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Dr. Okun

Post of the Week: Withholding Parkinson's Medications Before Surgery

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Dr. Okun    409

Dear forum members,

 

This topic of when and how long to withold PD meds before surgery, and also when to restart them after surgery is a really important topic. The authors suggest that PD patients should have an early morning surgery after witholding PD meds the night prior.

 

 

Am J Nurs. 2012 Dec 14. [Epub ahead of print]

Perioperative Medication Withholding in Patients with Parkinson's Disease: A Retrospective Electronic Health Records Review.

 

Source

 

Kathleen Fagerlund is a clinical associate professor ad Honorem and Olga Gurvich is a statistician at the University of Minnesota School of Nursing in Minneapolis. Lisa Carney Anderson is an assistant professor in the Department of Integrative Biology and Physiology at the University of Minnesota Medical School. The authors acknowledge Brandon Thiemann, DNP, CRNA, for assistance with data entry; and Brian Warzecha, MS, CRNA, and Melanie Zenzen, MS, CRNA, for assistance with data abstraction. Contact author: Kathleen Fagerlund, fager003@umn.edu. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Abstract

 

: The authors explore medication withholding times and symptom management.

BACKGROUND:

 

Carbidopa-levodopa (Sinemet), the gold-standard treatment for Parkinson's disease, has a short half-life of one to two hours. When patients with Parkinson's disease are placed on npo (nil per os, or nothing by mouth) status for surgery, they may miss several doses of carbidopa-levodopa, possibly resulting in exacerbation of Parkinson's disease symptoms. Clear guidelines regarding perioperative symptom management are lacking.

OBJECTIVES:

 

The goals of this study were threefold: to measure the perioperative duration of the withholding of carbidopa-levodopa in patients withParkinson's disease, to record the time of day surgeries were performed on these patients, and to record perioperative exacerbations of Parkinson's disease symptoms.

METHODS:

 

We conducted a retrospective review of patient electronic health records at a Midwestern public medical center. After applying inclusion and exclusion criteria and evaluating the eligible records, we had a final sample of 89 separate surgical events for 67 discrete patients who had been diagnosed with Parkinson's disease, had undergone any type of surgery excepting Parkinson's disease surgeries, and were taking carbidopa-levodopa.

RESULTS:

 

The median duration of carbidopa-levodopa withholding was 12.35 hours, with most surgical procedures (86%) starting at 9 AM or later. The most commonly reported exacerbation of Parkinson's disease symptoms was agitation or confusion.

CONCLUSIONS:

 

For best symptom management, careful consideration should be given to scheduling surgery at the earliest possible time, administering medications as close to the patient's usual dosing schedule as possible, and providing nursing education about optimal medication management for this patient population.

PMID: 23247677 [PubMed - as supplied by publisher]

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Island Woman    130

Dr. Okun, thank you for that info...I'm planning on catarach surgery and wisdom removal in the spring. I take sinemet and azilect...so far haven't talked to Drs. about when and if I should stop meds. prior to both surgery.

 

Patricia

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Dr. Okun    409

Best to talk to them and it would be ideal to be off meds for as short a period as possible and safe.

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Golden01    330

What about Azilect? My husband recently had surgery and was instructed by his MDS to be off the Azilect for seven days prior to surgery. We used the NPF "Be Award in Care Kit" and had great care at an orthopedic hospital for his shoulder surgery. What about urinary retention and surgery for people with PD? They used on a catheter on my husband to empty his bladder at the end of the surgery because of concerns about his urinary retention and his PD. Is that common?

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Dr. Okun    409

It is common to stop Azliect 7-10 days before surgery so there are no side effects with anaesthesia or with pain meds.

 

Urinary retention and the use of an in and out catheter are common procedures in PD patients. It is best if possible not to leave the catheter in place as the catheter can be an infection risk.

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xaxa    23

Off the record, but I have never withheld meds pre-op. Anesthesia has instructed me that it's OK to take them with a small amount of water, as long as it's not immediately prior to anesthesia. For example, I could take them at 5am for a 7pm or later procedure. I believe the odds of aspiration are next to nothing for me; HOWEVER, I can imagine that in an older, more debilitated patient the decision might be different. ALSO, wouldn't recovery likely go more smoothly medicated rather than "off"?? ALSO, aren't there IV/IM options such as apomorphine? Just thinking, waiting for my morning java to finish brewing... And my meds to kick in... ;)

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Dr. Okun    409

Some docs and anaesthesia teams allow meds before procedures. They are just worried that if you vomit during the procedure it will get into your lungs (regardless of your age). This is all negotiated between the patient and doc.

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cdjhead06    0

Dr. Okun - I have a similar type of question about withholding medicines, but this relates to the night before my movement disorder appointments.  My doctor want me off all meds. for at least 12 hours prior to my DBS adjustments.  Unfortunately, in doing so, my PD symptoms only on the DBS (and residual Azilect in my system since I take daily) are really bad with the restless legs, tremors, facial distortion, uncontrolled emotions (laughing and crying at the same thing), etc.  I can honestly live with the PD effects besides the restless legs (especially knees).  I generally am awake the whole night and pace (actually shuffle) through the house all night in order to deal with the legs tremors and restless legs.  Is there some thing that I can ask my movement doctor about using the night before so I can at least control the legs enough to get some sleep without affecting the appointment baseline adjustments on my DBS.  don't want to take a sleep drug because I am afraid that it will really mess up me when I am at my appointment

 

For my DBS, I find overall that it controls the dyskinesia from the Stalevo I take several times a day so I am not frozen up or moving so uncontrollably.  The DBS allows me to take the correct level of Stalevo so I am not frozen up abd can function at work.

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Dr. Okun    409

In many cases it is easier to program the device if off meds.  One strategy is to stop the meds a few hours before the appointment so that you will predictably be "off" at the appointment time.

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