Turk J Anaesthesiol Reanim. Reanim. 2014 Oct; 42(5): 280282. !u"lishe# online 2014 Jul $. #oi: 10.5152%TJAR.2014.4&1'5 !*+: !48$41&,
Parkinson’s Disease and Spinal Anaesthesia -lem O/u O/u "rahim 3trk 3trk +era 3kan 3kan Jli#e -ril -ril an# 67#e umin A#9n Author inormation Article Article notes o<ri o<riht ht an# =icens =icense e inorm inormation ation
Abstract
6o to: Introduction Parkinson’s disease is a neurodegenerative disease characterized by neurotransmitter imbalance due to relative dopamine deficiency in caudate nucleus and putamen and loss of pigmented cells in substantia nigra nigra (1 ( 1). Current theories on its aetiology include mitochondria dysfunction and exposure to various toxins that leads to continuous activation of glutamate receptors (1 ( 1 !). "ts clinical picture depends on increased gamma#aminobutyric acid activity due to dopamine deficiency. Conse$uently Conse$uently characteristic symptoms such as resting tremor rigidity in the extremities bradykinesia fixed facial expression and gradually %orsening gait disturbances are seen ( !). "n addition orthostatic hypotension dysphagia diaphragmatic spasms dementia and mental depression may also be seen ( !). &aintenance of the balance bet%een cholinergic and striatal dopaminergic activity forms the basis of medical treatment in Parkinson’s disease %hich can be treated either medically or surgically. 'evodopa selegiline dopamine agonists (bromocriptine) and catechol #methyltransferase (C&) inhibitors are used for this purpose ( 1). *mong anaesthesia techni$ues general anaesthesia is usually preferred in patients %ith Parkinson’s disease. disease. +o%ever general anaesthesia may mask the symptoms of Parkinson or may trigger the symptoms in the postoperative period. +erein therefore %e %ould like to present our spinal anaesthesia experience experience %hich is rarely used in Parkinson’s Parkinson’s patients. patients.
6o to: Case Presentation * ,,#year#old ,,#year#old female patient %as scheduled for elective surgery due to fracture in the distal left tibia- informed consent %as obtained from the patient. Preoperative evaluation revealed that she has been receiving treatment for Parkinson’s disease for 1 years. he patient %ith
bilateral Parkinson’s symptoms and mild gait disturbance on physical examination %as considered to have /tage """ disease according to the 0+oehn and ahr’ Parkinson’s disease rating scale. *s she had %heezing consultation %as re$uested from the pneumology department. /he %as diagnosed to have obstructive pulmonary disease based on respiratory function tests and treatment %as commenced. &adopar2 (levodopa3benserazide) %hich she has been receiving for the treatment of Parkinson’s disease %as continued at a dose of 1!4 mg tablet (561). "n addition it %as learned that she had hyperlipidaemia (for 14 years) hypertension (for 57 years) and coronary artery disease (for 14 years) and has been receiving 8eloc#zok2 4 mg tablet (161) Co#9iovan2 1:;1!.4 tablet (161) *tor2 ! mg tablet (161) *mlokard2 1 mg tablet (161) Plavix2 ,4 mg tablet (161) and Coraspin2 1 mg tablet (161). /ince the patient %ith *merican /ociety of *nesthesiologists (*/*) """ disease %as scheduled for spinal anaesthesia oral anticoagulant medications %ere discontinued for , days and daily subcutaneous enoxaparin at a dose of .7 m' %as commenced (161). 8lood analysis performed on the day before surgery revealed no coagulation defect or b iochemical abnormality. he patient %as admitted to the operating room and 1 mg midazolam %as administered via intravenous route for sedation after intravenous line %as established. hereafter spinal anaesthesia %as performed using !.4 m' of .4< hyperbaric bupivacaine through '5=7 space using !4> needle after the patient %as placed in decubitus position %ith assistance. Pinprick test %hich %as performed five minutes later indicated that a 1 the level of anaesthesia %as achieved. +er haemodynamic condition %as stable during the surgery. ?ear the end of the surgery dexketoprofen 4 mg %as administered as "@ infusion. he patient %as admitted to the recovery room %ithout any problem at the end of the surgery that lasted for !.4 hours and then transferred to the %ard %ithout any complication.
