A 72-year-old male with severe Parkinson’s disease is admitted to your ICU ventilated following emergency abdominal surgery. Enteral administration of medications is not possible.

List five potential problems specific to the Parkinson’s disease that may affect his acute and long-term post-op management.                                                                                                         (25% marks)

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College answer

1)    severe muscle and trunk rigidity due to medication withdrawal
2)    likely to be wasted and deconditioned
3)    autonomic neuropathy and with CVS instability
4)    gut failure and pseudo-obstruction
5)    vocal cord dysfunction and upper airway dysfunction on extubation
6)    failure of temperature regulation
7)    greatly elevated risk of confusion
8)    enhanced sedation effects and sensitivity
9)    mobilisation and rehabilitation likely to be compromised.

Discussion

In short, there are a lot more than five potential problems here. The PD patient is likely to have a plethora of problems, and the trainee is spoiled for choice. 

  •  Airway issues:
    • Upper airway obstruction may develop due to laryngeal muscle involvement, which may complicate extubation by virtue of stridor (Vincken et al, 1984)
  • Respiratory issues:
    •  Swallowing difficulty predisposes this patient to aspiration
    • The rigidity of chest wall muscles makes total lung compliance worse
    • Post extubation, this rigidity predisposes them to atelectasis
    • While ventilated, muscle tremor may cause patient-ventilator dyssynchrony, and rigidity may make triggering more difficult
  • Haemodynamic issues
    • There may be haemodynamic instability because of autonomic involvement (i.e. the patient will remain hypotensive even though their sepsis is resolving
  • Neurological problems
    • Parkinsonian medications may need to be converted to parenteral forms (eg. rotigotine patches).
    • Often, anti-Parkinsons medications are themselves a risk factor for delirium and confusion, as is abrupt withdrawal thereof
    • There is an increased sensitivity to sedative medications
    • Once they do become confused, anti-dopaminergic medications (eg. antipsychotics) are relatively contraindicated
  • Gastrointestinal problems
    • Autonomic dysfunction of the gut leads to slower recovery from bowel surgery
    • The patient may be coming from a poor nutritional baseline 
    • Perioperative antiemetics and prokinetics (mainly metoclopramide and droperidol) are antidopaminergic and will worsen the symptoms

Problems of routine housekeeping:

  • Once a normal diet is permitted, it may be difficult to institute because of swallowing difficulty
  • There is an increased risk of DVT and PE due to immobility and rigidity
  • There is often delayed mobilisation due to this movement disorder, which promotes muscle wasting and deconditioning
  • Autonomic dysfunction also leads to a failure of thermoregulation (piloerection and cutaneous vascular supply is not under such tight control as it should be).

References

References

Freeman, William D., et al. "ICU management of patients with Parkinson's disease or Parkinsonism." Current Anaesthesia & Critical Care 18.5-6 (2007): 227-236.

Vincken, Walter G., et al. "Involvement of upper-airway muscles in extrapyramidal disorders: a cause of airflow limitation." New England Journal of Medicine 311.7 (1984): 438-442.

Katus, Linn, and Alexander Shtilbans. "Perioperative management of patients with Parkinson's disease." The American journal of medicine 127.4 (2014): 275-280.