Morbus Parkinson: Perioperatives Management und Anästhesie

Pharmacotherapy of motor symptoms in early and mid-stage Parkinson's disease: guideline "Parkinson's disease" of the German Society of Neurology

BACKGROUND AND OBJECTIVE

There are multiple pharmacological treatment options for motor symptoms of Parkinson's disease (PD). These comprise multiple drug classes which are approved for the condition, including levodopa, dopamine agonists, COMT inhibitors, MAO-B inhibitors, NMDA-receptor antagonists, anticholinergics, and others. Some of the drugs are approved for monotherapy and combination therapy while others are only approved as adjunctive therapy to levodopa. Furthermore, treatment for special treatment situations, e.g., rescue medication for off-phases, for tremor, treatment during pregnancy and breast feeding is discussed and recommendations are given with further details.

METHODS

The recommendations were based on systematic literature reviews, drafted by expert teams, consented in online polls followed by online consensus meetings of the whole German Parkinson's Guideline Group, and publicly released in November 2023.

RESULTS

In the new S2k (i.e., consensus-based) guidelines, the pharmacotherapy of the motor symptoms of PD is discussed in five chapters. These comprise "Parkinson medication", "Initial monotherapy", "Early combination therapy", "Fluctuations and dyskinesia", and "Parkinsonian tremor". Furthermore, there is a chapter for special treatment situations, including perioperative management, freezing of gait, and pregnancy and breastfeeding.

CONCLUSION

The recommendations for the pharmacotherapy of motor symptoms of PD have been updated. Newly available drugs have been added, while other drugs (e.g., ergoline dopamine agonists, anticholinergics, budipine) have been removed from the recommendations.

[Anaesthesia and Perioperative Management for Patients with Parkinson's Disease]

Idiopathic Parkinson's syndrome is associated with the loss of dopaminergic cells. It is defined by the presence of akinesia together with one of the cardinal symptoms: rigor, tremor, or postural instability. As the perioperative management of these patients can be challenging and they have an increased perioperative risk, every anaesthesiologist should know some special features. If a patient with Parkinson's disease does not receive the required amount of dopa, akinetic crisis may occur. Moreover, the administration of dopamine-antagonistic drugs can trigger a malignant neuroleptic syndrome. These are life-threatening clinical pictures that require intensive medical treatment. Therefore, patients with Parkinson's disease should be enabled to keep the period without the intake of the specific medication as short as possible. General anaesthesia should be performed with short acting anaesthetics and a regional anaesthesia might be beneficial. Besides, all dopamine antagonists sometimes used for prophylaxis or therapy of delirium or PONV (haloperidol, metoclopramide) are contraindicated. Alternatives are short-acting benzodiazepines, atypical neuroleptics and domperidone.

[Anaesthetic Implications of Psychotropic and Neurologic Agents]

More than a third of all patients undergoing surgery take psychotropic agents on a regular basis. Aside from classical indications like depression and psychosis these drugs are often prescribed for treatment of pain, anxiety and panic disorder. Over the last 30 years the frequency of prescription of psychotropic drugs increased by seven times. Of note, drug interactions of psychoactive medications and anaesthetic agents are common, and the therapeutic range is narrow. Since not all of these agents can be stopped uncritically, careful assessment of risks and benefits is obligatory. The anaesthesiologist has to take special care or avoid the use of certain medications.Medical treatment is crucial for the treatment of several neurological disorders. Frequently, anaesthesiologists are faced with common diseases like seizure disorders, Parkinson's disease and Myasthenia gravis. Perioperative withdrawal of specific medication implies the risk of recurrence of the neurological symptoms. Therefore, these drugs should be continued postoperatively as soon as possible.

Preoperative Evaluation of Parkinson's Disease

Parkinson's disease (PD) is a common disease of older adults. It presents a unique set of anesthetic challenges. With increasing life expectancy and the rapid growth of oldest-old patients, it is now more likely for anesthesiologists to encounter older patients with PD. Due to polypharmacy in the older adults with PD a potential for drug interactions during and after surgery needs to be considered. More data from prospective, multicenter trials about short- and long-term outcomes of anesthesia in PD patients are needed.

Preserved micturition after intradetrusor onabotulinumtoxinA injection for treatment of neurogenic bladder dysfunction in Parkinson's disease

BACKGROUND

To assess the efficacy and safety of intradetrusor onabotulinumtoxinA (OnabotA) injection treatment in patients with neurogenic lower urinary tract dysfunction (NLUTD), especially for patients with Parkinson disease (PD).

