Abstract ID: A33
Abstract Title: Regional Anesthesia for Patient’s with Parkinson’s Disease; Current Challenges.
Authors: Fanning R1, Brown A2
Columbia University New York New York USA1, Columbia University New York New York USA2
Poster Type: Either
ABSTRACT BODY
Introduction
Parkinson’s disease is a common disorder affecting 1-2 % of the population over the age of 65. Improved medical therapy, and advancement in surgical treatments such as deep brain stimulation, have improved symptomatology, but the illness still presents many challenges to the Anesthesiologist. This case illustrates two such challenges, firstly the appropriate choice of anesthetic technique, and secondly the technical, practical, and safety issues related to the presence of an indwelling deep brain stimulator.
Case
A 73 year old female with a history of severe debilitating Parkinson’s disease, presented for right total shoulder replacement. She was diagnosed with Parkinson’s disease in 2000, which became increasingly resistant to medical therapy. In May 2004, she underwent placement of bilateral deep brain stimulators (DBS). We elected to perform an interscalene brachial plexus block( ISB) because of the many benefits attributed to regional anesthesia over general anesthesia in patients suffering from Parkinson’s disease. On identifying the landmarks, we noted that the electrodes of the DBS traversed the upper portion of the interscalene groove, and were easily palpable. An ISB was performed with a 22 gauge 4 cm stimuplex needle. The stimulating electrodes, easily palpable through the skin, were retracted away from the advancing needle. After obtaining a deltoid muscle twitch at 0.3mA, 40 mls of 0.5% ropivacaine was injected.
Prior to the start of surgery, the DBS, which had been disabled was disconnected, and externalized. This was necessary to improve surgical access for the shoulder replacement, and as a safety measure, as the surgeon wished to use monopolar diathermy. Following completion of the joint replacement, the stimulating electrodes were reconnected to the generator, and the subthalamic device placed into its pseudocapsule. Both surgery and anesthesia were uneventful.
Discussion
The use of regional anesthesia in this case, though technically challenging, enabled us to avoid many of the sequelae of general anesthesia in our patient with Parkinson’s disease. Movement disorders, dysautonomia, pharyngeal muscle dysfunction and risk of aspiration make general anesthesia less than desirable in this patient population.(1)
Inhalational anesthetic agents have complex effects on brain dopamine concentrations (2). Neurological problems such as confusion, and hallucinations occur commonly after general anesthesia (3).In patients with DBS in situ, caution is advised regarding the use of diathermy. In our case, the stimulator was disabled, and the generator removed. However, bilateral subthalamic electrodes remained in situ serving as a potential electrical current conduit that could result in brain injury. Our patient suffered no ill effects from the procedure, and concomitant use of monopolar diathermy. On follow up neurological visits, the stimulator provided optimal symptomatic relief at pre surgical settings, and medication dosages remained at a preoperative level.
The high prevalence of Parkinson’s disease and increasing use of deep brain stimulators provides Anesthesiologists with complex issues to contemplate when deciding on the most appropriate anesthetic care for such patients.
References
(1) Chaudhuri KR. Autonomic dysfunction in movement disorders. Curr Opin Neurol 2001; 14: 505–11.
(2) El-Maghrabi EA, Eckenhoff RG. Inhibition of dopamine transport in rat brain synaptosomes by volatile anesthetics. Anesthesiology 1993; 78: 750–6.
(3) Golden WE, Lavender RC, Metzer WS. Acute postoperative confusion and hallucinations in Parkinson’s disease. Ann Intern Med 1989; 111: 218–22.
ATTACHED FILES
Reg Anesth Pain Med 2005; 30(3):A33