Anaesthesia for patients with

Parkinson's Disease
Dr.J.Parthasarathy
 Involuntary tremulous motion, with lessened muscular power, in
parts not in actions and even when supported; with a propensity to
bend the trunk forward, and to pass from a walking to a running
pace: the senses being uninjured.
James Parkinson, 1817

• Affects approx 3% of population > 66yrs of age

• Occurs worldwide / all ethnic groups / slight male
preponderance
• Young onset Parkinson’s disease - < 40 yrs of age
 Resting Tremor / Muscle Rigidity / Bradykinesia

• Idiopathic Parkinson’s Disease

Hypothesized to be due to Neurodegeneration induced by genetic,
environmental or infectious disorders

• Syndrome of Parkinsonism
May occur due to
Arteriosclerosis repeated head trauma
Diffuse CNS degen Tumor
Wilson’s disease Metabolic defects

• Drug Induced Parkinsonism

Phenothiazines Metoclopramide
Butyrophenones
Pathophysiology

Progressive loss of Dopaminergic neurons in Substantia Nigra(part of

basal ganglia) altering normal Motor system control.

Loss of Dopaminergic Neurons

I
Imbalance of Ach : dopamine ratio
I
I
Increased inhib.activity of GABA in basal ganglia
I
I
Excessive Thalamic Inhibition
I
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I I
Suppression of cortical Inhibition of brainstem
Motor system locomotor areas
Akinesia abnormal posture
Rigidity abnormal gait
Tremor
 Clinical Features

Classical Triad :
Resting tremor – “pill rolling movement”
Muscle rigidity - “cog wheel type”
Bradykinesia

Micrographia
expressionless face
Festinant gait
Dysautonomia
Treatment :
Medical

• L-DOPA with Dopa decarboxylase inhibitor

• Dopamine agonists - bromocriptine Ropinirole
Pergolide pramipexole
Cabergoline
Apomorphine
• MAO Inhibitors - Selegiline
• COMT Inhibitors - Tolcapone, Entacapone

Surgical
Deep brain stimulation
Subthalamic nucleus stimulation
Cell transplantation (fetal mesencephalic tissue
Anaesthetic considerations
In addition to routine assessment consider
 
Head & Neck : Dysphagia , Sialorrhoea

RS : Rigidity

CVS : Orthostatic hypotension Arrhythmias

Hypertension Hypovolemia

GIT : Reflux
Respiratory system

Aspiration pneumonia

COAD

Upper airway dysfunction - retained secretions

Atelectsasis
Resp tract infection

Post extubation laryngospasm

Post op respiratory failure

CVS : Orthostatic hypotension ( drug effect)
 

ANS :
Difficulty with salivation
Micturition
Swallowing
Defective temperature regulation
 

GIT : Sialorrhoea
Anaesthetic Management

Timing of drug therapy

Pre and post op doses not to be missed
Regional anaesthesia where possible
Avoid phenothiazines/metoclopramide
 

Hyper reflexia I
Decerebrate posture I during
Post op confusion I recovery phase
Hallucinations I
 
Inhalation agents

Halothane - avoided all others – safe

Exaggerated Hypotension
 

IV Induction agents

Ketamine - exaggerated sympathetic response

Propofol - Ideal
Thiopental – few case reports of parkinsonian
episodes
Neuromuscular blockers

Succinylcholine - single case report of

hyperkalemia
Non depolarizers - safe
 
 
 Opioids

Fentanyl - Muscle rigidity

Morphine - muscle rigidity
Alfentanil - dystonic reactions
 SUMMARY
• Elderly patients with coexisting diseases

• Medication at odd times

• Not to miss medication pre and post op

• Avoiding precipitant drugs

• Recovery period may not be smooth

• Aim should be to reduce post op morbidity