General Anesthesia Management during Surgical Fixation of a Zygomatic and Maxillary Fracture in a Patient Taking Multiple Anti-Parkinsonian Drugs

Abstract

  General anesthesia in patients with Parkinson disease should be performed with caution. Caution is particularly needed when patients with Parkinson disease have been prescribed opioids, since the combination of opioids and MAO inhibitors can cause serotonin syndrome and the use of fentanyl can increase muscle stiffness. The withdrawal of anti-Parkinsonian agents can cause the worsening of symptoms and the development of neuroleptic malignant syndrome, while their continued use may cause intraoperative circulatory changes.

  Here, the case of a 70-year-old male patient with previously diagnosed Parkinson disease who underwent surgical fixation of a left zygomatic and maxillary fracture is reported. The severity of the Parkinson disease was Ⅲ-Ⅳ on the Yahr Scale, and the patient was taking multiple anti-Parkinsonian drugs including dopamine/carbidopa, pramipexole hydrochloride, selegiline hydrochloride, entacapone, and droxidopa. A neurologist instructed the surgical team to limit the use of opioids and to administer levodopa intraoperatively. The patient’s routine medications were continued until the morning of surgery. General anesthesia was induced with intravenous thiamylal sodium, rocuronium bromide, and remifentanil, and the patient was orally intubated. Remifentanil was stopped immediately after intubation. The patient’s blood pressure was controlled with phenylephrine and ephedrine, as appropriate. General anesthesia was maintained with air, oxygen, and sevoflurane ; levodopa was administered intraoperatively. After an uneventful surgery, sugammadex sodium was administered, and the patient was extubated after awakening. Intravenous acetaminophen and flurbiprofen axetil were administered for postoperative analgesia. No worsening of the Parkinson disease symptoms was observed after the operation.

  In this case, we report a good surgical outcome with minimal opioid use and the continued perioperative administration of antiparkinsonian agents.