|Year : 2019 | Volume
| Issue : 1 | Page : 68-70
Successful use of regional anesthesia in an elderly with Parkinson's disease
Department of Anaesthesiology, Pondicherry Institute of Medical Sciences, Puducherry, India
|Date of Submission||20-Mar-2019|
|Date of Acceptance||18-Apr-2019|
|Date of Web Publication||19-Jun-2019|
Department of Anaesthesiology, Pondicherry Institute of Medical Sciences, Kalathumettupathai, Ganapathichettikulam, Village 20, Kalapet, Puducherry
Source of Support: None, Conflict of Interest: None
Parkinson's disease (PD) is a relatively common neurological disorder which an anesthesiologist often encounters, especially with an increasing elderly surgical population. PD is associated with certain physiological aberrancies in the cardiovascular, respiratory, autonomic, and neurological systems that can have profound anesthetic implications. Drugs used in anesthesia may also interact with antiparkinsonian medications. There is controversy about the optimal anesthetic management of patients with PD. However, both general and regional anesthesia have been successfully used and described in these patients. We describe a case of a 65-year-old male with recently diagnosed PD posted for rectopexy. The patient underwent regional anesthesia successfully, and the perioperative period was uneventful. Hence, anesthetic management of patients with PD involves comprehensive evaluation, careful consideration, and meticulous planning to prevent and manage the complications that arise perioperatively.
Keywords: Autonomic system, Parkinson's disease, postural hypotension, saddle anesthesia
|How to cite this article:|
Thangavelu R. Successful use of regional anesthesia in an elderly with Parkinson's disease. J Curr Res Sci Med 2019;5:68-70
| Introduction|| |
Parkinson's disease (PD) is among the most disabling neurological diseases caused by dopamine–acetylcholine imbalance in the nigrostriatal pathway.
The involvement of various systems in PD, namely respiratory, cardiovascular, autonomic, and neurological systems along with the interaction of common anesthetics with the drug therapy of the patient presents an anesthetic challenge and directly influences the perioperative morbidity and mortality., In this case report, we present the successful anesthetic management of a patient with PD posted for rectopexy.
| Case Report|| |
A sixty year old male with rectal prolapse was posted for rectopexy. He had a history of tremors of the upper limbs and body from the past 5 years. On further eliciting history, he had features of increased sweating, increased salivation, alternating diarrhea, and constipation with giddiness on standing upright. He also complained of hoarseness of voice and cough with expectoration. There was no history of any previous surgeries. On general physical examination, he was noted to have resting tremors of the upper limbs and the body along with typical short stepping gait. The patient had a stooping posture with masklike facies. Vitals showed a pulse rate of 98/min with a blood pressure (BP) of 120/80 mmHg in the right upper limb in lying position. BP rechecked after making the patient stand for 3 min showed a BP of 100/60 mmHg suggesting a probable postural hypotension. Neurology consultation was sought, and he was diagnosed with PD and started on tablet amantadine 200 mg hs. In view of voice hoarseness and persistent cough, a diagnosis of laryngopharyngeal reflux probably due to the laryngeal muscles' involvement in PD was entertained in consultation with the ENT team. Furthermore, a nodular mass was detected on the chest X-ray in the left lung fields extending from the third to fifth rib. Contrast-enhanced computed tomography chest revealed a calcified pericardial hydatid cyst. However, since the patient was asymptomatic, there was no intervention advised from the cardiothoracic team.
It was decided to go ahead with subarachnoid saddle block for the rectopexy procedure. The usual night dose of amantadine 200 mg was administered. Tablet ranitidine 150 mg and lorazepam 2 mg were given orally on the morning of surgery. Metoclopramide was withheld due to risk of drug-induced Parkinsonism More Details. After shifting to the operation theatre, American Society of Anesthesiologists standard monitors were attached, and baseline parameters were recorded. A heart rate (HR) of 90 beats/min with a BP of 126/78 mmHg were recorded with a room air saturation of 95%. After preloading the patient, spinal anesthesia with 1.5 ml of 0.5% bupivacaine and 25 mcg of fentanyl (a total volume of 2 ml) was administered to the patient in sitting position. The patient was left in the sitting position for 10 min to achieve a saddle block. However, within 3 min of administration of spinal anesthesia, there was a fall in BP to 86/57 with a HR of 86/min. Injection ephedrine six mg was given intravenously, and the patient was made to lie supine to facilitate venous return. Soon, BP improved to 110/58 mmHg. Spinal level was checked, and once the level was fixed at T 10, lithotomy position was given and surgery was initiated. There was no further disturbance in hemodynamics throughout the surgery. The postoperative period was uneventful, and on the same night, oral amantadine was resumed.
| Discussion|| |
Apart from a routine history and physical examination, patients with PD often require additional assessment. Respiratory abnormalities along with cardiovascular and neuropsychiatric involvement have been described in PD making administration of anesthesia to these patients challenging.
An upper airway dysfunction along with intrinsic laryngeal muscle involvement leads to retained secretions, aspiration, atelectasis, and respiratory infections. These factors predispose patients to anesthesia complications including aspiration pneumonia, postextubation laryngospasm, and respiratory failure. Furthermore, an exaggerated hypotensive response to induction of anesthesia and postoperative emergence reactions associated with tremors and rigidity have been found in PD patients undergoing anesthesia.
Here, we had a patient with PD who was started on medication just 2 days before surgery and had features of autonomic dysfunction, thus placing the patient at risk of exaggerated, hemodynamic disturbance with regional anesthesia. Administration of drugs during spinal anesthesia as well as monitoring noninvasive BP and electrocardiography was difficult due to the constant tremors. Choosing general anesthesia (GA) on the other hand was difficult due to poor preoperative respiratory status of the patient. The patient had a room air saturation of 93% with increased salivation and persistent cough, signifying probable silent aspirations. Administering GA would place the patient at increased risk of perioperative aspiration pneumonia. Considering the risks and benefits of spinal and GA, we proceeded with low-dose spinal anesthesia. Postspinal, there was a fall in BP which was successfully treated with a small dose of sympathomimetic.
Regional anesthesia has been reported to have obvious advantages in the form of better communication of subjective feelings accompanying PD attacks. The interaction of general anaesthetics with anti parkinsonian medications, the muscle rigidity exaggerating effects of some opioids, arrythmogenic effect of inhalational agents and postoperative nausea vomiting due to polypharmacy are all avoided with the use of regional anaesthesia. These patients have better postoperative pain relief with less incidence of perioperative chest infections when compared with GA. Successful management of our case matches with few other case reports in the literature.
One of the case reports described a 77-year-old patient posted for tibia fracture surgery. She successfully underwent spinal anesthesia with levodopa continued till the morning of surgery. Spinal anesthesia was preferred to avoid the risk of perioperative aspiration pneumonia associated with GA.
A significant number of cases under GA have also been described. GA was administered to these patients with adequate care taken to prevent PD exacerbations as well as aspiration pneumonia perioperatively.,
There are not adequate randomized control trials that support any one single or simple anesthesia technique to be preferred in patients with PD. A detailed preoperative evaluation with details of drug history, the possible drug interactions, and choosing the most appropriate anesthetic technique on a case-to-case basis would go a long way in achieving an uneventful perioperative period and a smooth recovery in these patients.
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Conflicts of interest
There are no conflicts of interest.
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