Continue patients drug regimen – The patient should remain on drug therapy until surgery and throughout the perioperative period. The exception to this is if the patient is scheduled to receive a deep brain stimulator and the physician has requested the discontinuation of drug therapy to allow the return of symptoms as a means of testing the effectiveness of the stimulator. Otherwise, If the patient goes without drug therapy for more than 6-12 hours, there will be acute loss of therapeutic affects, which can complicate anesthetic care (eg. rigidity can interfere with ventilation). Oral levadopa can be given 20 minutes prior to induction and intraoperatively every 2 hours via orogastric/nasogastric routes. The patient should resume their normal drug regimen as soon as possible after surgery.

Intraoperative drugs – choice of NMB is NOT affected by parkinsons disease. Ketamine is generally safe when the patient is still taking Levadopa. Ketamine, in combination with levadopa, can cause exaggerated sympathomimetic affects. Studies show that sympathomimetics and ketamine can still be safely administered – just administer with caution. Avoid phenothiazine, butyrophenone, and metoclopramide as these can precipitate/exacerbate Parkinsons disease. Diphenhydramine is particularly useful where sedation is necessary – this is particularly true during ophthalamic cases. Robinul is preferred over atropine because it does not cross the BBB. Ondansetron is preferred over droperidol as an antiemetic. Rigidity can be exacerbated by rapid administration of fentanyl. For pain, It is recommeded to use opioids (eg fentanyl) lightly and use toradol and adjuvants where not contraindicated. Succinylcholine has been shown in one study to be associated with cardiac arrest, and conversely in other studies to have no effect.

Aspiration risk – Rigidity of the pharangeal tissue may impair the patients ability to adequately swallow and/or clear the airway. Assess and document. Preoperative acid aspiration prophylaxis should be administered.

Nausea and vomiting – Parkinsons patients that are taking levadopa can exhibit extreme nausea and vomiting. This dysrupts normovolemia and contributes to aspiration risk. Treat with fluids in the preoperative period and administer aspiration prophylaxis

Assess cognition – these patients often have a dysruption of normal cognition, mood, and/or behavior. These can be blamed on the anesthetic approach so assess and document prior to the procedure.

Dopamine inhibits the affects of acetylcholine on the extrapyramidal motor system in the brain. As dopamine fibers are diminished, acetylcholine goes unchecked, which results in the symptoms seen in Parkinsons disease.

Etiology – The array of symptoms related to Parkinsons disease are caused by the loss of dopaminergic fibers in basal ganglia of the brain. The exact reason for the loss of those fibers is unclear.

Incidence – about 1% of the total population over 60 years of age

Diagnosis – Diagnosis can typically be made if the patient demonstrates two of the following: rest tremor, rigidity, and bradykinesia

Symptoms – The four cardinal signs/symptoms of this disease are skeletal muscle tremor, rigidity, bradykinesia, and impaired postural reflexes. Dimentia and depression are also common. Tremors are rhythmic, often manifesting as the iconic “pill rolling” motion in the hands. These rhythmic tremors tend to disappear with deliberate movement.

Treatment – Treatment is designed to alleviate symptoms. There currently is no cure for Parkinsons disease. Levadopa and a decarboxylase inhibitor (eg. carbidopa) are the most common and most effective drug treatment. A deep brain stimulating device is a common surgical treatment.