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Precautions for patients considering
medical or surgical treatment
People with Parkinson's disease should be aware of several precautions when planning major medical or surgical treatments (for example, abdominal surgery or joint replacement surgery). Similar precautions apply to a person with Parkinson's disease who must be taken to a hospital emergency department for urgent treatment (for example, fever, chest pain or confusion).
When someone with Parkinson's disease is being evaluated for medical or surgical treatment, it is extremely important to make sure that that all health care providers know that he/she has Parkinson's disease. It is also necessary to review with the doctor(s) what medications should be avoided because of the disease or its treatment.
For patients who are to be sedated or require treatment for agitation or confusion
Avoid the following medications:
Chlorpromazine (Thorazine®)
Fluphenazine (Prolixin®)
Haloperidol (Haldol®)
Loxapine (Loxitane®; Loxapac®)
Molindone (Moban®)
Olanzapine (Zyprexa®)
Perphenazine (Trilafon®)
Risperidone (Risperdol®)
Thioridazine (Mellaril®)
Thiothixene (Navene®)
Trifluoperazine (Stelazine®)
The following medications may be used if needed:
Clozapine (Clozaril®)
Diazepam (Valium®)
Lorazepam (Ativan ®)
Propofol (Diprivan®)
Quetiapine (Seroquel ®)
For patients who require treatment for nausea
Avoid the following medications:
Chlorpromazine (Thorazine®)
Droperidol (Inapsine®)
Metoclopromide (Reglan®; Maxeran®)
Prochlorperazine (Compazine®; Stemetil®)
Trimethobenzamide (Tigan®)
Medications that may be used include:
Domperidone* (Motilium®)
Dolasetron (Ansemet®)
Granisetron (Kytril®)
Ondanzatron (Zofran®)
*not available the United States but available in Canada
Patients receiving selegeline or rasagiline
Individuals who take selegiline (Eldepryl®, Atapryl®, Carbex®) or rasagiline (Azilect®)should never receivemeperidine (Demerol®), a pain medication frequently used before or after medical or surgical procedures. Rarely, severe reactions have occurred in people taking both selegiline and certain antidepressants (both tricyclic and SSRIs). For individuals planning elective surgery with general anesthesia, it is generally recommended to stop treatment with selegiline or rasagiline 2 weeks prior to the operation to reduce the chance of unfavorable medication interactions.
Antiparkinsonian medication and surgery
Prior to surgery, levodopa (carbidopa/levodopa or Sinemet®) as well as dopamine agonists (bromocriptine (Parlodel®), pergolide (Permax®), pramipexole (Mirapex) or ropinirole (Requip®)) should be continued as late as possible on the day of the operation and resumed as early as possible after the operation (with sips of water or by nasogastric tube).
The time for recovery after a surgical procedure or major medical problem may be prolonged in people with Parkinson's disease. Resuming Parkinson's disease medication as soon as possible and early mobilization (sitting up in bed, sitting in a chair, and walking if possible) may help prevent complications and shorten time spent in the hospital.
Precautions for those with deep brain stimulators
You must alert health care providers that deep brain stimulators are in place. When exposed to strong electrical fields, the deep brain stimulator system can carry unintended electrical energy even if the system is turned off. For this reason, patients with stimulators in place must avoid circumstances in which they may be exposed to electrical currents.
Patients must avoid diathermy, a form of treatment which delivers heat to tissue using an electrical energy. Diathermy is used by a variety of health care professionals, including physical therapists, nurses, chiropractors, dentists, sports therapists, and others. Health care professionals may refer to diathermy using the term "deep heat" or similar terms. These electrical devices (shortwave, microwave, or therapeutic ultrasound diathermy) may cause damage even if no heat is created. The exact nature of the tissue or nerve damage depends on the location of the stimulation electrodes implanted in the patient (e.g. brain, spinal cord, sacral nerve, stomach), and the extent of the exposure to diathermy treatment.
Electrocautery (a surgical technique used to cut tissue) can damage the deep brain stimulator lead or extension. . It can also cause temporary suppression of neurostimulator output and/or reprogramming of the neurostimulator. If electrocautery is necessary, the current path (ground plate) should be kept as far away from the neurostimulator, extension, and lead as possible. Bipolar electrocautery is recommended.
MRI (magnetic resonance imaging), particularly when body parts other than brain are imaged, may cause damage to the deep brain stimulators or brain.
If more specific information is needed, questions can be directed to Medtronic's Technical Support Line for Activa Therapy: 1-800-707-0933
Summary
These precautions for a person with Parkinson's disease who is about to undergo major surgical or medical care can be summarized as follows:
1) Be sure that all medical personnel are aware of the Parkinson's disease diagnosis.
2) Avoid medications that block dopamine receptors. Many medications used for anxiety, confusion, and psychosis as well as antinausea medications block dopamine receptors. Meperidine must not be used in individuals who take selegiline or rasagline. Share the list (above) with your doctor(s).
3) If surgery using general anesthesia is planned, selegiline and rasagiline should be discontinued 2 weeks prior to surgery to avoid unfavorable medication interactions.
4) Take Parkinson's disease medications until the surgical or medical procedure and then resume these medications as soon after the procedure as possible.
5) Because recovery from major surgery may take longer for people with Parkinson's disease, physical therapy and extra recovery time may be necessary.
6) If deep brain stimulators are in place, diathermy must be avoided. Electrocautery and MRI scanning should only be performed by staff knowledgeable about their use in patients with deep brain stimulators.
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