proven.

OBJECTIVE

To assess whether sedation or general anesthesia (GA) improve the quality of MR imaging (MRI).

METHODS

The records of DBS procedures for Parkinson's disease (PD), dystonia, and essential tremor in our tertiary neurosurgical unit between January 2011 and June 2016 were reviewed. Adult patients with preoperative MR images were included. Patient records concerning MRI, surgery, adverse events, and clinical outcome were retrospectively scrutinized and analyzed. MR image quality was assessed by two independent radiologists.

RESULTS

A total of 215 preoperative MR images for 177 DBS procedures were analyzed. The MRI sequences performed under GA were superior to those performed without anesthesia or under sedation (p < 0.01). Virtually all images captured under GA were of good quality, while the proportions among those captured with sedation or without anesthesia were <65%. Good image quality was not associated with better clinical outcome (>50% improvement in the Unified Parkinson's Disease Rating Scale III score) among patients with PD.

CONCLUSION

GA was associated with better MRI sequences than intravenous sedation or no anesthesia.

Spinal versus General Anesthesia for Patients with Parkinson's Disease

Background

Anesthesiologists prefer using general anesthesia (GA) in Parkinson’s disease (PD). However, GA may mask neurological symptoms in the intraoperative period and exacerbate them postoperatively. Furthermore, the anesthetics used in GA have clear interactions with the drugs used to control PD. On the other hand, drugs used in spinal anesthesia (SA) might be safer for patients with PD. The aim of this study is to evaluate the effect of SA and GA in patients with PD who underwent hip fracture repairs.

Methods

Retrospectively, we identified those patients with PD who were admitted due to hip joint fracture. The following information were obtained: demographics, preoperative assessment information of the patients, type of anesthesia, and types of fractures and orthopedic procedures. In addition, intraoperative and postoperative complications were studied. The patients were divided based on the type of anesthesia received and were compared.

Results

Ten (8 males) patients with PD who underwent hip fracture surgery included in the study. Six patients received SA and 4 patients received GA. The mean age was 73.2 years. The preoperative assessment was not significant for all patients. Postoperatively, within the inpatient period, 3 out of 4 patients received GA developed complications (two atelectasis and urinary tract infection) while no patient developed complication from the SA group. Postoperative outpatient complications within one-month included 3 out of 4 cases in the GA group and only one complication in the SA group. The mean hospitalization period was 9 days for patients received GA and 5.8 days for patients received SA.

Conclusion

This study reported less perioperative complications in the SA. Accordingly, further investigations and rp-randomized controlled trials evaluating various anesthetic techniques or drugs are needed.

Dopamine neuronal protection in the mouse Substantia nigra by GHSR is independent of electric activity

Objective

Dopamine neurons in the Substantia nigra (SN) play crucial roles in control of voluntary movement. Extensive degeneration of this neuronal population is the cause of Parkinson's disease (PD). Many factors have been linked to SN DA neuronal survival, including neuronal pacemaker activity (responsible for maintaining basal firing and DA tone) and mitochondrial function. Dln-101, a naturally occurring splice variant of the human ghrelin gene, targets the ghrelin receptor (GHSR) present in the SN DA cells. Ghrelin activation of GHSR has been shown to protect SN DA neurons against 1-methyl-4-phenyl-1,2,5,6 tetrahydropyridine (MPTP) treatment. We decided to compare the actions of Dln-101 with ghrelin and identify the mechanisms associated with neuronal survival.

Methods

Histologial, biochemical, and behavioral parameters were used to evaluate neuroprotection. Inflammation and redox balance of SN DA cells were evaluated using histologial and real-time PCR analysis. Designer Receptors Exclusively Activated by Designer Drugs (DREADD) technology was used to modulate SN DA neuron electrical activity and associated survival. Mitochondrial dynamics in SN DA cells was evaluated using electron microscopy data.