6o to: Discussion /pinal anaesthesia %as planned for the patient presented herein as she had advanced stage chronic obstructive pulmonary disease. Aor this purpose anticoagulant drugs that she has been receiving %ere discontinued seven days before the surgery and subcutaneous enoxaparin %as commenced. *nti#Parkinson’s treatment %as continued up to and including the morning of surgery since the half#life of levodopa is short and severe muscle rigidity might be encountered :=1! hours after discontinuation of the drug ( !). Parkinson’s disease involves many systems and therefore comprises various signs and symptoms. ?euromuscular system involvement forms a basis for prolonged immobilization and related increased risk of venous thromboembolism- gastrointestinal motility disorder and dysphagia forms a basis for aspiration ileus and constipation- and obstructive or restrictive pulmonary disease and %eakened respiratory muscles due to respiratory system involvement forms a basis for extubation difficulty atelectasis and pneumonia ( 5). "t has been demonstrated that patients %ith Parkinson’s disease have a higher risk of aspiration pneumonia and urinary tract infections and bacterial infections as compared to those %ithout Parkinson’s disease (7). "n the present case %e preferred spinal anaesthesia as it enables early mobilization and thereby reduces the risk of venous thromboembolism as %ell as to
eliminate the probability of difficulty in %eaning from mechanical ventilation due to muscle relaxation provided by neuromuscular blockers during general anaesthesia. 8esides the perioperative complications due to clinical organ involvement %e aimed to avoid drug interactions and likely adverse effects of drugs that are fre$uently used in anaesthesia practice. *s Parkinson’s patients are prone to developing cardiac arrhythmias the use of arrhythmogenic inhalation anaesthetics such as halothane should be avoided in these patients (4). Bven though it has been stated that modern inhalation anaesthetics %ould probably be safer (:) the fact that sevoflurane might cause electrocardiographic alterations that could progress to malignant arrhythmia is an important point ( ,). *mong intravenous anaesthetics the effect of ketamine leading to sympathetic nervous system response that results in tachycardia and hypertension is an effect that should be taken into account particularly in patients %ith cardiac disease (!). Concurrent cardiac disease in Parkinson’s patients makes the use of ketamine and sevoflurane debatable. Preferring propofol because of its rapid metabolism necessitates patient#based decision as it causes dyskinesia in Parkinson’s patients (). n the other hand the fact that opioids %hich are po%erful analgesics lead to acute dystonic reactions and muscle rigidity restricts its usage in Parkinson’s patients (!). herefore %e performed spinal anaesthesia only %ith local anaesthetics because of probability of passing into systemic circulation. &oreover %e used a non#opioid analgesic (dexketoprofen 4 mg "@) for postoperative analgesia. /pinal anaesthesia is generally not preferred in patients %ith neurological diseases. he possibility of exacerbation of disease symptoms is the basic concern. "n the literature the use of spinal anaesthesia in Parkinson’s patients is very rare ( D 1). herefore there is no definitive data %hether spinal anaesthesia poses an absolute or a relative contraindication. n the other hand the possibility of multiple drug use during general anaesthesia and disease# specific complications make spinal anaesthesia particularly at the levels (belo% 7) that %ould not cause cardiac adverse effects (hypotension bradycardia) more convenient in some selected patients.
6o to: Conclusion Ee are in the opinion that spinal anaesthesia does not pose an absolute or a relative contraindication and can be safely and effectively used in Parkinson’s patients.
