CASE REPORT


https://doi.org/10.5005/jp-journals-10049-2037
Journal of Research and Innovation in Anesthesia
Volume 8 | Issue 02 | Year 2023

Anesthetic Challenges in a Parkinson’s Patient with Deep Brain Stimulation Undergoing Knee Replacement: A Case Report


Arun K Patra1, Ipsita Choudhary2, Aditya Sapra3, Vikas Kulshrestha4, Sanjay Kumar5https://orcid.org/0000-0002-9737-7327, Ankur Gupta6, Chandrakant Reddy7, Manimaran Pushparaj8https://orcid.org/0009-0008-6566-5210

1,8Department of Anaesthesiology & Critical Care, Command Hospital Air Force Bangalore, Bengaluru, Karnataka, India

2Department of Biochemistry, Rama University, Kanpur, Uttar Pradesh, India

3,7Department of Anaesthesia, Command Hospital Air ForceBangalore, Bengaluru, Karnataka, India

4Department of Orthopaedics, Command Hospital Air Force Bangalore, Bengaluru, Karnataka, India

5Department of ENT, Command Hospital Air Force Bangalore, Bengaluru, Karnataka, India

6Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune, Maharashtra, India

Corresponding Author: Sanjay Kumar, Department of ENT, Command Hospital Air Force Bangalore, Bengaluru, Karnataka, India, Phone: +91 9935501481, e-mail: kumarsanjay79@yahoo.co.in

Received: 03 November 2023; Accepted: 02 December 2023; Published on: 29 December 2023

ABSTRACT

Deep brain stimulation (DBS) have progressively emerged as a crucial therapeutic option for those suffering from Parkinson’s disease (PD), refractory to conventional pharmacological treatments. Although the therapeutic benefits of deep brain stimulation (DBS) have been recognized, the perioperative anesthetic challenges associated with DBS, especially in the setting of unrelated surgical procedures, remain a complex and intricate challenge. In the case under report, a female patient who had undergone DBS implantation was scheduled to undergo a partial knee replacement (PKR) procedure. The administration of anesthesia was complicated by additional challenges, particularly involuntary movements and rigidity, which presented significant challenges for conventional techniques of ventilation and intubation. The situation was made more complex by the possibility of unfavorable interactions occurring between electromedical devices and the DBS system. This case serves as a unique example of the importance of a multidisciplinary approach, where the collaboration of specialists from various fields like anesthesiology, neurophysician, and orthopedic surgeons was vital. The case study provides evidence of the paramount importance of collaborative decision-making, thorough comprehension, and rigorous perioperative planning in the effective management of patients undergoing deep brain stimulation (DBS) procedures.

How to cite this article: Patra AK, Choudhary I, Sapra A, et al. Anesthetic Challenges in a Parkinson’s Patient with Deep Brain Stimulation Undergoing Knee Replacement: A Case Report. Res and Innov Anesth 2023;8(2):60–62.

Source of support: Nil

Conflict of interest: None

Keywords: Anesthesia management, Deep brain stimulation, Implantable pulse generator, Neurostimulators, Parkinson’s disease, Partial knee replacement

INTRODUCTION

Deep brain stimulation (DBS) has developed as an innovative therapeutic approach, particularly for those patients experiencing severe or refractory Parkinson’s disease (PD). According to Schuepbach et al., deep brain stimulation (DBS) has significantly improved the overall quality of life for a large percentage of patients by providing substantial relief from incapacitating motor symptoms.1 However, like other interventions that necessitate the implantation of electronic devices, DBS brings along its unique set of perioperative challenges. While there is a substantial body of literature addressing the management of patients with cardiac implants, there is a noticeable gap in offering comprehensive guidelines related to individuals with neurostimulators, such as DBS.2

The challenges encountered with DBS extend beyond the surgical problem associated with its implantation. They prominently manifest when these patients require unrelated surgical procedures. The anesthetic implications, especially the potential for involuntary movements, rigidity, and the distinct interactions between diverse electromedical devices and the DBS, become focal points of concern.3

Moreover, with the rising acceptance and prevalence of DBS, the medical community is increasingly encountering patients equipped with such devices, presenting for surgeries, irrespective of their association with their neurological condition. This development necessitates a profound understanding of the challenges inherent to DBS, particularly for anesthesiologists. This report aims to shed light on the anesthetic challenges encountered and the multidisciplinary approach adopted in managing a PD patient equipped with a DBS device undergoing a unilateral partial knee replacement (PKR). The aim of our study is to share our experience and provide an academic update on the existing literature in this field, emphasizing the role of anesthesiologists in ensuring favorable outcomes.

CASE PRESENTATION

Our 67-year-old female patient was diagnosed with PD 10 years ago. This patient’s journey highlights the complexities associated with managing advanced neurological conditions during the perioperative period. On evaluation, she scored “0” for subscale I of the Unified Parkinson’s Disease Rating Scale (UPDRS).4 Initially, she started on her therapeutic journey with dopaminergic medications. However, as time progressed, the menacing on–off fluctuations became increasingly evident. The reported episodes showed a notable association between increased mobility (on periods) and impaired movement due to rigidity (off periods). These occurrences were not only symptomatic recurrences but also impediments that significantly disturbed her daily activities. Despite the increasing pharmaceutical dosages, the persistent off periods continued to act as a significant barrier to her overall well-being.

