What is the recommended perioperative management plan for a patient with Parkinson's disease undergoing surgery?

Perioperative Management Plan for Patients with Parkinson's Disease

Patients with Parkinson's disease should continue their anti-parkinsonian medications throughout the perioperative period with minimal interruption to maintain optimal symptom control and prevent complications. 1

Preoperative Planning

Medication Management

• Schedule surgery early in the morning to minimize medication disruption 2
• Administer Parkinson's medications as close to the patient's usual dosing schedule as possible 2
• For patients on carbidopa-levodopa (Sinemet):
  • Continue medication up to 3 hours before surgery
  • Consider alternative administration routes when NPO status is required:
    • Intravenous levodopa infusion if available 3
    • Crushing immediate-release tablets and administering via nasogastric tube

Risk Assessment

• Identify higher-risk patients:
  • Advanced age
  • ASA status 3-4
  • Low BMI
  • History of previous delirium
  • Preoperative cognitive impairment 1

Intraoperative Management

Anesthetic Considerations

• Monitor depth of anesthesia to prevent overdosing 1
• Avoid medications that can worsen parkinsonian symptoms:
  • Dopamine antagonists (metoclopramide, droperidol, haloperidol)
  • Phenothiazines
  • Butyrophenones 1

Temperature Management

• Prevent hypothermia using forced-air or circulating-water warming systems 4

Postoperative Management

Pain Management

• Implement multimodal pain management approach:
  • Mid-thoracic epidural analgesia for major open abdominal surgery (provides superior pain relief with fewer respiratory complications) 4
  • Acetaminophen (650-1000 mg IV every 4-6 hours, max 4g/day) 1
  • NSAIDs if not contraindicated 1
  • Minimize opioid use to prevent confusion and respiratory depression 1
  • Consider regional anesthesia techniques when appropriate 1

Medication Resumption

• Resume Parkinson's medications immediately after surgery when patient is able to take oral medications 5
• If unable to take oral medications:
  • Use alternative administration routes (NG tube, transdermal)
  • Minimize duration of missed doses (half-life of carbidopa-levodopa is only 1-2 hours) 2

Preventing Complications

Respiratory Care

• Encourage incentive spirometry to prevent pneumonia 5
• Assess swallowing ability frequently to prevent aspiration 5
• Remove nasogastric tubes as early as possible (pre-emptive use does not improve outcomes) 4

Gastrointestinal Management

• Allow normal diet after surgery without restrictions, starting carefully and increasing according to tolerance 4
• Consider multimodal approach to stimulate bowel movement:
  • Oral laxatives (magnesium sulphate, bisacodyl)
  • Chewing gum 4

Fluid Management

• Maintain near-zero fluid balance, avoiding overload of salt and water 4
• Encourage oral fluids unless contraindicated 1
• Restrict IV fluids to no more than 500 ml to reduce risk of urinary retention 1

Urinary Function

• Perform regular bladder scans to assess for retention 5
• Remove urinary catheters early (postoperative day 1 or 2) 4
• Avoid Foley catheters when possible 5

Mobilization

• Implement early mobilization to prevent deconditioning 1
• Provide aggressive physical therapy 5
• Assist with gradual position changes to prevent dizziness 1

Managing Psychiatric Symptoms

• Avoid benzodiazepines as first-line treatment for agitation/delirium 1
• For postoperative nausea and vomiting, use:
  • Ondansetron or other 5-HT3 antagonists
  • Dexamethasone
  • Domperidone (if available) 1

Common Pitfalls and How to Avoid Them

1. Medication timing disruption

   • Use medication administration schedules that align with patient's home regimen
   • Minimize NPO duration
   • Have alternative administration routes ready

2. Worsening of motor symptoms

   • Avoid dopamine-antagonizing medications
   • Continue Parkinson's medications perioperatively

3. Postoperative confusion/delirium

   • Minimize sedating medications
   • Promote sleep hygiene and reduce noise
   • Ensure adequate nutrition 1

4. Respiratory complications

   • Early mobilization
   • Regular swallowing assessments
   • Incentive spirometry

By following this comprehensive perioperative management plan, you can minimize complications, reduce hospital length of stay, and improve outcomes for patients with Parkinson's disease undergoing surgery.