6o to: Footnotes Informed Consent: >ritten inorme# consent ?as o"taine# rom the
+.3. J.-.; +ata ollection an#%or !rocessin -.O. .3. 6..A.; Analsis an#%or *nterriter -.O. .3. 6..A.; ritical ReBie? +.3. J.-.
Conflict of Interest: Do conlict o interest ?as #eclare# " the authors. Financial Disclosure: The authors #eclare# that this stu# has receiBe# no inancial su<
6o to: eferences 1. Felton &c Clung + /carfo F +ecker G>. ?eurologic 9iseases. "nH Aleisher '* editor. *nesthesia and Incomman 9iseases. 4th edition. PhiladelphiaH E. 8. /aunders Company- !4. pp. !:1=51. !. 9ierdorf /A Ealton /. *nesthesia for patients %ith rare and coexisting diseas. "nH 8arash P> Cullen 8A /toelting JF editors. Clinic *nesthesia. Aifth Bdition. PhiladelphiaH 'ippincott Eilliams Eilkins- !:. pp. 4!=!. 5. Patel /> /tickrath CJ *nderson & Flepitskaya . +o% should Parkinson’s disease be managed perioperativelyK L(!5.D.!15)M. he %eb siteH httpH;;%%%.the# +ospitalist.org;details;article;,7D5,; 7. Pepper P@ >oldstein &F. Postoperative complications in Parkinson’s disease. G *m >eriatr /oc. 1DDD-7,HD:,=,!. LPub&edM 4. ?icholson > Pereira *C +all >&. Parkinson’s disease and anaesthesia. 8r G *naesth. !!-DHD7=1:.httpH;;dx.doi.org;1.1D5;bNa;aef!:. LPub&edM :. Judra * Judra P ChatterNee / 9as Jay & Fumar P. Parkinson’s 9isease and *naesthesia. "ndian G *naesth. !,-41H5!=. ,. Fleinsasser * Fuenszberg B 'oeckinger * Feller C +oermann C 'indner F+ et al. /evoflurane but not propofol significantly prolongs the O# interval. *nesth *nalg. !-DH!4=,.httpH;;dx.doi.org;1.1D,;45D#!1#:. LPub&edM . Frauss GF *keyson BE >iam P Gankovic G. Propofol#induced dyskinesias in Parkinson’s disease. *nesth *nalg. 1DD:-5H7!=!. httpH;;dx.doi.org;1.1!15;45D#1DD:# 5,. LPub&edM D. *lkaya A Frdemir P *tay . Jegional anesthesia for parkinson 9iseaseH Case report. urkish Gournal of >eriatrics. !1!-14H7,5=4. 1. /hipton B* Joelofse G*. *naesthesia in a patient %ith ParkinsonQs disease. * case report. / *fr &ed G. 1D7-:4H57=4. LPub&edM
Articles rom Turkish Journal o Anaesthesiolo an# Reanimation are
pengantar Penyakit Parkinson adalah penyakit neurodegeneratif yang ditandai dengan ketidakseimbangan neurotransmitter akibat kekurangan dopamin relatif berekor inti dan putamen dan hilangnya sel-sel berpigmen di substansia nigra (1). teori terkini tentang etiologi meliputi disfungsi mitokondria dan paparan berbagai racun yang menyebabkan aktivasi terus menerus reseptor glutamat (1, 2). Gambaran klinis tergantung pada peningkatan aktivitas asam gamma-aminobutyric karena kekurangan dopamin. kibatnya, ge!ala khas seperti beristirahat tremor, kekakuan pada ekstremitas, bradikinesia, ekspresi "a!ah tetap, dan secara bertahap memburuk gangguan kiprah terlihat (2). #elain itu, hipotensi ortostatik, disfagia, ke!ang diafragma, demensia dan depresi mental !uga dapat dilihat (2). Pemeliharaan keseimbangan antara kolinergik dan aktivitas dopaminergik striatal membentuk dasar dari pera"atan medis pada penyakit Parkinson, yang dapat diobati baik secara medis atau pembedahan. $evodopa, selegiline, agonis dopamin (bromokriptin) dan katekol %-methyltransferase (&%') inhibitor