Parkinson’s disease is a common condition that affects over 100,000 people in the UK. Patients with Parkinson’s disease have a higher perioperative mortality rate and length of stay than those without Parkinson’s disease. Missed doses of dopaminergic medication due to perioperative water fasting may lead to serious life-threatening complications. Additional complications may arise if accompanied by impaired drug absorption. Recognizing these risks is the first step in reducing the risk of inappropriate medication use during the perioperative period in patients with Parkinson’s disease, in addition to the three principles of advance planning, rational medication use, and consultation with a specialist.
The potential complications of missed medications, although individual differences exist, should never be taken lightly due to the seriousness of the consequences!
The consequences of missed Parkinson’s disease medications can vary widely. Some patients can tolerate an occasional missed dose of medication without significant clinical manifestations, while others may suffer from motor inability. In some patients, missed doses of dopaminergic medications may lead to a malignant-like syndrome, manifested by fever, confusion, elevated muscle enzymes and even death. This syndrome is most often seen in patients with severe Parkinson’s disease or in patients receiving higher doses of levodopa therapy.
What are the specific risks we face?
Some risks are related to Parkinson’s disease itself, while others are related to missed doses of medication. A retrospective cohort study of 234 patients with Parkinson’s disease who underwent major abdominal surgery and 40,979 controls found that the odds of developing aspiration pneumonia, bacterial infections and urinary tract infections were significantly higher in the Parkinson’s disease group than in the control group.
Case reports also describe other complications during the perioperative period in patients with Parkinson’s disease, including postoperative respiratory failure and laryngospasm after extubation. Intraoperative exacerbation of Parkinson’s symptoms has also been reported, and in one case, a malignant syndrome-like presentation was precipitated by fasting during the perioperative period of coronary artery bypass grafting.
Access to regular medication at the right time after admission to hospital for Parkinson’s disease remains a major challenge. This has led to a domestic missionary campaign by the Parkinson’s UK charity. Failure to understand the importance of medication maintenance during surgery for Parkinson’s disease significantly increases the patient’s risk of surgery.
Reduce risk, plan ahead
A mission plan for patients with Parkinson’s disease should include encouraging patients to request a consultation with a physician from a movement disorders specialty group prior to admission to the hospital. This facilitates the identification of high-risk patients and the administration of individualized treatment plans. This referral can come from the patient’s general practitioner, surgical clinic, or preoperative evaluation clinic.
The purpose of this is to clarify whether the patient’s treatment plan needs to be changed during the perioperative period and whether additional evaluation is required.
Who is responsible for giving expert advice?
In some places, Parkinson’s disease specialist nurses can play a key role. They can give advice directly or discuss the condition with the patient’s consulting physician. If there is no nurse specialist support, these recommendations may be given by the patient’s geriatrician or neurologist.
Unplanned surgery and complex elective surgery
Preoperative specialist advice is not always available, especially for emergency surgery. To ensure that a treatment plan can be developed at all times, we recommend that hospitals should develop appropriate guidelines for treatment. We recommend that non-(Parkinson’s disease) specialists use the flow chart as a guide until they have received a specialist opinion from the movement disorder team. Clinicians unfamiliar with Parkinson’s disease medications can consult with a pharmacist for additional assistance.
Anesthesia and surgical considerations
Preoperative
Patients undergoing surgery with either general or local anesthesia are required to fast before surgery. However, it is currently considered safe to consume a clean, liquid meal via the mouth 2 hours prior to elective surgery. It is routine practice that oral medications should be continued until the induction of anesthesia. This should be encouraged even more in patients with Parkinson’s disease. Care should also be taken to schedule such patients for the first surgery of the day whenever possible, a move that facilitates better prediction of the timing of fasting and surgery and ensures that reasonable treatment is given as early as possible after surgery.
Induction – local versus general anesthesia
Multiple factors influence the choice of anesthesia. Local anesthesia allows observation of symptoms in patients with Parkinson’s disease and can be used in patients treated with frequent dopaminergic medications. Intraoperative administration of oral medications may be considered in some special cases, but there have been cases reported of exacerbation of Parkinson’s symptoms despite these treatments.
The recommended anesthetic for patients with Parkinson’s disease with severe motor impairment is general anesthesia. Anesthesiologists need to be aware of the effects of conventional anesthetic drugs on patients with Parkinson’s disease. Propofol is a commonly used anesthetic induction agent, and two case reports have suggested that it can exacerbate dyskinesia in patients with Parkinson’s disease [11]. However, propofol temporarily reduces tremor symptoms in patients with Parkinson’s disease, so it is still the first choice of most anesthesiologists. Its antiemetic efficacy is also its strength.