Results

Here, we report that the human isoform displays an equivalent neuroprotective factor. However, while exogenous administration of mouse ghrelin electrically activates SN DA neurons increasing dopamine output, as well as locomotion, the human isoform significantly suppressed dopamine output, with an associated decrease in animal motor behavior. Investigating the mechanisms by which GHSR mediates neuroprotection, we found that dopamine cell-selective control of electrical activity is neither sufficient nor necessary to promote SN DA neuron survival, including that associated with GHSR activation. We found that Dln101 pre-treatment diminished MPTP-induced mitochondrial aberrations in SN DA neurons and that the effect of Dln101 to protect dopamine cells was dependent on mitofusin 2, a protein involved in the process of mitochondrial fusion and tethering of the mitochondria to the endoplasmic reticulum.

Conclusions

Taken together, these observations unmasked a complex role of GHSR in dopamine neuronal protection independent on electric activity of these cells and revealed a crucial role for mitochondrial dynamics in some aspects of this process.

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Dln101 is a human splice-variant of the ghrelin gene with different expression pattern.

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Ghrelin and Dln101 display equivalent levels of neuroprotection of SN DA cells.

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Modulation of electrical activity of SN DA cells is not relevant for neuroprotection.

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Mitochondrial fusion protein 2 (MFN 2) blocks DLN101-induced mitochondrial fusion in SN DA neurons and prevents DLN101-induced neuroprotection.

Considerations for general anaesthesia in Parkinson's disease

Parkinson's disease is a common neurodegenerative disorder in the elderly which when present has a significant influence on surgical management. These patients necessitate additional perioperative and anaesthetic considerations across disease specific domains as well as in relation to the respiratory and cardiovascular systems. This brief review focuses on the factors which contribute to perioperative morbidity, including the use of medications that may exacerbate symptoms or adversely interact with treatments for Parkinson's disease. Recommended dosing practices to reduce complications during hospitalisation are covered. In addition, recent concerns regarding anaesthetic exposure in early childhood as a risk factor for the development of Parkinson's disease are discussed in light of data from animal models of anaesthetic neurotoxicity and epidemiological studies.

Perioperative sublingual levodopa in Parkisnon's Disease: A useful alternative!

Timely administration of dopamine agonists is of the essence in Parkinson's disease. The perioperative period especially for abdominal surgeries under general anaesthesia poses a challenge to oral drug administration. Alternatives such as rotigotine patches and subcutaneous apomorphine administration have been described but unavailability restricts their use. Sublingual administration of tablet levodopamine as an alternative worked well in our patients and we would like to describe the same.

Whether to Proceed With Deep Brain Stimulator Battery Change in a Patient With Signs of Potential Sepsis and Parkinson Hyperpyrexia Syndrome: A Case Report

Parkinsonism-hyperpyrexia syndrome (PHS) is a neurologic emergency associated with anti- Parkinson medication withdrawal; however, its clinical presentation mimics sepsis. We describe the case of a 69-year-old man with advanced Parkinson disease who presented for exchange of the depleted battery in his subthalamic deep brain stimulator. The patient's preoperative symptoms of fever, rigidity, altered consciousness, and autonomic instability presented a dilemma whether to proceed with battery exchange to treat PHS or postpone surgery due to potential sepsis. The administration of dopaminergic medications, dantrolene, and antipyretic drugs are temporary supportive measures, while prompt restoration of deep brain stimulator function is the most important therapeutic treatment for PHS.

Anaesthesia for deep brain stimulation: a review

PURPOSE OF REVIEW

Deep brain stimulation (DBS) is a well tolerated and efficacious surgical treatment for movement disorders, chronic pain, psychiatric disorder, and a growing number of neurological disorders. Given that the brain targets are deep and small, accurate electrode placement is commonly accomplished by utilizing frame-based systems. DBS electrode placement is confirmed by microlectrode recordings and macrostimulation to optimize and verify target placement. With a reliance on electrophysiology, proper anaesthetic management is paramount to balance patient comfort without interfering with neurophysiology.

RECENT FINDINGS

To achieve optimal pain control, generous amounts of local anaesthesia are instilled into the planned incision. During the opening and closing states, conscious sedation is the prevailing method of anaesthesia. The preferred agents are dexmedetomidine, propofol, and remifentanil, as they affect neurocognitive testing the least, and shorter acting. All the agents are turned off 15-30 min prior to microelectrode recording. Dexmedetomidine has gained popularity in DBS procedures, but has some considerations at higher doses. The addition of ketamine is helpful for pediatric cases.

