1、 Preoperative evaluation
1. In addition to routine evaluation, it is necessary to fully understand the patient's condition and the anti Parkinson's drugs used before surgery. The second, third, and fourth generation drugs have a certain impact on anesthesia. 2. Such patients are prone to other important organ lesions. In addition to detailed medical history, physical examination, and preoperative examination, attention should also be paid to changes in the patient's respiratory, cardiovascular, and autonomic nervous system functions. Respiratory system lesions are more common and require focused evaluation. If conditions permit, lung function and blood gas analysis tests can be completed. In addition, organic changes in the respiratory system such as difficulty swallowing, respiratory muscle rigidity, and respiratory organ damage caused by involuntary movement are common. Preoperative assessment should be conducted to determine if the airway is difficult, and a rigorous plan should be developed for intraoperative respiratory management. Patients of this type often experience respiratory dysfunction after surgery. For those who have COPD before surgery, they may have obstructive ventilation disorders. Therefore, preoperative preparation should strictly quit smoking, control infections, reduce secretions, and engage in appropriate respiratory exercise. 3. In addition, the medication situation of the patient needs to be considered. As for anesthesia surgery, mild symptoms have little impact on anesthesia surgery, while severe symptoms such as respiratory muscle rigidity and diaphragmatic spasm can affect ventilation. Patients who are satisfied with symptom control generally do not discontinue treatment drugs during the perioperative period. Patients may increase or decrease their medication dosage before surgery, so it is important to inquire carefully, accurately assess the dosage, and bring the medication into the operating room for future use.
2、 Anesthesia treatment
1. Anesthesia method selection: Reasonably choose the anesthesia method according to the patient's condition and surgical needs:
(1) Local anesthesia is superior to general anesthesia - there is no need to use general anesthesia drugs and neuromuscular blocking drugs that mask tremors, reducing the aggravation of the patient's condition due to drug interactions. (2) Nausea and vomiting after local anesthesia are rare, and oral medication can be quickly resumed. (3) General anesthesia must be used, and attention should be paid to the rational selection of anesthetics. L-DOPA can be administered through a gastric tube after surgery. (4) General anesthesia combined with epidural anesthesia is a good choice for surgery in the chest, abdomen, and below areas: a. Both can reduce the amount of general anesthesia used during surgery. b、 Reduce the adverse reactions caused by medication and shorten the duration of discontinuation of anti PD drugs as much as possible, so that patients can smoothly pass the perioperative period.
2. Selection of Anesthetics:
(1) The effect of inhaled anesthetics on dopamine concentration in the brain is complex. Inhaled anesthetics at clinical concentrations can inhibit synaptic reuptake of dopamine, thereby increasing its extracellular concentration. (2) Those taking L-DOPA or monoamine oxidase inhibitors should avoid inhaling halothane, as it can increase the sensitivity of the heart to catecholamines and induce arrhythmia. (3) Enflurane can cause explosive suppression of electroencephalography, producing convulsive spikes, and can also cause muscle rigidity or spasms in the face, neck, and limbs, exacerbating Parkinson's symptoms. (4) Isoflurane and sevoflurane rarely cause arrhythmia, but attention should be paid to hypotension caused by low blood volume, autonomic dysfunction, and concomitant use of other medications. (5) Patients taking bromoergotide or pergolide are prone to excessive vasodilation, which further exacerbates hypotension. (6) Long term exposure to trichloroethylene may also induce PD. (7) Midazolam and etomidate are ideal intravenous anesthetics. (8) Scolin may cause hyperkalemia, and its clinical application must be noted. Low doses of morphine can alleviate patients' movement disorders, while high doses can make patients unable to move. It is believed that morphine can adjust the output of basal ganglia dopamine and alleviate movement disorders caused by L-DOPA. (9) Fentanyl can cause muscle rigidity, and its clinical application should be noted. There are reports that Afenicol can cause muscle tone disorders. (10) Duromeprazole is contraindicated for anesthesia in PD patients treated with selegiline. The combination of the two can lead to delirium, muscle rigidity, and high fever, ultimately resulting in death.
3. Precautions for anesthesia: During anesthesia, it is necessary to closely observe changes in the patient's vital signs.
(1) PD patients may experience some transient pathological reflexes during surgery, such as stretch reflex, ankle spasm, Babinski reflex, and cerebral rigidity. (2) Postoperative confusion and hallucinations are often prone to occur. (3) Muscle rigidity may occur after the application of fentanyl. (4) Common shivering symptoms after local anesthesia and general anesthesia. (5) PD patients are prone to postoperative aspiration pneumonia and respiratory failure. (6) Throat spasms often occur after extubation, so the respiratory tract should be thoroughly cleared before and after extubation, and the movements should be gentle. It is best to extubate with a certain level of sedation. (7) After surgery, anti PD medication should be resumed as soon as possible, and drugs that induce and worsen PD symptoms should be avoided during anesthesia. (8) Antidopaminergic effects: Thiamethoxam, butyrylbenzenes (chlorpromazine, fluoxetine), and metoclopramide, postoperative antiemetic effects: Obe or granisetron, etc. (9) Ephedrine indirectly promotes the release of dopamine; Lixiaping can prevent dopamine storage in dopaminergic nerve endings and avoid using ephedrine and Lixiaping to adjust blood pressure during surgery. (10) MAOl-A can block the degradation of tyramine in the digestive tract, causing tyramine crisis (hypertension, arrhythmia, malignant hyperthermia) in patients under general anesthesia.