Intubation needs to be assessed on an individual basis. Patients with severe Parkinson’s disease have excessive salivation due to swallowing impairment. If swallowing difficulties are suspected, intubation is a safer option. Anticholinergic drugs need to be used with caution in such patients because they increase the viscosity of saliva, further impairing swallowing function.
Intraoperative
Antiemetics are routinely administered intraoperatively. Centrally acting dopaminergic antagonists such as prochlorperazine and metoclopramide have the potential to exacerbate Parkinson’s disease symptoms. Domperidone is recommended because it exhibits mostly peripheral effects, and suppositories are available. Other appropriate antiemetics include 5-hydroxytryptamine-3 antagonists such as ondansetron and the antihistamine seclizine.
Some patients are fitted with a brain pacemaker, which needs to be highlighted in the medical record. Electrocautery has the potential to disrupt intracranial wiring and is therefore recommended by the manufacturer to be avoided if possible. However, if necessary, the application of bipolar electrocoagulation can be considered [14].
Postoperative period
Parkinson’s patients need to be evaluated as early as possible after surgery and their ability to absorb intestinal medications needs to be determined. If oral feeding is not possible or if there is severe vomiting, the drug should be administered by other routes. If intestinal obstruction or delayed gastric emptying occurs, parenteral administration is more likely to be required. Specialist advice from a Parkinson’s disease nurse or consultant is required in this case.
Appropriate prescribing
The overall strategy is to make the treatment of patients with Parkinson’s disease as similar as possible to the usual treatment. Depending on the patient’s specific medication and surgical approach, there are several variations to choose from
Use different dosage forms of the same drug
Patients who normally use levodopa may be given benserazide levodopa dispersible tablets via nasal cannula as an alternative treatment during prolonged surgery. A patient with severe Parkinson’s disease who underwent liver resection did not experience any exacerbation after applying the above approach. The patient had previously experienced significant postoperative myalgias and dysphagia.
The above technique is not suitable for patients with paralytic intestinal obstruction. Two case reports both suggest that patients recovering from surgery with intestinal obstruction had exacerbation of parkinsonian symptoms despite treatment with oral benserazide levodopa dispersible tablets.
When converting levodopa controlled-release tablets to benserazide levodopa dispersible tablets, it is generally recommended that the dosage be reduced by about 30% because of the lower bioavailability of the controlled-release tablets.
Perioperative Parkinson’s drug replacement therapy
Enteral administration is not indicated for patients with postoperative intestinal obstruction or delayed gastric emptying. Treatment options for such patients are concomitant risky suboptimal therapy or consideration of switching to parenteral medications (apomorphine or rotigotine).
Apomorphine is a potent dopamine agonist that can be administered subcutaneously. Switching from oral medication to apomorphine may avoid impaired drug absorption in patients with paralytic intestinal obstruction. Because of its potent effect, apomorphine is effective in controlling symptoms even in patients who are usually treated with high doses. The main side effects include vomiting (with concomitant use of domperidone), neuropsychiatric symptoms such as hallucinations and hypotension.
Rotigotine is a relatively newer drug. It is also a dopamine agonist and can be administered transdermally via a patch. In an open study, 14 patients changed their usual treatment to rotigotine 1 day before surgery. Both clinicians and patients felt the switch was easy and only one patient experienced side effects (transient hallucinations and nausea). It has the advantage of being simple to use and well tolerated, but it is not potent enough to provide satisfactory efficacy in patients requiring larger doses of the drug.
Drug switching of apomorphine or rotigotine
Many literature reports levodopa-equivalent doses of multiple therapeutic agents. Based on the above data and the results of several head-to-head studies on rotigotine and ropinirole, a table of currently available equivalent doses of various drugs can be constructed. In this case, our experience is to start with a lower dose than the equivalent dose to reduce the risk of drug side effects, but early follow-up and adjustment of the drug dose is recommended.
Expert advice
Even with a consensus advance plan or written protocol, it is important to schedule a visit with a Parkinson’s disease nurse specialist or movement disorders consultant as early as possible for patients who have difficulty resuming their regular Parkinson’s disease medication regimen soon. This will allow timely adjustments to the treatment plan based on the patient’s starting response.
The length of stay for Parkinson’s disease patients after knee replacement can be significantly reduced with follow-up by a neurologist. More research is needed to confirm whether this approach can benefit Parkinson’s disease patients undergoing other procedures.