Sedation And Regional Anesthesia For Deep Brain Stimulation In Parkinsons Disease
Dilek Yazicioglu
1Ankara Diskapi Yildirim Beyazit Teaching and Research Hospital, Irfan Bastug Caddesi, Dskap, 06330 Ankara, Turkey
Academic Editor:
Abstract
Objective. To present the conscious sedation and the regional anesthesia technique, consisting of scalp block and superficial cervical plexus block, used in our institution for patients undergoing deep brain stimulation for the treatment of Parkinsons disease . Methods. The study included 26 consecutive patients. A standardized anesthesia protocol was used and clinical data were collected prospectively. Results. Conscious sedation and regional anesthesia were used in all cases. The dexmedetomidine loading dose was 1gkg1 and mean infusion rate was 0.26gkg1h1 . Propofol was used to facilitate regional anesthesia. Mean propofol dose was 1.68mgkg . Scalp block and superficial cervical plexus block were used for regional anesthesia. Anesthesia related complications were minor. Postoperative pain was evaluated; mean visual analog scale pain scores were 0 at the postoperative 1st and 6th hours and 4 at the 12th and 24th hours. Values are mean . . Dexmedetomidine sedation along with scalp block and SCPB provides good surgical conditions and pain relief and does not interfere with neurophysiologic testing during DBS for PD. During DBS the SCPB may be beneficial for patients with osteoarthritic cervical pain. This trial is registered with Clinical Trials Identifier .
1. Introduction
Patient Preference No Surprise
Reached for comment, Michele Tagliati, MD, neurologist and director of the movement disorders program at Cedars-Sinai Medical Center, Los Angeles, California, said “this randomized trial confirms that doing DBS surgery awake or asleep makes no difference in terms of outcomes.”
“The reason why DBS surgery has been developed as an awake procedure has been that general anesthesia might affect the neuronal recordings that the surgeon uses to localize the perfect lead placement,” Tagliati told Medscape Medical News.
“Based on the fact that the DBS outcomes were the same, it can be assumed that the precision of the implant was not affected by being asleep or awake,” said Tagliati, who was not involved with the study.
He said it’s no surprise that patient satisfaction was higher with general anesthesia.
“Most patients prefer to be asleep during DBS surgery. They don’t like the idea of being awake when someone drills a hole in their skull,” he said.
He noted that a limitation of the most promising asleep-based implantation procedure MRI-guided surgery is capital expense, “because you basically have to either reserve an MRI for a number of hours or purchase a dedicated MRI just to do DBS, which not every hospital may want to do.”
JAMA Neurology. Published online September 7, 2021. Abstract
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A Pragmatic Approach To The Perioperative Management Of Parkinsons Disease
Published online by Cambridge University Press:;22 September 2020
- Department of Neurology, Georgetown University Hospital, Washington, DC, USA
- Shivam Om Mittal
- Department of Neurology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
- Guillaume Lamotte
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Fernando Luis Pagan
- Department of Neurology, Georgetown University Hospital, Washington, DC, USA
- *
- Correspondence to: Dr. Abhishek Lenka MD, Ph.D., Department of Neurology, Georgetown University Hospital
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What Does Parkinsons Do To The Brain
Deep down in your , theres an area called the substantia nigra, which is in the basal ganglia. Some of its cells make , a chemical that carries messages around your . When you need to scratch an or kick a ball, dopamine quickly carries a message to the nerve cell that controls that movement.
When that system is working well, your body moves smoothly and evenly. But when you have Parkinsons, the cells of your substantia nigra start to die. Theres no replacing them, so your dopamine levels drop and you cant fire off as many messages to control smooth body movements.
Early on, you wont notice anything different. But as more and more cells die, you reach a tipping point where you start to have symptoms.
That may not be until 80% of the cells are gone, which is why you can have Parkinsons for quite a while before you realize it.
What Is The Outlook For Persons With Parkinsons Disease
Although there is no cure or absolute evidence of ways to prevent Parkinsons disease, scientists are working hard to learn more about the disease and find innovative ways to better manage it, prevent it from progressing and ultimately curing it.
Currently, you and your healthcare teams efforts are focused on medical management of your symptoms along with general health and lifestyle improvement recommendations . By identifying individual symptoms and adjusting the course of action based on changes in symptoms, most people with Parkinsons disease can live fulfilling lives.
The future is hopeful. Some of the research underway includes:
- Using stem cells to produce new neurons, which would produce dopamine.
- Producing a dopamine-producing enzyme that is delivered to a gene in the brain that controls movement.
- Using a naturally occurring human protein glial cell-line derived neurotrophic factor, GDNF to protect dopamine-releasing nerve cells.
Many other investigations are underway too. Much has been learned, much progress has been made and additional discoveries are likely to come.
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Other Concerns To Be Aware Of
There are a few other possible concerns to be aware of when having surgery. Again, not everyone will experience these issues, but it is wise to understand them and be aware so that you can plan accordingly and be prepared.
- The effect of even mild dehydration may be exacerbated in PD.