yang digunakan untuk tu!uan ini (1). i antara teknik anestesi, anestesi umum biasanya disukai pada pasien dengan penyakit Parkinson. *amun, anestesi umum dapat menutupi ge!ala Parkinson atau dapat memicu ge!ala pada periode pasca operasi. i sini, oleh karena itu, kami ingin menya!ikan pengalaman anestesi spinal kami, yang !arang digunakan pada pasien Parkinson. Pergi ke+ Presentasi kasus #eorang pasien "anita berusia tahun itu di!ad"alkan untuk operasi elektif karena patah tulang pada tibia kiri distal informed consent diperoleh dari pasien. evaluasi pra operasi mengungkapkan bah"a dia telah menerima pengobatan untuk penyakit Parkinson selama 1 tahun. Pasien dengan ge!ala bilateral Parkinson dan kiprah gangguan ringan pada pemeriksaan /sik, dianggap memiliki penyakit ahap 000 sesuai dengan skala penilaian penyakit oehn dan 3ahr4 Parkinson. #aat ia memiliki mengi, konsultasi diminta dari departemen pneumologi. ia didiagnosis memiliki penyakit paru obstruktif didasarkan pada tes fungsi pernafasan dan pengobatan dimulai. 'adopar5 (levodopa 6 bensera7ide), yang ia telah menerima untuk pengobatan penyakit Parkinson, dilan!utkan dengan dosis 128 mg tablet (9 : 1). #elain itu, diketahui bah"a ia memiliki hiperlipidemia (selama 18 tahun), hipertensi (selama 9; tahun) dan penyakit arteri koroner (selama 18 tahun) dan telah menerima 12.8 tablet (1 : 1), tor5 2 mg tablet (1 : 1), mlokard5 1 mg tablet (1 : 1), Plavi?5 8 mg tablet (1 : 1) dan &oraspin5 1 mg tablet (1 : 1). @arena pasien dengan merican #ociety of nesthesiologists penyakit (#) 000, di!ad"alkan untuk anestesi spinal, obat antikoagulan oral dihentikan selama hari dan eno?aparin subkutan dengan dosis ,; m$ dimulai (1 : 1). nalisis darah dilakukan pada hari sebelum operasi menun!ukkan tidak ada cacat koagulasi atau kelainan biokimia. Pasien dira"at di ruang operasi dan 1 mg mida7olam diberikan melalui intravena rute untuk sedasi setelah !alur intravena didirikan. #etelah itu, anestesi spinal dilakukan dengan
menggunakan 2,8 ml ,8A bupivacaine hiperbarik melalui ruang $9-; menggunakan 28G !arum setelah pasien ditempatkan pada posisi dekubitus dengan bantuan. tes cocokan peniti, yang dilakukan lima menit kemudian, menun!ukkan bah"a 1 tingkat anestesi dicapai. @ondisi hemodinamik nya stabil selama operasi. 'en!elang akhir operasi, e?ketoprofen 8 mg diberikan sebagai infus 0B. Pasien dira"at di ruang pemulihan tanpa masalah di akhir operasi yang berlangsung selama 2,8 !am, dan kemudian dipindahkan ke bangsal tanpa komplikasi iskusi anestesi spinal direncanakan untuk pasien yang disa!ikan di sini karena dia memiliki stadium penyakit paru obstruktif kronik canggih. Cntuk tu!uan ini, obat antikoagulan bah"a dia telah menerima dihentikan tu!uh hari sebelum operasi dan eno?aparin subkutan dimulai. pengobatan anti-Parkinson dilan!utkan sampai dengan dan termasuk pagi operasi, se!ak paruh levodopa pendek dan kekakuan otot yang parah mungkin dihadapi =-12 !am setelah penghentian obat (2). Penyakit Parkinson melibatkan banyak sistem dan karena terdiri dari berbagai tanda dan ge!ala. @eterlibatan sistem neuromuskuler membentuk dasar untuk