J Clin Diagn Res. 2013 Jan; 7(1): 148149.

Published online 2013 Jan 1. doi: 10.7860/JCDR/2012/5175.2691

PMCID: PMC3576772

Anaesthetic Management of a Geriatric Patient with

Parkinsons Disease, who was Posted for Emergency
Laparotomy- A Case Report
Renuka T Holyachi,1 Santosh Karajagi,2 and Siddanagouda M Biradar3

Author information Article notes Copyright and License information

Abstract
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INTRODUCTION
Parkinsons Disease (PD) is a degenerative disease of the central nervous system which is
caused by the loss of dopaminergic fibres from the basal ganglia. It affects all the age groups
but about 20% cases have been seen in less than 50 years. PD affects approximately 3% of
the population which is over 66 years of age [1].
Many patients may be newly diagnosed at the time of their pre anaesthetic examinations [2].
Few case reports are available, but controversies and dilemmas still exist regarding the role
of spinal anaesthesia, the choice of opioid analgesics and depolarizing muscle relaxants like
succinyl choline andoptimal and the methods of continuation of the anti- Parkinsonian
medication in the perioperative period [3].This case report describes the anaesthetic
management of a patient with a history of Parkinsons disease, who was posted for
emergency laparotomy.
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CASE REPORT
A 76 years old male, who weighed 65 kg and had Parkinsons disease was scheduled for
emergency exploratory laparotomy for a suspected acute intestinal obstruction. He had been
diagnosed as PD seven months back and was on irregular treatment with oral tab. ropinorole
1 mg; tab. trihexyphenydyl 2 mg and tab. propranolol 10 mg, thrice daily. There was no
history of hypertension, diabetes mellitus, ischaemic heart disease or bronchial asthma. He
was a non smoker and a non alcoholic. There was a history of bladder dysfunction in the
form of an increased urinary frequency and urgency. There was no history of any other long
term medication or drug abuse or any psychiatric illness. There was no history of any
previous anaesthetic exposure.
The patient had pill rolling tremors of his fingers at rest and cog wheel rigidity. He was
oriented to the time, place and person. He was co- operative, with a history of elicitation and
was able to recollect his medication regime, which was suggestive of no impairment in his
memory and intelligence. He was able to perform his routine daily activities with assistance.
His muscle power was 4/5 in both the upper and lower limbs. His sensory system was
normal. The patients gait could be assessed with difficulty, due to an abdominal discomfort
and it was slow, with a stooped posture.
He had pallor and signs of mild dehydration. He was edentulous, with adequate mouth
opening, Mallampati grade II and normal neck flexion and extension movements. His pulse
was 80 beats/ min and it was regular, with good volume. His blood pressure was 150/80
mmHg in while he was in the supine position and it was 140/72 mmHg when he was in the
sitting position. His respiratory rate was 40/min. Auscultation of his chest revealed bilateral
crepitations. His cardiovascular system examination was normal. His routine blood
investigations, ECG and electrolytes were within normal limits. His chest X-ray showed
prominent bronchovascular markings and COPD changes. Ultrasonography of his abdomen
showed features of intestinal obstruction and grade II prostatic hypertrophy, with no
organomegaly or ascitis. The patient was accepted for anaesthesia with ASA grade III E.
The patient was given his usual anti Parkinsonian medications via a nasogastric tube, one
hour before the operation. Nebulization with Salbutamol and ipratropium bromide was given
pre operatively. Intra venous premedication was given with inj. glycopyrollate 0.2 mg, inj.
ondansetron 4 mg, and inj. midazolam 1.5 mg. His monitoring included pulse oximetry,
ECG, NIBP, ETCO2, his temperature and his urine output. We had difficulty in recording his
basal vital parameters due to the tremors and rigidity. A general anaesthesia with
endotracheal intubation and a controlled ventilation was planned. After preloading with 500
ml of Ringers lactate, pre oxygenation was done with 100% oxygen for 5 min. The patient
was induced with inj. thiopentone 200mg iv. Rocuronium 30 mg iv was given to facilitate the
tracheal intubation with a 8.5 cuffed endotracheal tube. The anaesthesia was maintained with
O2 + isoflurane + atracurium. Morphine 4 mg iv was used for the intra operative analgesia.
The operative procedure, which lasted for three hours, consisted of the release of the
adhesive bands in the ileal region. The intra operative urine output was 300 ml and the blood
loss was around 400 ml. Two litres of crystalloids were used intra operatively. The patient
was haemodynamically stable throughout the procedure.
At the end of the surgery, he was extubated, following a reversal with neostigmine and
glycopyrolate. His post operative pain was managed with NSAIDs. His anti Parkinsonian
medications were continued after surgery via a feeding tube for 2 days. He was then allowed
to take them orally and he resumed his usual medication. His postoperative course was
uneventful.
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DISCUSSION
The degeneration of the dopaminergic neurons of the substantianigra leads to PD. The
autonomic dysfunction can manifest as orthostatic hypotension, leading to a sudden
exaggerated response to the central neuraxial blockade. A delayed gastric emptying and a
thermoregulatory or a genitourinary dysfunction are common. The patients show altered
responses to the vasopressors [35].
Upper airway dysfunction can cause retained secretions, atelectasis, aspiration, lower
respiratory tract infections and post extubation laryngospasms [6]. The Parkinsonism-
Hyperpyrexia Syndrome (PHS) can occur in the perioperative period. It is characterized by
high fever, extreme muscle rigidity, autonomic instability, altered consciousness, acute renal
failure and a disseminated intravascular coagulation. PHS occurs in up to 4% of the PD
patients; the mortality ranges from 4% for the treated to 20% for the untreated episodes. PHS
can be prevented by an uninterrupted administration of medications. An early recognition
and an aggressive treatment with fluid replacement, resuming of the dopaminergic therapy
and supportive care, is necessary for a successful recovery [7].
Dopa agonists can be given orally, intravenously or transdermally. In the patients who are
unable to take medications orally or through a gastric tube, parenterally administered
anticholinergic drugs such as trihexyphenidyl, benztropine, or diphenhydramine can be
given. Levodopa and carbidopa are absorbed in the small intestine. A duodenal feeding tube
may be useful [3]. Dopamine antagonists like droperidol, haloperidol, risperidone,
metaclopramide, prochlorperazine, promethazine, phenothiazines, butyrophenones, etc
should be avoided. Regional anaesthesia has advantages over general anaesthesia as it avoids
the effects of the general anaesthetics and the neuromuscular blocking drugs, which may
mask the tremors. The high incidence of nausea and vomiting which is associated with
general anaesthesia, prevents the effective administration of the oral medications and
exacerbation can occur in the postoperative period [8].
Thiopentone and propofol are relatively safe. Ketamine is contraindicated due to the
exaggerated sympathetic responses which it produces. There are numerous reports of muscle
rigidity following the use of fentanyl [9]. Neuromuscular blocking agents can be used safely
in patients with Parkinsons disease. Investigations which were done, have suggested that
succinyl choline does not induce hyperkalaemia [10]. Halothane, which sensitizes the heart
to catecholamines, should be avoided in patients who are on Levodopa. Isoflurane is safe, as
it does not sensitize the myocardium to catecholamines.
Numerous case reports have described various approaches which were made to the
perioperative management [4,5], but there are no definite treatment guidelines. The major
goal of the management in the perioperative period, is to continue the administration of the
dopamine replacement therapy.
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CONCLUSION
The patients with PD can be safely anaesthetized, but a thorough preoperative assessment,
minimizing the interruption of the drug therapy perioperatively and avoiding the known
precipitating agents, are very important to reduce the postoperative mortality and the
morbidity. Regional anaesthesia is the technique of choice, whenever it is possible.
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Notes

