Perioperative Management of Patients with Parkinson's Disease

General Principles

• Prevent hypothermia using forced-air or circulating-water warming systems to maintain optimal symptom control and prevent complications, as recommended by the Clinical Nutrition guideline society 1
• Implement multimodal pain management approach, including mid-thoracic epidural analgesia for major open abdominal surgery, which provides superior pain relief with fewer respiratory complications, according to the Clinical Nutrition guideline society 1
• Remove nasogastric tubes as early as possible, as pre-emptive use does not improve outcomes, as stated by the Clinical Nutrition guideline society 1
• Allow normal diet after surgery without restrictions, starting carefully and increasing according to tolerance, as recommended by the Clinical Nutrition guideline society 1
• Consider multimodal approach to stimulate bowel movement, including oral laxatives and chewing gum, as suggested by the Clinical Nutrition guideline society 1
• Maintain near-zero fluid balance, avoiding overload of salt and water, as recommended by the Clinical Nutrition guideline society 1
• Remove urinary catheters early, on postoperative day 1 or 2, as recommended by the Clinical Nutrition guideline society 1

Postoperative Care

• Check vital signs to rule out serious causes of post-operative dizziness, such as hypotension, bleeding, and hypoglycemia, but do not rely on them alone for pain assessment, as recommended by the American Society of Anesthesiologists 2
• Identify significant risk factors for postoperative dizziness, including advanced age, ASA status 3-4, low BMI, history of previous delirium, preoperative cognitive impairment, elevated preoperative C-reactive protein levels, male sex, emergency/urgent procedures, and longer duration of surgery/anesthesia, according to the American Medical Association 3
• Encourage oral fluids unless contraindicated, restrict IV fluids to no more than 500 ml to reduce the risk of urinary retention, and assist with gradual position changes to prevent dizziness, as recommended by the Anaesthesia society 4
• Reduce noise, promote sleep hygiene, and ensure adequate nutrition to prevent dizziness and improve patient outcomes, as suggested by the British Journal of Anaesthesia 5
• Implement early mobilization, as evidence suggests that prolonged bed rest after procedures does not reduce adverse events compared to immediate mobilization, according to the Alzheimer's and Dementia society 6
• Monitor depth of anesthesia to prevent overdosing, which is crucial in preventing postoperative dizziness, as recommended by the American Society of Anesthesiologists 7

Medication Management

• Implement minimally sedating multimodal pain management as the first-line approach, including acetaminophen (650-1000 mg IV every 4-6 hours, max 4g/day) and NSAIDs if not contraindicated, as suggested by the Anaesthesia society 4
• Avoid or minimize opioids, benzodiazepines, and gabapentinoids, which can cause dizziness, and consider the risk vs. benefit of these medications, as recommended by the British Journal of Anaesthesia 5
• Adjust anesthetic and analgesic medications, use multimodal analgesia to reduce opioid requirements, and implement regional anesthesia when appropriate to help prevent postoperative dizziness, as suggested by the American Society of Anesthesiologists 8, 9
• Continue Parkinson's medications perioperatively with minimal interruption to maintain optimal control of symptoms in patients with Parkinson's disease, as recommended by the American Academy of Neurology 8, 5
• Follow specific medication recommendations for patients with Parkinson's disease:

Complication Prevention

• Ensure the affected limb is protected and provide written instructions about the expected duration of blockade for patients recovering from regional anesthesia, as recommended by the Anaesthesia society 4
• Be aware that patients with Parkinson's disease are at higher risk of postoperative delirium, and benzodiazepines should be avoided as first-line treatment unless benefits outweigh risks, according to the British Journal of Anaesthesia 5