In the face of such therapeutic resistance and to halt her rapid deterioration, she was implanted a deep brain stimulation (DBS) in 2021, employing the Medtronic DBS 37642 Activa PC system. This sophisticated device, stimulating the bilateral subthalamic nuclei through its four electrodes, brought about a significant relief from her symptoms. The critical function of the deep brain stimulation (DBS) in her symptomatology was apparent as its deactivation resulted in a nearly immediate recurrence of her incapacitating symptoms associated with PD. Such rapid and intense recurrences emphasized the device’s indispensable role and necessity of an instantaneous reactivation to restore her neurological balance.

The subsequent decision for her to undergo a PKR in view of advanced medial compartment osteoarthritis of the right knee, refractory to conservative therapeutic interventions, presented an array of complexities, primarily from an anesthesiologic perspective. The preoperative procedure involved more than routine surgical assessments. The focus centered on the numerous challenges posed by her deep brain stimulation (DBS) device, particularly in the setting of anesthesia. The perioperative phase presented considerable issues in terms of potential involuntary movements and severe rigidity, which posed a threat to the successful execution of intubation and ventilation procedures. The collaborative association between the neurologists, orthopedic surgeons, and, importantly, the anesthesiologists was crucial. The integration of multidisciplinary insights influenced the perioperative approach, prioritizing patient safety and optimizing surgical outcomes.

DISCUSSION

Parkinson’s disease (PD) is a neurodegenerative condition characterized by its hallmark motor manifestations such as tremors, rigidity, bradykinesia, and gait disturbances.5 Beyond these motor symptoms, PD patients often suffer from a myriad of nonmotor symptoms ranging from gastrointestinal disturbances like constipation to cognitive impairments.6 Although dopaminergic medications remain the cornerstone of PD management, their efficacy tends to diminish over prolonged usage, leading to the exploration of alternative therapeutic interventions.

Deep brain stimulation (DBS) has emerged as a pivotal modality in treating drug-resistant PD, offering significant benefits beyond PD to conditions like essential tremor and dystonia (Bronstein et al.).7 The underlying principle of DBS revolves around targeted electrical stimulation of specific brain regions facilitated by implanted electrodes. The Medtronic DBS 37642 Activa PC device, which our patient was equipped with, is designed to provide bilateral subthalamic nuclei stimulation, exemplifying the advancements in DBS technology.

While the clinical advantages of DBS are well established, its perioperative implications, particularly concerning anesthesia, are areas of active research.3 Modern DBS systems come equipped with wireless handheld devices that enable mode alterations and device activation or deactivation (Fig. 1). While such innovations offer precision in DBS management, they also introduce challenges. For instance, deactivating the pulse generator can precipitate severe PD symptoms, highlighting the intricate balance between surgical needs and neurological stability (Volkmann et al.).8

Fig. 1: Handheld remote used to change the modes (on and off) of the DBS

Historically, DBS devices operated on voltage control, but contemporary devices, like the one our patient had, are current-controlled, offering refined calibration capabilities. The calibration to specific milliampere values, based on individual symptomatology, highlights the significance of bespoke care and collaborative decision-making (Hariz).9

The device consists of an implanted pulse generator, which is placed subcutaneously in the left subclavicular area and wires extended up to the desired areas in the brain (Fig. 2). Interference from electromagnetic fields remains an important concern. Devices like DBS can indeed disrupt electrocardiography readings, while medical equipment, especially electrocautery, might compromise the DBS’s functionality. Such cross-interactions can either amplify or suppress stimulations or potentially incapacitate the device altogether (Nutt et al.).10 The gravity of these interactions is further underscored by instances of brain damage due to excessive heat at the electrode sites (Kuncel and Grill).11 In our patient, the preference for bipolar cautery over its unipolar counterpart was a conscious decision to mitigate such risks.

Fig. 2: X-ray showing the implanted pulse generator and the wires extended to desired brain surface

The selection of anesthesia for patients with PD and an implanted DBS is intricate. While spinal anesthesia with an adductor canal block is our standard for knee surgeries, the unique challenges presented by PD and DBS—such as involuntary movements and potential drug-device interactions—prompted our choice of general anesthesia for this patient. It’s important to emphasize that anesthesia selection for DBS patients demands individualized assessment to ensure safety and efficacy (Fluchere et al.).3

CONCLUSION

The management of patients with DBS undergoing surgery presents distinct anesthetic challenges. In our experience, understanding the complexity of DBS, combined with multidisciplinary collaboration, was paramount in ensuring a successful outcome. Considering the increasing prevalence of deep brain stimulation (DBS) devices in clinical settings, it is essential to engage in comprehensive research initiatives aimed at developing optimal approaches. The use of standardized protocols based on evidence-based medicine would provide an organized framework for anesthesiologists, thus enabling the best perioperative care of these individuals. This case highlights the importance of comprehensive planning and collaboration in managing patients with DBS, ensuring optimal patient safety and care.

Consent for Publication

Written informed consent was obtained from the patient for the publication of any potentially identifiable images or data included in this article.

ORCID

Sanjay Kumar https://orcid.org/0000-0002-9737-7327

Manimaran Pushparaj https://orcid.org/0009-0008-6566-5210

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