© 2018 Kurt Pfeifer.

NEUROLOGIC DISEASE

ASSESSMENT

Data Gathering

History

Symptoms

  • Previous neurologic evaluations (brain imaging, EEG, etc)

  • History of perioperative neurologic complications (seizures, worsened neurologic function, respiratory failure)

  • Seizure triggers & date of last seizure

  • History of progression of neurologic disease & last exacerbation

  • Pulmonary function testing (in patients with neuromuscular disorders)

  • Past and recent glucocorticoid use

  • Focal weakness/numbness

  • Paresthesias

  • Seizures - date of last episode

  • Dyspnea

  • Fatigue

  • Dysphagia

  • Lightheadedness

  • Syncope

  • Urinary/fecal incontinence/retention

  • Memory problems

Exam

  • Focal neurologic deficits

  • Deep tendon reflexes

  • Cogwheeling/rigidity

  • Gait abnormalities

  • Cognitive dysfunction

Risk Stratification

No well-validated risk stratification tools​ specific for any of the neurologic diseases. Risk assessment should focus on assuring disease has been appropriately evaluated in the past and is optimized as much as possible for the necessary surgical timeframe.

Diagnostic Studies

  • BMP, CBC and LFTs as indicated for medications requiring these for long-term management

  • Anti-seizure medication levels: only obtain if recommended by patient's neurologist

  • ECG within 6 months for patients on medications for movement disorders (eg, Parkinson disease)

  • Pulmonary function tests within past year (or sooner if recent change in symptoms) for patients with neuromuscular diseases (eg, myasthenia gravis)

MANAGEMENT

Seizure Disorders

  • Continue all anti-seizure medications uninterrupted

  • If prolonged NPO period anticipated, discuss with patient's neurologist what parenteral alternatives should be used

  • Maintain seizure precautions in the immediate postoperative period

Parkinson Disease

  • Avoid missed doses of medications - withdrawal may dramatically worsen symptoms or preciptate Parkinsonism Hyperpyrexia Syndrome (presentation and morbidity similar to malignant hyperthermia)

    • If prolonged NPO period anticipated, discuss with patient's neurologist what parenteral or orally dissolving alternatives should be used​

  • Alert anesthesiology to patients on MAO-B inhibitors (typically would not discontinue these)​

  • Counsel patients on the increased risk of aspiration pneumonia, respiratory failure, delirium, and prolonged functional decrease

Multiple Sclerosis

  • Typically continue all disease-modifying medications uninterrupted, but discuss with surgeon and neurologist since many are immunosuppressive

  • Counsel patients on the increased risk of infection (from immunosuppressants), aspiration, respiratory failure, and prolonged worsening of neurologic status

Myasthenia Gravis

  • Typically continue all medications uninterrupted

  • Discuss perioperative care with patient's neurologist

  • Avoid non-depolarizing neuromuscular blockade

  • Counsel patients on the increased risk of infection (from immunosuppressants), aspiration, and respiratory failure

  • Avoid outpatient surgery (plan on admission for observation) if general anesthesia is used