Financial or Other Competing Interests

None.
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REFERENCES
[1] Rudra A, Rudra P, Chatterjee S, Das T, Ray M, Kumar P. Parkinsons Disease and
Anaesthesia. Indian J Anaesth. 2007;51:382.
[2] Kalenka A, Hinkelbein J. Anaesthesia in patients with Parkinsons
disease. Anaesthetist. 2005;54:40109. [PubMed]
[3] Jankovic J. Complications and limitations of drug therapy for Parkinsons
disease. Neurology. 2000;55:S26. [PubMed]
[4] Christopher B, Susan M, Calne RN. The management of medical and surgical problems
in Parkinsons disease. BCMJ. 2001;43(4):21923.
[5] Furuya R, Hirai A, Andoh T, Kudoh I, Okumura F. Successful perioperative management
of a patient with Parkinsons disease by enteral levodopa administration under
propofolanaesthesia. Anesthesiology. 1998;89:26163. [PubMed]
[6] Easdown LJ, Tessler MJ, Minuk J. Upper airway involvement in Parkinsons disease
resulting in postoperative respiratory failure. Can J Anaesth. 1995;42:34447. [PubMed]
[7] Nicholsan G, Pareira AC, Hall GM. Parkinsons disease and anesthesia. Br J
Anaesth. 2002;89:90416.[PubMed]
[8] Shaikh SI, Verma H. Parkinsons disease and anaesthesia. Indian J Anaesth. 2011;55:228
34.[PMC free article] [PubMed]
[9] Comstock MK, Scamman FL, Carter JG, Moyers JR, Stevens WC. Rigidity and
hypercarbia on fentanyl-oxygen induction. Anesthesiology. 1979;51:S28.
[10] Muzzi DA, Black S, Cucchiara RF. The lack of effect of succinylcholine on serum
potassium in patients with Parkinsons disease. Anesthesiology. 1989;71:322. [PubMed]

Articles from Journal of Clinical and Diagnostic Research : JCDR are provided here courtesy
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PENGANTAR

Penyakit Parkinson (PD) adalah penyakit degeneratif sistem saraf pusat yang disebabkan oleh
hilangnya serat dopaminergik dari ganglia basal. Ini mempengaruhi semua kelompok umur tapi
sekitar 20% kasus telah terlihat dalam waktu kurang dari 50 tahun. PD mempengaruhi sekitar 3%
dari populasi yang lebih dari 66 tahun [1].

