Regarding anesthetics consideration,attention shoud be directed towards maintainance of drugs theraphy associated physiologic disturbance and potential adverse drugs interaction. Parkinson related disturbance of systemic physiology include respiratory dysfunction,dysphagia,autonomic dysfunction and sleep related ventillatory abnormalities.(2)
Respiratory dysfunction is a particularly prominent feature,PD can produce restrictive lung disease secondary to chestwall rigidity but pulmonary function often reveal an obstructive pattern with characteristic sawtooth pattern on flow volume loops.
Upper airway abnormalities also occur,involuntary movements of the glottis and superglottic cause intermittent airway obstruction,a condition that can be exacerbated by levodopa withdrawal.
Upper airway obstruction laryngospasm and respiratory arrest are documented complications of PD and may occur outside the setting of anesthesia and surgery.Therefore perhaps not surprisingly,laryngospasm has been reported post operatively in awake patient hours after surgery.
Autonomic dysfunction can also be a problem,this condition affects the ability of PD patients to respons the hypovolemia and vasodilatation sometimes ascociated with anestheisa and surgery.
Orthostatic hypotension or thermoregulatory or genitourinary dysfunction suggest preexisting autonomic insufficiency and should heighten awareness of the potential for perioperative hemodynamic instability and altered respons to vasopressor such as nor adrenaline.
Especially PD patients with preexisting disturbance of cardiac conduction or coronair disease,cardiac arrhythmia is often occured.(3)
PD patients are predisposed to aspiration because they often have severe but asymptomatic,dysphagia and dysmotility that combined with upper airway abnormality,present an especially troublesome situation.
In fact pulmonary aspiration is a common cause of death among patients with PD. Administration of antacids and prokinetic agents should be considered,
Metoclopropamide should be avoided however,because it is dopamine receptor antagoinist and could acutely exacerbate the disease.In contrast,prokinetic agents such casapride or domperidone have no effects on dopaminergic balance and reasonable alternatives.(2)
Emotional stress in the perioperative period can also exacerbate the disease, Levodopa therapy shoud be continued through out the perioperative period because abrupt stopping levodopa may result execerbation of PD symptoms. and to avoid skletal muscle rigidity (3,4).
Long term levodopa treatment can also cause CNS dysfunction ,such as dyskinesia,agitation, confusion, overt psychosis have been reported in the postoperative priod.
Anesthetics and a number of other agents used perioperatively may affect the disease process.
Volatiles anesthetics can alter dopaminergic balance in the brain.
Dopamine that results from levodopa administration can augment cardiac irritability , a result cardiac arrhythmia may occur frequently under halothane anesthesia although this has not proved to be clinically significant.Drugs with dopamine antagonizing properties such as phenothiazine and butyrophenones should also be avoided. In at least one case butyrophenone may have induced parkinsonism in normal patient. Side effects of anticholinergics drugs such as dry mouth,urinary retention,and confusion especially in the elderly can be troublesome.
The use of ketamine has been questioned in those being treated with levodopa because of the possibility of exagerated sympathetics respons, However in a single case report,ketamine temporarily stopped the motor symptoms of the disease. Propofol produces both dyskinesias and ablation of resting tremor, suggesting that it may have both excitatory and inhibitory effects in this patient population.
Opioids are considerably more likely to produce muscular rigidity in a patient with PD,but acute dystonia has been observed in only a single patient with untreated disease.
Mepiridine should probably be avoided in the patient taking an MAOI because of the potential for development of stupor,rigidity,agitation and hyperthermia.(2)
One case report exist of an exacerbation of PD after fentanyl administration,it was suggested that alfentanyl may have precipitated this reaction through a dopaminergic blocking action in the nigrostriatal system.
The choice of muscle relaxants does not to be influenced by the presence of PD. However succinylcholine should be used with caution there has been report of succinylcholine induced hyperkalemia in a patient with PD.
SUMMARY :
Parkinson's disease is manifestation of relative imbalanced between dopaminergic and chlonergic within the striatum.
The patient PD,the basal ganglia content of dopamine in only 10% of normal,as a result there is an excess of excitatory chlinergic activity manifesting as tremor,skletal muscle rigidity and disturbanced of posture.
-The goal of treatment of PD is to enhance the inhibitory effect of dopamine or reduce the stimulatory effect of acetylcholine.
-Levodopa as the immediated metabolic precursor of dopamine acts by replenishing the depleted store of dopamine in the basal ganglia.
-Abrupt discontinuation of levodopa therapy may result in precipituous return of symptoms
For this reason levodopa therapy should be continued throughout the perioperative period.
-Regarding anesthetic consideration attention should be directed toward maintanance of perioperative drugs therapy,ascociated physiologic disturbance and
potential drug interaction.
REFERENCES :
1.Abine M,Solomone D : Neurologic Syndromes and Disorders with their Anesthesia Complication in Textbook of Neuroanesthesia with Neuro Surgical and Neuroscience Perspective,The McGraw-Hill Companies,Newyork,St.Louis
,San Fransisco,1977 pp 409-11.
2.Culley J.Deborah
Cottrell E,Smith C.D. : Neurologic Disease and Anesthesia in Textbook of Neuroanesthesia and Neurosurgery,4th edition, Mosby Company,St.Louis-London, Philadelphia,Sidney,Toronto 2001,pp 611-13.
3. Stoelting Robert : Drugs used for Treatment of Parkinson's Disease in Textbook of Pharmacology and Physiology in Anaesthetic Practice, J.B.Lippincott Company,Philadelphia,1987,pp 508-13.
4 Leisure S.G : Anesthesia for the patient with Neurologic disease in The Neuro Stone J.D. anesthesia Handbook,Mosby Company,St. Louis,Baltimore,Boston, 1996,pp 151-3.
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