SUMMARY

DBS is a robust surgical treatment for a variety of neurological disorders. Appropriate anaesthetic agents that achieve patient comfort without interfering with electrophysiology are paramount.

Dementia With Lew Body: Impacts of Surgery

Patients who have dementia with Lewy bodies (DLB) and undergo surgery may develop aggravated postoperative cognitive dysfunction or postoperative delirium. Many patients with DLB respond poorly to surgery and anesthesia, and their conditions may worsen if they have other medical complications along with dementia. They may also face high risk of prolonged hospital stay, increased medical problems and/or mortality, causing significant physical, psychosocial, and financial burdens on individuals, family members, and society. Anesthesia, pain medications, old age, and surgery-related stresses are usually held responsible for the complications; however, the exact causes are still not fully understood. Literature on surgery-related complications for patients with DLB appears to be inadequate, and hence the topic merits detailed and systematic research. This article reviews postoperative complications and various surgery-related risk factors for DLB in light of other dementias such as Alzheimer's disease, as their neuropathologic features overlap with those of DLB.

Occurrence, management and outcomes of hip fractures in patients with Parkinson's disease

INTRODUCTION

Hip fractures can be debilitating, especially in patients with pre-existing Parkinson's disease; they have reportedly worse outcomes than non-Parkinson's disease patients.

SOURCES OF DATA

A computerized literature search on PubMed, Medline, Embase, and CINAHL, supplemented by a manual search of related publications.

AREAS OF AGREEMENT

Parkinson's disease patients were found to have significantly lower bone mineral density; higher incidence of falls and hip fractures; delays to receiving their Parkinson's disease medication and surgery; higher risk of pneumonia, urinary infection, pressure sores, post-operative mortality; surgical complications and sequelae, including failed fixation, dislocation, longer hospital stay, re-operation; and increased risk of contralateral hip fracture.

AREAS OF CONTROVERSY

Regain of mobility and return to previous residential status have been variably reported.

GROWING POINTS

All Parkinson's disease patients should be screened and considered for primary prevention treatment. On admission with hip fractures, attention should be paid to avoid delays to medication, ensuring safe anaesthetic and timely surgery, and post-operative chest physiotherapy and mobilization.

RESEARCH

Research is needed in minimizing the bone-resorptive effects of anti-Parkinson's disease medication.

Perioperative management of patients with Parkinson's disease

Parkinson's disease is the second most common neurodegenerative disease worldwide, leading to a wide range of disability and medical complications. Managing patients with Parkinson's disease in the perioperative hospital setting can be particularly challenging. Suboptimal management can lead to medical complications, prolonged hospital stays, and delayed recovery. This review aims to address the most important issues related to caring for patients with Parkinson's disease perioperatively who are undergoing emergent or planned general surgery. It also intends to help hospitalists, internists, and other health care providers mitigate potential in-hospital morbidity and prevent prolonged recovery. Challenges in managing patients with Parkinson's disease in the perioperative hospital setting include disruption of medication schedules, "nothing by mouth" status, reduced mobility, and medication interactions and their side effects. Patients with Parkinson's disease are more prone to immobility and developing dysphagia, respiratory dysfunction, urinary retention, and psychiatric symptoms. These issues lead to higher rates of pneumonia, urinary tract infections, deconditioning, and falls compared with patients without Parkinson's disease, as well as prolonged hospital stays and a greater need for post-hospitalization rehabilitation. Steps can be taken to decrease these complications, including minimizing nothing by mouth status duration, using alternative routes of drugs administration when unable to give medications orally, avoiding drug interactions and medications that can worsen parkinsonism, assessing swallowing ability frequently, encouraging incentive spirometry, performing bladder scans, avoiding Foley catheters, and providing aggressive physical therapy. Knowing and anticipating these potential complications allow hospital physicians to mitigate nosocomial morbidity and shorten recovery times and hospital stays.