imobilisasi berkepan!angan dan peningkatan risiko terkait tromboemboli vena gangguan motilitas gastrointestinal dan disfagia membentuk dasar untuk aspirasi, ileus dan sembelit dan penyakit paru obstruktif atau restriktif dan otot pernapasan melemah karena keterlibatan sistem pernapasan membentuk dasar untuk kesulitan ekstubasi, atelektasis dan pneumonia (9). elah menun!ukkan bah"a pasien dengan penyakit Parkinson memiliki risiko lebih tinggi aspirasi pneumonia dan infeksi saluran kemih dan infeksi bakteri dibandingkan dengan mereka yang tanpa penyakit Parkinson (;). alam kasus ini, kita lebih suka anestesi spinal karena memungkinkan mobilisasi dini dan dengan demikian mengurangi risiko tromboemboli vena, serta untuk menghilangkan kemungkinan kesulitan dalam menyapih dari ventilasi mekanik akibat relaksasi otot yang disediakan oleh blocker neuromuskuler selama anestesi umum. #elain komplikasi perioperatif karena keterlibatan organ klinis, kami bertu!uan untuk menghindari interaksi obat dan efek samping kemungkinan obat yang sering digunakan dalam praktek anestesi. #ebagai pasien Parkinson rentan untuk mengembangkan aritmia !antung, penggunaan anestesi inhalasi aritmogenik seperti halotan harus dihindari pada pasien ini (8). 'eskipun telah menyatakan bah"a anestesi inhalasi modern yang mungkin akan lebih aman (=), fakta bah"a sevoDuran dapat menyebabkan perubahan elektrokardiogra/ yang bisa ma!u ke aritmia ganas adalah poin penting (). i antara anestesi intravena, efek ketamin yang mengarah ke simpatik respon sistem saraf yang menghasilkan takikardia dan hipertensi adalah efek yang harus diperhitungkan terutama pada pasien dengan penyakit !antung (2). Penyakit !antung bersamaan pada pasien Parkinson membuat penggunaan ketamin dan diperdebatkan sevoDurane. $ebih memilih propofol karena metabolisme yang cepat memerlukan keputusan berbasis pasien karena menyebabkan tardive di Parkinson pasien (E). i sisi lain, fakta bah"a opioid, yang analgesik kuat, menyebabkan reaksi distonik akut dan kekakuan otot membatasi penggunaan dalam Parkinson pasien (2). %leh karena itu, kami melakukan anestesi
spinal hanya dengan anestesi lokal karena kemungkinan mele"ati ke dalam sirkulasi sistemik. #elain itu, kami menggunakan analgesik non-opioid (e?ketoprofen 8 mg 0B) untuk analgesia pascaoperasi. anestesi spinal umumnya tidak disukai pada pasien dengan penyakit saraf. @emungkinan eksaserbasi ge!ala penyakit adalah perhatian dasar. alam literatur, penggunaan anestesi spinal pada pasien Parkinson sangat langka (F, 1). %leh karena itu, tidak ada data yang pasti apakah anestesi spinal menimbulkan mutlak atau kontraindikasi relatif. i sisi lain, kemungkinan penggunaan beberapa obat selama anestesi umum dan penyakit-spesi/k komplikasi membuat anestesi spinal, khususnya pada tingkat (di ba"ah ;) yang tidak akan menyebabkan efek !antung yang merugikan (hipotensi, bradikardia), lebih nyaman pada beberapa pasien yang dipilih . Pergi ke+ @esimpulan @ami berada dalam berpendapat bah"a anestesi spinal tidak menimbulkan mutlak atau kontraindikasi relatif dan dapat dengan aman dan efektif digunakan pada pasien Parkinson.
