If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
Electronic Letters to:
|
|
E-letters: Electronic letters published:
-
![[Read E-letter]](/icons/misc/sectionDOWN.gif)
DEEP BRAIN STIMULATORS AND ANESTHESIA MANAGEMENT
- Dr Vinod Parashar, Dr. Deepak Tiwari (20 March 2006)
|
|
|||
|
Dr Vinod Parashar, Doctor member of indian assosiation of anaesthetist, Dr. Deepak Tiwari
Send letter to journal:
|
To, The Editor, British Journal of Anesthesia. Dear Sir, DEEP BRAIN STIMULATORS AND ANESTHESIA MANAGEMENT We read with interest the anesthetic management of a patient with a deep brain stimulator (DBS) 1. Recently we successfully anesthetized a patient with similar device implanted. A 61 year old female was scheduled for surgery of a (R) intertrochentric fracture. She was suffering from Parkinson’s disease for the last 12 years and had a deep brain stimulator implanted for control of bradykinesia, rigidity and gait abnormality. From her records, it was known that two electrodes of an implantable pulse generator (IPG) were implanted in the fronto parietal region. She was taking levodopa with carbidopa daily. She also suffered from osteo-arthrosis and scoliosis of the spine. On preoperative evaluation, we found, apart from Parkinsonism no hypertension, diabetes mellitus or other significant illness. She had restricted neck movements some neck rigidity and two upper front teeth missing. Her routine investigations were within normal limits. It was decided to conduct the surgery under general anesthesia. She was pre-medicated with diazepam 5mg and pantoparazole 40mg, given orally at bedtime and repeated 2 hours before shifting her to O.R. With standard monitoring, anesthesia was induced with atropine 0.6mg slow I.V., oxygen, tramadol 100mg, thiopentone 250mg and succinylcholine 100mg. Orotracheal intubation was carried out with a 8.0mm tracheal tube and anesthesia was maintained with oxygen, nitrous oxide and isoflurane 0.6% to 0.8% with vecuronium. The surgeon was advised to use only bipolar cautery in short bursts. Surgery lasted for 6 hours and the patient was reversed with atropine 1.2mg and prostigmine 2.0mg. We observed that the effect of the initial dose of vecuronium lasted for nearly 2 hours despite an adequate urine output and hydration, and only one dose was required thereafter till the conclusion of anesthesia. This was the first time that we had to deal with a patient with Parkinson’s disease who had a DBS implanted. We obtained information on the precautions to be followed from the circular supplied to the patient by Medtronic, the manufacturer of the IPG, and from their website.2 These included use of bipolar cautery and protection of device from radiation during the surgery. In this patient, we opted for general anaesthesia because of rigidity and her spinal problem. We used atropine to decrease secretions and muscle rigidity. For induction we used tramadol and thiopentone, avoiding fentanyl & propofol, both of which can increase muscle rigidity 3, 4. As rightly pointed out by Davies1 it is important to follow certain precautions like avoiding monopolar diathermy. If a defibrillator is to be used, the paddle should be parallel and as far away from the device as possible and should be used with the lowest clinically appropriate energy output. We continued levodopa with carbidopa till the morning of surgery to decrease salivation and also to aid mechanical ventilation by reducing rigidity5. Atropine was similarly helpful. We did not use phenothiazenes or butorophenon which inhibit the release of dopamine 3, 4. For analgesia tramadol 1 to 1.5mg/kg was used, as it causes less respiratory depression than stronger narcotics. For prevention of post operative nausea & vomiting, ondansetron was instituted after 6 hours. Thanking you, Yours sincerely Dr. V. K. Parashar *, Dr. Deepak Tiwari Department of Anesthesiology, Santokba Durlabhji Memorial Hospital cum Medical Research Institute, Jaipur, Rajasthan, INDIA. 1. Davies RG. Deep brain stimulators and anaesthesia. Br J Anaesth 2005; 95(3): 424 2. www.medtronic.com/physician/neurology/activa 3. Wiklund RA, Ngai SH. Rigidity and pulmonary edema after innovar in a patient on levodopa therapy; report of a case. Anesthesiology 1971; 35: 545 4. Mets B. Acute dystonia after alfentanil in untreated Parkinson’s disease. Anesth Analg 1991; 72: 557 5. Ngai SH. Parkinsonism, levodopa, and anesthesia. Anesthesiology 1972; 37: 344 *Corresponding author. E-mail: drparashar_21oct@yahoo.com Conflict of Interest:None declared |
|||