The perioperative management of Parkinson's disease revisited

The perioperative management of patients with Parkinson's disease (PD) has received little attention in the neurologic literature. Expertise in the management of PD is of the utmost importance if the afflicted patient is to have an uneventful recovery. Parkinson's disease, characterized by rigidity, bradykinesia/akinesia, tremor and postural instability, affects all ages but particularly the elderly. It has been estimated that PD has a prevalence of 59 to 187 per 100,000 population worldwide [1] with an annual incidence of 20 per 10,000 [2,3], and in North America 1% of the population over age 60 is affected by the disease [1,3,4]. Current advances in surgical techniques and other therapeutic modalities are responsible for an increase in the number of elderly patients undergoing surgical procedures [5], including those with PD. The expected worsening of parkinsonian rigidity and bradykinesia coupled with swallowing difficulties and inability to clear oral and pulmonary secretions make these patients prone to postoperative complications such as aspiration pneumonia and deep vein thrombosis. Dysfunction of the striated muscle of the upper airway has been reported to cause postoperative respiratory failure [6]. In addition, the remote but real possibility for the development of neuroleptic malignant syndrome due to withdrawal of antiparkinsonian medications [7] makes these patients a special surgical challenge. In the postoperative period, rigidity can render the patient immobile; this adds to their discomfort, hampers nursing care, and increases the risks of deep vein thrombosis and pulmonary emboli. Other miscellaneous "off period" symptoms such as dyspnea, laryngeal stridor and hypokinesia, rigidity of voluntary respiratory muscles [8], as well as a variety of sensory, autonomic, cognitive, and psychiatric disturbances, may make postoperative care difficult. These factors and other difficulties with nursing care become especially important in the postoperative care of patients who cannot take oral medication, because most available antiparkinsonian drugs can only be administered orally.