What anesthesia should be avoided in patients with Parkinson's disease?

Anesthesia Management in Patients with Parkinson's Disease

Dopamine antagonists and certain inhaled anesthetics should be avoided in patients with Parkinson's disease as they can worsen parkinsonian symptoms and trigger life-threatening complications. 1

Anesthetic Agents to Avoid

• Dopamine Antagonists:

  • Metoclopramide
  • Droperidol
  • Haloperidol
  • Other phenothiazines and butyrophenones

• Inhaled Anesthetics to Use with Caution:

  • Halothane
  • Isoflurane
  • Sevoflurane

• Muscle Relaxants:

  • Succinylcholine (especially in advanced disease with muscle rigidity) 1

Preferred Anesthetic Approaches

1. Regional Anesthesia:

   • Spinal, epidural, or peripheral nerve blocks are associated with fewer perioperative complications and shorter hospitalization periods 1
   • These techniques avoid potential interactions with parkinsonian medications and reduce the risk of postoperative delirium

2. When General Anesthesia is Required:

   • Total intravenous anesthesia (TIVA) with propofol is preferable to inhaled agents 1
   • Use depth of anesthesia monitoring (BIS/entropy) to prevent overdosing
   • Consider multimodal analgesia to reduce opioid requirements

Perioperative Medication Management

• Continue Parkinson's medications perioperatively with minimal interruption 1
• Keep NPO (nothing by mouth) period as short as possible
• Maintain regular dosing schedule of anti-Parkinsonian medications
• Consider alternative routes (nasogastric tubes) if oral intake is restricted

Postoperative Considerations

• Avoid benzodiazepines for postoperative delirium unless benefits outweigh risks 1

• For postoperative nausea and vomiting, use:

  • Ondansetron and other 5-HT3 antagonists
  • Dexamethasone
  • Domperidone (if available)
  • NOT metoclopramide 1, 2

• Monitor closely for worsening of parkinsonian symptoms

• Resume regular Parkinson's medication schedule as soon as possible

Special Considerations

• Patients with Parkinson's disease are at higher risk for postoperative delirium 3
• Drugs that precipitate delirium (including benzodiazepines, opioids, antihistamines, atropine, sedative hypnotics, and corticosteroids) should be used cautiously 3
• Multimodal analgesia including nerve blockade, paracetamol, and cautious use of NSAIDs may help reduce opioid requirements 3

By carefully selecting appropriate anesthetic techniques and avoiding medications that can exacerbate Parkinson's disease symptoms, anesthesiologists can significantly reduce perioperative complications and improve outcomes for these vulnerable patients.