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How Perioperative Medication Withholding Affects Patients with Parkinson’s Disease

February 4, 2013

By Sylvia Foley, AJN senior editor

The timing of antiparkinson medications has pro­found implications for motor and cognitive function.… If perioperative surgical staff aren’t sufficiently aware of the importance of minimizing disruptions to patients’ antiparkinson medication regimens, prolonged medi­cation withholding of several hours’ duration can occur. And patients with Parkinson’s disease whose doses are delayed may deteriorate quickly.

In January and again this month, we bring you a pair of CE–Original Research articles that describe the findings of two companion studies on how perioperative medication withholding affects patients with Parkinson’s disease. Here’s a short summary.

The quantitative study—what the EHRs said. The first article, “Perioperative Medication Withholding in Patients with Parkinson’s Disease,” discusses the results of a retrospective review by Kathleen Fagerlund and colleagues. The authors reviewed the electronic health records (EHRs) of 67 surgical patients who had undergone 89 surgeries unrelated to Parkinson’s disease. They looked at the duration of perioperative withholding of carbidopa-levodopa (Sinemet)—the gold standard treatment for Parkinson’s disease, it has a short half-life of just one to two hours—and at symptom exacerbations.

What they found was that medication withholding tended to be prolonged. The median duration of withholding for 32 inpatient and 57 outpatient procedures was more than 16 hours and more than 11 hours, respectively. They also found that for 56% of the inpatient procedures, the patient’s EHR contained a note referencing Parkinson’s disease symptoms or symptom management, which included increased agitation or confusion, increased tremors, and symptom management complicated by pain or pain medications. (Because outpatient EHRs contained minimal nursing notes and patients were discharged quickly, only inpatient EHRs were reviewed.)

figure_captureThe authors offer several recommendations, which include a call for improved nursing education about Parkinson’s disease; they state,

nursing education should stress the importance of patients continuing to take their antiparkinson medications with a sip of water up until shortly before the initiation of anesthesia, and of their resuming these medications as soon as possible after surgery.

The qualitative study—the patients’ take. The second CE, “The Perioperative Experience of Patients with Parkinson’s Disease,” discusses findings from a qualitative study by Lisa Carney Anderson and Kathleen Fagerlund. Its goals were “to hear from patients with Parkinson’s disease about their perioper­ative experiences and to describe those experiences using the patients’ own words, particularly with regard to antiparkinson medication withholding and symptom exacerbation.” The researchers performed 14 semistructured interviews with 13 participants and, after analyzing the data, identified four themes:

  • medication timing may not fit with hospital routine
  • patients know their own bodies and the best med­ication regimen
  • education is needed for hospital staff
  • there is an interaction between surgery or anesthe­sia and Parkinson’s disease

The first theme above was the one that emerged most often in participants’ comments. One participant said, “OK, so I refused the pill one time, and then an hour later needed it, and the nurses had a hard time understanding why.” And several participants expressed “dismay” at the deficits in clinicians’ knowledge. One said, “I’m still surprised at how many staff don’t understand Parkinson’s. You run into a wall, and they don’t know anything.”

Participants “made it clear that the actions of nurses could affect the perioperative experience for better or for worse.”  The authors conclude,

Participants’ comments suggested that there are two actions nurses could take that would immensely improve the perioperative experience: advocate flex­ibility in the patient medication schedule; and rely on patients’ self-knowledge regarding antiparkinson med­ication, dosing, and timing.

To learn more, read the articles, which are free online. And please share your own relevant experiences in the comments.

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One comment

  1. OR nurses should also be aware that many Parkinson’s patients are also on COMT (Catechol-O-Methyltransferase) inhibitors . Comtan/entacapone, Tasmar/tolcapone are a few examples. Epinephrine is one of the drugs known to be metabolized by COMT and is also frequently in local anesthetics (Marcaine, Lidocaine, ect). Epinephrine should be administered with caution in patients receiving COMT inhibitors REGARDLESS of the route of administration as their interaction may result in increased heart rates, possibly arrhythmias, and excessive changes in blood pressure. This may or may NOT be known by the surgeon or anesthesiologist. The interaction (no matter what the chance) should be made known prior to dispensing the drug to the surgical field

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