• Parkinson's disease (PD)
    • Characterised by bradykinesia, tremor and rigidity
    • Associated features: akinesia, postural imbalance, blank facial expression, festinant gait, restless legs, loss of arm swinging on walking, depression, dementia, pressure sores, micrographia, aspiration, drooling, restrictive lung defect, flexion deformity of the neck
    • Causes
      • Degenerative
        • Idiopathic (85%)
        • Multi system atrophy
          • Parkinson '+' syndromes
        • Familial
      • Pharmacological
        • Affecting synthesis/storage/release
          • Reserpine
        • Blocking dopamine receptors
          • Prochlorperazine
      • Structural
        • NPH, trauma
      • Toxic
        • CO poisoning, cyanide
      • Infective
        • AIDS, encephalitis
      • Vascular
        • Multi-infarct dementia
    • Common pathology is loss of dopaminergic transmission in the substantia nigra
    • Pharmacological management
      • Dopamine precursors
        • Converted to dopamine in CNS
          • Levodopa
      • Dopamine agonists
        • Mimics action of dopamine
          • Ropinirole
      • MAOI(B)
        • Prevent breakdown of dopamine
          • Selegiline
      • Anticholinergics
        • Antagonises unopposed excitatory of cholinergic pathways in PD
          • Orphenadrine
      • COMT inhibitors
        • Peripheral dopa-decarboxylase inhibitor
          • Entacapone
      • Atypical
        • Amantadine
    • Peri-operative management
      • Organisational
        • Inform PD physician
        • Parkinson's nurse
      • Anaesthetic factors
        • Pre-op assessment considering the complications of PD
        • Aim to stop treatment as close to surgery as possible and restart ASAP
        • Stopping medication can cause neuroleptic malignant syndrome
        • Levodopa can be given via NGT
        • Apomorphine may need to be given (requires dose establishment)
        • Airway assessment is needed
        • Assessment of swallowing, drooling
        • Use glycopyrrolate not atropine (central anticholinergic syndrome)
        • Consider ETT and RSI
        • Adequate hydration to prevent orthostatic hypotension
        • Beware of coexisting diseases and autonomic dysfunction
        • Regional anaesthesia may be difficult
        • Tremor may cause difficulty in monitoring
        • Etacapone may complicate the use of vasoconstrictors
        • Opioids may worsen rigidity but might be needed
        • PCA use may be impaired
        • PONV
          • Avoid centrally acting anti-dopaminergic drugs
          • Cyclizine and ondansetron are safe
        • May need HDU care
        • Post-op delirium is common
        • Anticipate respiratory compromise post-op
        • Physiotherapy to avoid post-op respiratory complications
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/2/3/69.full.pdf