- People with PD may have swallow dysfunction. This can be exacerbated by anesthesia and make people with PD at higher risk for aspiration, defined as the tendency for food or liquid to get into the airway. Therefore, it is best to introduce soft foods slowly after surgery.
- People with PD may have significant fluctuations of blood pressure which can be magnified in the post-operative period. Episodes of low blood pressure can cause dizziness and even fainting. This problem is most prominent when changing head position that is moving from lying down, to sitting to standing. Therefore, these changes should be made very slowly.
- Urinary dysfunction is common in PD, and people with PD may be particularly prone to urinary tract infections . It is important to note that UTIs or any infection may first manifest as an unexplained worsening of PD symptoms or initiation of hallucinations.
- People with PD are particularly prone to constipation and this can be exacerbated in the post-operative period. Taking a daily medication to prevent constipation may become necessary after surgery.
Tips and takeaways
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Caring For Someone With Parkinsons
Practice patience and understanding when dealing with Parkinsons. You may be very frustrated and challenged as a caregiver, but those with Parkinsons are just as frustrated. Their physical and mental conditions can be debilitating, depressing, and humiliating.
Diet and nutrition can have a huge impact on the health and comfort of a Parkinson patient. Eating well, getting more rest, sleeping well, fresh air, and exercise can make a difference. Getting the right medication and complementary therapies is also important.
As Parkinsons impacts a patients motor skills, modifications to the living environment may have to be made to accommodate wheelchairs and limited mobility issues. Professional in-home assistance for Parkinsons can allow Parkinson patients to remain independent and can enhance quality of life.
Most importantly, seek help and support from family, friends, and caregiving support groups. Take advantage of the resources in your community. Shouldering all the burden can take a toll on a caregiver.
Take care of yourself or you wont be able to take care of your loved one. Follow the preventive advice provided above for yourself as well, and take deep breaths!
Resources
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Be Prepared: Communication Is Key
Despite these challenges, your healthcare team wants to give you the best care. While the Parkinsons Foundation works to ensure that health professionals have access to the latest PD research and care, you can take charge of your own care by educating hospital staff about the disease.
Like any other potential emergency, prepare now. If you havent already, request your free Parkinsons Foundation Aware in Care kit to help you convey important information about your PD when hospitalized. Each Aware in Care kit contains useful tools and information to help a person with Parkinsons during the next hospital visit. Each kit includes tools to help educate everyone who provides care to you or your loved one in the hospital, including information about the importance of medication timing and medications that should be avoided for people with Parkinsons.
Keep your Aware in Care kit in an easily accessible place, such as a kitchen cabinet. Tell your family and friends where to find it. Find an advocate a loved one or friend who can take charge of communication with hospital staff during a stay. You or your advocate should immediately contact your neurologist to let him or her know about your hospital stay. If the stay is planned, call in advance.
Ethics Approval And Consent To Participate
This study was reviewed and approved by the Institutional Board Review of King Abdullah University Hospital and Jordan University of Science and Technology. This study was conducted in accordance with the Declaration of Helsinki. The consent was waived due to the retrospective nature of the study. We confirm that the privacy of the participants was saved, and the data were anonymized and maintained with confidentiality.
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Epidemiological And Experimental Research
Different combinations of anesthesiologist, anesthetic gases, nitrous oxide, halothane, isofluorane, sevofluorane, Parkinsons disease, dopamine, dopaminergic neurons, substantia nigra, striatum, vitamin B12, cobalamine, amyloid were searched in PubMed and Scopus.
An association between exposure to anesthetic gases and PD was suggested for the first time by a casecontrol study conducted in Italy , in which the risk of PD was evaluated with odds ratio and 95% confidence interval estimated with logistic regression analysis. Smoking adjusted ORs were: 41.7 for family history of PD; 10.8 for family history of essential tremors; 2.6 for advanced maternal age at the time of childbirth; 7.7 for employment in agriculture; 2.0 for the use of well water; and 2.2 for general anesthesia .
A cohort study compared mortality from PD between two large groups of US male doctors that were followed up from 1979 to 1995 . The standardized mortality ratio was estimated separately in anesthesiologists and internists in two follow up periods and, in each follow-up period, a risk ratio was obtained. Table; shows that in each group of doctors, mortality was lesser with respect to that in the US population. When the two groups were directly compared, RR becomes 3.47 in the second period, a statistically significant excess indicating that PD risk was higher in anesthesiologists compared to internists .
Should General Anesthesia Be Avoided In The Elderly
As a caregiver, it can be hard to know what to do when a doctor says your loved one needs surgery. The link between dementia and anesthesia remains fuzzy, but there is no doubt that going under can cause lingering physical and cognitive issues for some older adults. Many seniors bounce back after procedures like hip replacements and open heart surgery, but some never return to their preoperative cognitive baseline.
It is crucial to communicate with all members of a seniors health care team to weigh the risks and benefits of every medical treatment, especially surgical procedures. When making this decision, consider the patients age, physical and mental health status, and the anticipated effects on their quality of life. For example, if a senior is still very active and in decent shape but suffers from excruciating arthritis, joint replacement surgery could significantly enhance their quality of life, mobility and functional ability.