Banyak pasien dapat yang baru didiagnosis pada saat pemeriksaan anestesi pra mereka [2].
laporan kasus yang tersedia, tetapi kontroversi dan dilema masih ada mengenai peran anestesi
spinal, pilihan analgesik opioid dan depolarisasi relaksan otot seperti suksinil kolin andoptimal dan
metode kelanjutan dari obat anti Parkinsonian dalam periode perioperatif [3] .Ini laporan kasus
menggambarkan manajemen anestesi pasien dengan riwayat penyakit Parkinson, yang telah
diposting untuk laparotomi darurat.

Pergi ke:

LAPORAN PERKARA

Sebuah 76 tahun laki-laki tua, yang beratnya 65 kg dan memiliki penyakit Parkinson dijadwalkan
darurat laparotomi eksplorasi untuk dicurigai obstruksi usus akut. Dia telah didiagnosis sebagai PD
tujuh bulan kembali dan pengobatan teratur dengan tab oral. ropinorole 1 mg; tab. trihexyphenydyl 2
mg dan tab. propranolol 10 mg, tiga kali sehari. Tidak ada riwayat hipertensi, diabetes mellitus,
penyakit jantung iskemik atau asma bronkial. Dia adalah seorang non perokok dan non alkohol. Ada
riwayat disfungsi kandung kemih dalam bentuk frekuensi kencing meningkat dan urgensi. Tidak ada
sejarah dari setiap pengobatan jangka panjang lainnya atau penyalahgunaan obat atau penyakit
jiwa. Tidak ada sejarah dari setiap paparan anestesi sebelumnya.

Pasien memiliki pil tremor bergulir dari jari-jarinya saat istirahat dan gigi roda kekakuan. Dia
berorientasi pada waktu, tempat dan orang. Dia operatif bersama, dengan sejarah elisitasi dan
mampu mengingat rezim obatnya, yang sugestif ada penurunan memori dan kecerdasan. Ia mampu
melakukan aktivitas sehari-hari rutin dengan bantuan. kekuatan otot nya 4/5 di kedua tungkai atas
dan bawah. Sistem sensorik nya normal. kiprah pasien dapat dinilai dengan kesulitan, karena
adanya ketidaknyamanan perut dan itu lambat, dengan postur bungkuk.
Dia memiliki pucat dan tanda-tanda dehidrasi ringan. Dia edentulous, dengan pembukaan mulut
yang memadai, Mallampati kelas II dan normal gerakan fleksi leher dan ekstensi. denyut nadinya
adalah 80 denyut / menit dan itu biasa, dengan volume yang baik. Tekanan darahnya 150/80 mmHg
sementara ia berada di posisi terlentang dan itu 140/72 mmHg ketika ia dalam posisi duduk. Tingkat
pernapasan nya adalah 40 / menit. Auskultasi dada mengungkapkan krepitasi bilateral. Pemeriksaan
sistem kardiovaskular nya normal. investigasi darah rutin nya, EKG dan elektrolit dalam batas
normal. Dadanya X-ray menunjukkan menonjol tanda bronchovascular dan perubahan COPD.
Ultrasonografi perutnya menunjukkan fitur dari obstruksi usus dan kelas II prostat hipertrofi, tanpa
organomegali atau asites. Pasien diterima untuk anestesi dengan ASA grade III E.

Pasien diberi biasa obat Parkinsonian anti-nya melalui selang nasogastrik, satu jam sebelum
operasi. Nebulization dengan Salbutamol dan ipratropium bromida diberikan pre operatif.
premedikasi vena Intra diberikan dengan inj. glycopyrollate 0,2 mg, inj. ondansetron 4 mg, dan inj.
midazolam 1,5 mg. pemantauan Nya termasuk oksimetri nadi, EKG, NIBP, ETCO2, suhu tubuhnya
dan output urin. Kami memiliki kesulitan dalam merekam parameter penting basal nya karena tremor
dan kekakuan. Sebuah anestesi umum dengan intubasi endotrakeal dan ventilasi terkontrol
direncanakan. Setelah preloading dengan 500 ml Ringer laktat, pre oksigenasi dilakukan dengan
oksigen 100% selama 5 menit. Pasien diinduksi dengan inj. thiopentone 200mg iv. Rocuronium 30
mg iv diberikan untuk memfasilitasi intubasi trakea dengan 8,5 tabung endotrakeal diborgol. anestesi
dipertahankan dengan O2 + isoflurane + atracurium. Morfin 4 mg iv digunakan untuk analgesia intra
operatif. Prosedur operasi yang berlangsung selama tiga jam, terdiri dari rilis dari band perekat di
wilayah ileum. Intra urin operasi adalah 300 ml dan kehilangan darah sekitar 400 ml. Dua liter
kristaloid digunakan operatif intra. Pasien itu hemodinamik stabil sepanjang prosedur.

