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.
⭕️Orthostatic hypotension, which can be compounded by NPO status
⭕️Chest wall rigidity➡️risk of respiratory failure
⭕️Gastric dysmotility➡️affects med bioavailability
❇️"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?
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)
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
❇️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
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
❇️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
❇️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
What else do I ask about?
⏺️Personal h/o delirium
⏺️History of aspiration and pneumonias, especially post-op
⏺️prior periop experiences including PD related complications
🔘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
🌀haldol relative contraindicated
🌀newer antipsychotics may be better tolerated
🌀ondansetron preferred as antiemetic
🌀Dopmeridone also recommended (and it’s a suppository)
early ambulation is “good for what ails you”, incl ⬇️risk of:
Get your pt with PD moving, which likely requires more intentionality to accomplish
Coordinate med dosing with PT sessions
❇️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
❇️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