Clinicians should carefully consider the scheduling of surgery for Parkinsons disease patients to ensure optimal treatment with carbidopa-levodopa (Sinemet), the “gold-standard treatment” for PD, according to a study.
Researchers with the University of Minnesota School of Nursing and the universitys medical school conducted a study to establish clear guidelines regarding perioperative symptom management in PD patients, who may miss several doses of carbidopa-levodopa when put on NPO (nil per os, or nothing-by-mouth) status for surgery.
“One concern with carbidopa-levodopa is its short, one-to-two-hour half-life, requiring dosing several times per day,” the researchers wrote in the January issue of the American Journal of Nursing (http://journals.lww.com/ajnonline/Fulltext/2013/01000/Original_Research___Perioperative_Medication.24.aspx).
“Moreover, because of wide variability in patients responses to this and other antiparkinson medications, individual regimens may be quite complex. Some regimens require frequent administration, alternating short-acting and sustained-release doses of carbidopa-levodopa. The complex medication regimens are of particular concern when a patient with Parkinsons disease must remain on NPO status for several hours postoperatively.”
Kathleen Fagerlund, RN, PhD, Lisa Carney Anderson, PhD, and Olga Gurvich, MA, conducted a retrospective review of patient electronic health records at a Midwestern public medical center, finishing with a sample of 89 surgical events in 67 PD patients who had undergone any type of surgery aside from PD-related surgery and were taking carbidopa-levodopa.
They found the median duration of carbidopa-levodopa withholding was 12.35 hours — more than 16 hours for patients undergoing inpatient procedures and more than 11 hours for those undergoing outpatient procedures.
“Given the implications of prolonged withholding times on the therapeutic effects of carbidopa-levodopa, researchers and clinicians must ask how such times can be reduced,” the authors wrote. “Operating room personnel, particularly certified registered nurse anesthetists, must be mindful that patients with Parkinsons disease can take carbidopa-levodopa and other antiparkinson medications with a sip of water until shortly before the initiation of anesthesia; and in many cases these medications can be resumed in the postanesthesia recovery unit. In the presence of gastric discomfort, nausea or vomiting, an orally disintegrating preparation of carbidopa-levodopa could be considered.”
Most surgical procedures began at 9 a.m. or later, with only 14% starting between 6 a.m. and 9 a.m. The most commonly reported exacerbation of PD symptoms was agitation or confusion.
The researchers concluded that for best symptom management, clinicians should schedule surgery on PD patients for as early in the day as possible, administer medications as close to the patients usual dosing schedule as possible and provide nursing education about optimal medication management for this patient population.
“Nurses can and should take the lead in ensuring that patients with Parkinsons disease receive their medications on time, that disruptions to the regimen are minimized and that optimal symptom management is achieved,” they wrote.