, 28 tweets, 19 min read Read on Twitter
#Periopmedicine #Medthread!
Based on requests (esp @JenniferBrokaw), a long over-due #tweetorial with my advice & pearls for providing patient-centered care for the surgical patient with #ParkinsonsDisease
@JenniferBrokaw Caveats
1⃣I’m not an anesthesiologist & don’t care for pts w PD #intraoperatively
2⃣I practice outpatient #PREoperative medicine, so I am not providing inpatient postop care
3⃣There are several high yield publications/resources, & much of this is pulled from my own experience
@JenniferBrokaw Caveats out of the way, let’s chat about why understanding #periop #ParkinsonsDisease management is so foundational.
Remember how Osler said to know syphilis is to know all of internal medicine?
Yeah…PD meets #periopmedicine is potentially THAT informative.
@JenniferBrokaw I see #periop PD as the epitome of head-to-toe comprehensive care:
❇️multi-organ system effects including respiratory and GI
❇️complex pharmacology
❇️increased risk of periop complications from the disease itself AND the meds required to manage it
@JenniferBrokaw #ParkinsonsDisease is also the epitome of #multidisciplinary team-based #perioperative care.

It’s not just the surgeon, anesthesiologist, and patients.

It’s also PCP/geriatrician, inpatient PT, OT, speech, nursing, pharmacy, case management, and family!
@JenniferBrokaw So where to start?

Don’t forget the big picture—you’re still performing a patient-centered pre-op evaluation & risk assessment, NOT clearance.

Get to know your patient as a person with comorbid conditions getting ready for surgery.
@JenniferBrokaw Complications of condition/meds to have on your radar?
⭕️Orthostatic hypotension, which can be compounded by NPO status
⭕️Chest wall rigidity➡️risk of respiratory failure
⭕️Impaired mobility
⭕️Gastric dysmotility➡️affects med bioavailability
@JenniferBrokaw so let’s really start with pharmacology

This. Med. Rec. REALLY. Matters.

I’m serious.
I’m typically on my soapbox about pre-op med recs (more to be had on that soon in another venue!)
But med rec for PD really REALLY matters

#ParkinsonsDisease meds 101?...
@JenniferBrokaw what times do patients take their medications?
❇️"QID" not enough-SPECIFIC times, ex. 0800, 1130, 1600, and 2000
❇️how close to usual dosing times they must take meds to avoid breakthrough symptoms? Down to the minute? 30 minutes?
❇️carbidopa/levodopa exact mg formulation?
@JenniferBrokaw PD meds 201:
Keep pts on home regimen as much as possible!
Real risk of withdrawal
❇️prolonged surgeries/NPO status,
❇️changes to gut function
❇️inability to take by mouth (ex dysphagia)
❇️inability to administer enterally (ex. GI surgery, post-op ileus)
@JenniferBrokaw Severe Med withdrawal risk?
Rare but potentially life-threatening Parkinsonism-hyperpyrexia syndrome (PHS), identical to neuroleptic malignant syndrome
4% mortality when treated, 20% mortality untreated
here's a case report of this occuring INTRAOP
@JenniferBrokaw Carbidopa/levodopa?
❇️Avoid abrupt discontinuation
❇️Dose AM of surgery
❇️2nd dose of day if late surgery start
❇️Consider having available in PACU immediately post-op
❇️No enteral option, know formulation options
❇️❇️Oral disintegrating, crush/dissolve and give via DHT/PEG
@JenniferBrokaw withdrawal and breakthrough symptoms is real (before point of PHS)!
Here’s one case report of someone with intraop exacerbation of symptoms even after taking meds on the AM of surgery

@JenniferBrokaw There are several articles on intraop management strategies, including this one for GI surgery
Recall that any change to gut function can significantly affect PD med bioavailability
@JenniferBrokaw Next!
Dopamine agonists (ex pramipexole, ropinirole)
❇️risk orthostatic hypotension, delirium
❇️Consider short term hold? (AM of surgery, maybe PM before)

Apomorphine is available as subQ option postop➡️severe nausea, potentially hypotension and hallucinations
@JenniferBrokaw MAO-I Bs (selegiline, rasagiline)
❇️Not as dangerous periop as MAO-A but become non-selective at ⬆️doses
❇️lots drug-drug interactions
❇️Limited non-oral options (selegiline patch)
❇️Mixed guidance to hold 1-2 weeks if able v continue and adjust anesthesia plan accordingly
@JenniferBrokaw COMT inhibitors (entacapone, tolcapone)
❇️Little guidance in literature, can likely be continued

Anticholinergics (benztropine, Trihexyphenidyl)
❇️Little guidance, based on anticholinergic SEs, hold AM of surgery seems reasonable

❇️some guidance to continue
@JenniferBrokaw Potpourri:
What else do I ask about?
⏺️Personal h/o delirium
⏺️Baseline dysphagia
⏺️History of aspiration and pneumonias, especially post-op
⏺️Orthostatic symptoms
⏺️prior periop experiences including PD related complications
@JenniferBrokaw I recommend:
🔘EARLY multidisciplinary involvement—RNs, PT, OT, speech
🔘Pharmacy—get the meds timed correctly!
🔘Consider neurology v hospitalist v geriatrics consult
🔘Engage pt and family
🔘Minimize aspiration risk
🔘Minimize delirium risk
🔘ICS and pulmonary hygiene
@JenniferBrokaw Avoid ANTIdopaminergic meds—This will counter the work you’ve done to ensure PD meds on board
🌀haldol relative contraindicated
🌀newer antipsychotics may be better tolerated
🌀ondansetron preferred as antiemetic
🌀Dopmeridone also recommended (and it’s a suppository)
@JenniferBrokaw Get your patient moving!
early ambulation is “good for what ails you”, incl ⬇️risk of:
🔘Respiratory complications
Get your pt with PD moving, which likely requires more intentionality to accomplish
Coordinate med dosing with PT sessions
@JenniferBrokaw A word on low risk sxs:
❇️Don’t overlook the combined pt/sx risk & modifications to standard anesthesia management that might be needed that would ⬆️overall risk
❇️may need deeper sedation to suppress tremor
ex. Cataract–sedation or even GA rather than topical anesthesia
@JenniferBrokaw also:
❇️if your patient is having a deep brain stimulator placed for their Parkinson’s Disease, confirm day of surgery med management with the neurosurgeon—this may be the occasion to hold meds DOS
❇️day surgery? ensure proper postop instructions about meds & risk reduction
@JenniferBrokaw For more reading, this is a fantastic review article:
@JenniferBrokaw Thank you for reading, and I hope you found this informative!

As always, I welcome any dialogue, discourse, difference of opinion on this wonderful space and place we call #medtwitter

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