A seniors ability to participate in post-op rehabilitation is also an important factor in this decision. Older adults with new or worsening cognitive decline often struggle to understand and comply with prescribed physical and occupational therapy sessions in senior rehab.
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What Are The Types Of Anesthesia And Their Side Effects
There are four main types of anesthesia used during medical procedures and surgery, and the potential risks vary with each. The types of anesthesia include the following:
General anesthesia. General anesthesia causes you to lose consciousness. This type of anesthesia, while very safe, is the type most likely to cause side effects. If youâre having general anesthesia, a physician anesthesiologist should monitor you during and after your procedure to address any side effects and watch for the possibility of more serious complications.
Side effects of general anesthesia can include:
Rarely, general anesthesia can cause more serious complications, including:
Monitored anesthesia care or IV sedation. For some procedures, you may receive medication that makes you sleepy and keeps you from feeling pain. There are different levels of sedation â some patients are drowsy, but they are awake and can talk; others fall asleep and donât remember the procedure. Potential side effects of sedation, although there are fewer than with general anesthesia, include headache, nausea, and drowsiness. These side effects usually go away quickly. Because levels of sedation vary, itâs important to be monitored during surgery to make sure you donât experience complications.
More serious but rare complications include:
The Spread Of Parkinsons
Researchers have found that areas of the brain stem below the substantia nigra show cell loss in Parkinsons. And cells in these areas have been found to contain clumps of alpha-synuclein protein, which may form before those in the substantia nigra.
These findings have led some researchers to suggest that . Indeed, there is evidence that, for some, Parkinsons may start in the gut and travel up the vagus nerve, which connects the gut and the brain, to the substantia nigra.
The theory that Parkinsons may spread up the brain stem and progress throughout the brain is the basis of the Braak staging of Parkinsons.
The 6 stages in Braaks theory aim to describe the spread of Parkinsons through the brain:
While there is still some debate over the origin of Parkinsons, and even competing and more complex theories about the spread of Parkinsons, attempts to understand how and why different areas of the brain are involved in the motor and non-motor symptoms are helping in the development of better treatments.
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Exposure To Anesthetic Gases
The search of occupational exposure, anesthetic gases and Veneto in PubMed and Scopus returned three citations . Available exposure data, collected with personal sampling in anesthesiologists in Veneto public hospitals from 1990 to 1999, are shown in Table;: means and standard deviations as well as percentage of exceedance with respect to a threshold of 50;ppm for nitrous oxide and 2;ppm for forane. Exposure over time decreased for N2O but not for forane. Compliance with exposure threshold values was assessed with the one-sided tolerance limits test, which places the statistic OTL against number of samples taken . As shown in Figure;, all measures were plotted in the unacceptable area.
Table 1 Anesthetist exposure to anesthetic gases measured in the operating rooms of the Veneto Region, 1990-2002, by personal sampling: survey year, number of samples, mean and standard deviation , percentage of measurement exceeding the standard , and referencesFigure 1
Compliance of exposures to anesthetic gases with exposure threshold values, assessed with the one-sided tolerance limits test: OTL on y-axis and number of samples on x-axis of the OTL diagram.
What Are The Symptoms Of Parkinsons Disease
Symptoms of Parkinsons disease and the rate of decline vary widely from person to person. The most common symptoms include:
Other symptoms include:
- Speech/vocal changes: Speech may be quick, become slurred or be soft in tone. You may hesitate before speaking. The pitch of your voice may become unchanged .
- Handwriting changes: You handwriting may become smaller and more difficult to read.
- Depression and anxiety.
- including disrupted sleep, acting out your dreams, and restless leg syndrome.
- Pain, lack of interest , fatigue, change in weight, vision changes.
- Low blood pressure.
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The Effects Of Parkinsons Disease
* Memories: Brain stores short-term memories of the experience in a part of the brain called the hippocampus, then those memories are later consolidated and transferred to another part of the brain, more precisely in neocortex, for a long-term storage; Memory cells are placed in three parts of the brain, the hippocampus, the prefrontal cortex, and also the basolateral amygdala, which is responsible of emotional associations. In fact these cells are necessary to evoke the emotions linked with
General Points To Be Aware Of When Entering The Hospital
- Provide a list of your medications with exact times, frequencies and dosages. Share your knowledge about PD, including on-off fluctuations and the importance of taking medications at specific time intervals.
- Bring medication in original bottles.
- Know which drugs can worsen the symptoms of PD
- Research study participants should provide information about experimental drugs. Inform the study coordinators that you are in the hospital.
- Speak up when medications are wearing off.
- Do not take medication on your own. Unless you have prearranged permission, the staff should administer all medication.
- Tell the staff if you have a implant. Bring the access review or magnet device to turn the stimulator on and off.
- Inform your neurologist that you are in the hospital. Provide your neurologist’s phone number of your neurologist to your hospital doctor.
- Be mobile, especially during prolonged stays! Walk around as much as possible. Inquire about physical therapy or occupational therapy.
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