METHODS

PD patients refractory to oral antimuscarinic participated in an off-label use study and were evaluated prior and after 200 IU OnabotA injection into detrusor muscle, including trigone. Changes due to treatment were evaluated using bladder diaries, urodynamics, and questionnaires. Statistical analysis comprised Wilcoxon rank-sum test. Values are presented as mean ± standard deviation.

RESULTS

Ten PD patients (4 female and 6 male, mean age: 67.9 ± 5.36 years) with LUTD were enrolled. All patients tolerated the treatment. Bladder diary variables decreased significantly (p ≤ 0.011) after OnabotA injection compared to variables prior injection. Desire to void and maximum bladder capacity increased significantly in urodynamics (p ≤ 0.05). Maximum detrusor pressure during voiding phase normalised from 56.2 to 18.75 cm/H20. Detrusor overactivity was less often detectable. All patients voided spontaneously. Mean post void residual (PVR) volume was 77.0 ± 119.78 mL postoperatively. No urinary retention or side effects have been observed during/after treatment. Mean follow-up time was 4 months (range of 1-12). 4 patients requested repeated injection after a mean period of 10 months between first and second injection.

CONCLUSIONS

Our data confirm the efficacy and safety of 200 IU OnabotA injection in patients with neurogenic LUTD due to PD. The risk of urinary retention or high post-urinary residual volumes seems to be minor after OnabotA-injection. More research is needed with larger sample size to confirm the significance of these findings.

TRIAL REGISTRATION

TRIAL NUMBER

ISRCTN 11857462 , Registration Date 2016/10/08.

Shoulder arthroplasty in patients with Parkinson's disease is associated with increased complications

BACKGROUND

Case series suggest a higher postoperative complication rate after shoulder arthroplasty in patients with Parkinson's disease (PD). The purpose of this study was to evaluate the perioperative complications in patients with PD undergoing conventional total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), and shoulder hemiarthroplasty (HA).

METHODS

Patients with PD who underwent TSA, RSA, or HA were identified in a national insurance database and then matched to controls without a diagnosis of PD based on age, gender, obesity, diabetes, and tobacco use. Complications were assessed, including infection, dislocation, revision, stiffness, fracture, component loosening, and systemic complications.

RESULTS

The final study cohorts included 3390 TSA patients with PD and 47,034 matched TSA controls; 809 RSA patients with PD and 14,262 matched controls; and 2833 HA patients with PD and 38,850 matched controls. PD was associated with significant higher rates of infection (odds ratio [OR], 1.5, 1.7, 1.5, respectively), dislocation (OR, 2.5, 2.0, 2.8, respectively), revision arthroplasty (OR, 1.7, 1.8, 1.4, respectively), and systemic complications (OR, 1.4, 1.7, 1.3, respectively) after all 3 types of shoulder arthroplasty and with higher rates of periprosthetic fracture after conventional TSA (OR, 1.5) and shoulder HA (OR, 1.5). Component loosening was also more commonly noted in patients with PD after conventional TSA (OR, 1.5) and HA (OR, 1.9).

CONCLUSION

PD is associated with increased rates of infection, dislocation, revision shoulder arthroplasty, fracture, component loosening, and systemic complications after conventional TSA, RSA, and shoulder HA.

[Anesthesiological aspects of deep brain stimulation : special features of implementation and dealing with brain pacemaker carriers]

Deep brain stimulation (DBS) provides a very effective treatment for a number of neurological diseases including Parkinson's disease, movement disorders and epilepsy. In DBS microelectrodes are positioned in defined cerebral target areas and connected to a pacemaker. It is most often performed as an awake craniotomy with intraoperative testing. Various anesthesiological regimes are used to protect the patient from surgical stress on the one hand and to achieve ideal test conditions on the other. They include local anesthesia or scalp blocks, intermittent general anesthesia or analgosedation with or without airway protection; however, anesthetic agents interfere with hemodynamic stability and ventilation, with vigilance and cooperation and in addition with the symptoms and microelectrode recording. Guidance and communication have a pivotal impact on patient needs for pharmacological interventions. With increasing numbers of DBS procedures, anesthesiologists are more often faced with patients carrying brain pacemakers. For anesthesia the characteristics of the disease as well as the respective long-term medication have to be considered. In addition, the rules for handling patients with pacemakers need to be followed to avoid both dysfunction of the generator and tissue damage due to overheating of the electrodes.

Management of patients with risk factors

This review addresses concomitant diseases and risk factors in patients treated for diseases of the ears, nose and throat in outpatient and hospital services. Besides heart disease, lung disease, liver disease and kidney disease, this article also covers disorders of coagulation (including therapy with new oral anticoagulants) and electrolyte imbalance. Special attention is paid to the prophylaxis, diagnosis and treatment of perioperative delirium. It is also intended to help optimise the preparation for surgical procedures and pharmacotherapy during the hospital stay.