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Department of Anesthesiology; University of Cologne; Cologne, Germany; oguzhan.dagtekin{at}uk-koeln.de (Dagtekin) Department of Anaesthesia; Royal Free Hampstead NHS Trust; London, UK (Berlet) Department of Anesthesiology; University of Cologne; Cologne, Germany (Gerbershagen) Central Critical Care Department; University of Cologne; Cologne, Germany (Dueck) Department of Anesthesiology; University of Cologne; Cologne, Germany (Giesecke)
To the Editor:
Deep brain stimulation (DBS) has emerged as an effective form of surgical therapy for Parkinson's disease. A 71-yr-old male was scheduled to undergo replacement of his DBS impulse generators as a result of battery depletion. Although ordered by the anesthesiologist, no premedication or antiparkinsonian medication was given preoperatively. General anesthesia was induced and maintained with propofol and remifentanil. A laryngeal mask was used.
Bilaterally, the generators were replaced. Postoperatively the patient did not regain consciousness for a period of time in excess of 40 min. His Glasgow Coma Scale score was 3. Generalized rigor and shallow breathing were also noted. It became evident that, contrary to usual practice, the impulse generators had not been activated after replacement. After the stimulators were activated with the preprogrammed stimulation parameters, the patient woke up instantly (Glasgow Coma Scale score, 13), and the rigor disappeared. His further postoperative course was uneventful.
Cases have been reported (1), in which an akinetic-rigid state emerged after only one stimulator had been turned off and which resolved when the stimulator was turned back on. Chronic stimulation of the subthalamic nucleus decreases the magnitude of the short-duration response to levodopa (2), which leads to a lack of response to levodopa treatment in these patients (3). Hence, we did not attempt treatment with dopaminergic drugs to resolve the akinetic-rigid state of our patient postoperatively.
In summary, DBS generators need to be activated immediately after replacement, while the patient is still under general anesthesia, to prevent an akinetic-rigid state that may be refractory to dopaminergic medication.
REFERENCES
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