Pada akhir operasi, ia diekstubasi, menyusul reversal dengan neostigmin dan glycopyrolate. nyeri
jabatannya operasi dikelola dengan NSAID. obat anti Parkinsonian nya dilanjutkan setelah operasi
melalui selang makanan selama 2 hari. Dia kemudian dibiarkan untuk membawa mereka secara
lisan dan ia kembali obat yang biasa. Tentu saja pasca operasi nya itu lancar.

DISKUSI
Degenerasi neuron dopaminergik dari substantianigra mengarah ke PD. Disfungsi
otonom dapat bermanifestasi sebagai hipotensi ortostatik, yang mengarah ke
respon berlebihan tiba-tiba blokade neuraksial pusat. Sebuah pengosongan
lambung tertunda dan termoregulasi atau disfungsi genitourinaria yang umum. Para
pasien menunjukkan respon diubah dengan vasopresor [3-5].
Disfungsi napas atas dapat menyebabkan sekresi dipertahankan, atelektasis,
aspirasi, infeksi saluran pernafasan bawah dan laryngospasms pasca ekstubasi [6].
Sindrom Parkinsonisme-hiperpireksia (PHS) dapat terjadi pada periode perioperatif.
Hal ini ditandai dengan demam tinggi, kekakuan otot ekstrim, ketidakstabilan
otonom, kesadaran diubah, gagal ginjal akut dan DIC. PHS terjadi di hingga 4% dari
pasien PD; mortalitas berkisar 4% untuk disuguhi 20% untuk episode yang tidak
diobati. PHS dapat dicegah dengan administrasi terganggu obat. Pengakuan awal
dan pengobatan agresif dengan penggantian cairan, melanjutkan terapi
dopaminergik dan perawatan suportif, diperlukan untuk pemulihan yang sukses [7].
agonis Dopa dapat diberikan secara oral, intravena atau transdermal. Pada pasien
yang tidak mampu untuk mengambil obat oral atau melalui tabung lambung,
parenteral diberikan obat antikolinergik seperti trihexyphenidyl, benztropine, atau
diphenhydramine dapat diberikan. Levodopa dan carbidopa diserap di usus kecil.
Sebuah tabung pengisi duodenum mungkin berguna [3]. Dopamin antagonis seperti
droperidol, haloperidol, risperidone, metaclopramide, proklorperazin, prometazin,
fenotiazin, butyrophenones, dll harus dihindari. anestesi regional memiliki
keunggulan dibandingkan anestesi umum karena menghindari efek dari anestesi
umum dan obat neuromuskular blocking, yang dapat menutupi tremor. Tingginya
insiden mual dan muntah yang berhubungan dengan anestesi umum, mencegah
administrasi yang efektif dari obat-obatan oral dan eksaserbasi dapat terjadi pada
periode pasca operasi [8].
Thiopentone dan propofol relatif aman. Ketamine merupakan kontraindikasi karena
respon simpatik berlebihan yang menghasilkan. Ada banyak laporan dari kekakuan
otot setelah penggunaan fentanyl [9]. agen memblokir neuromuskuler dapat
digunakan dengan aman pada pasien dengan penyakit Parkinson. Investigasi yang
dilakukan, telah menyarankan bahwa suksinil kolin tidak menyebabkan
hiperkalemia [10]. Halotan, yang peka hati untuk katekolamin, harus dihindari pada
pasien yang berada di Levodopa. Isoflurane aman, karena tidak peka miokardium
terhadap katekolamin.
laporan kasus banyak telah menggambarkan berbagai pendekatan yang dilakukan
untuk pengelolaan perioperatif [4,5], tetapi tidak ada pedoman pengobatan yang
pasti. Tujuan utama dari manajemen dalam periode perioperatif, adalah untuk
melanjutkan pemberian terapi pengganti dopamin.
Pergi ke:
KESIMPULAN
Para pasien dengan PD dapat dengan aman dibius, namun penilaian pra operasi
menyeluruh, meminimalkan gangguan dari terapi obat perioperatif dan
menghindari agen pencetus diketahui, sangat penting untuk mengurangi angka
kematian pasca operasi dan morbiditas tersebut. anestesi regional adalah teknik
pilihan, setiap kali itu mungkin.