title: Factors predicting incremental administration of antihypertensive boluses during deep brain stimulator placement for Parkinson's disease.
abstract: Hypertension is common in deep brain stimulator (DBS) placement predisposing to intracranial hemorrhage. This retrospective review evaluates factors predicting incremental antihypertensive use intraoperatively. Medical records of Parkinson's disease (PD) patients undergoing DBS procedure between 2008-2011 were reviewed after Institutional Review Board approval. Anesthesia medication, preoperative levodopa dose, age, preoperative use of antihypertensive medications, diabetes mellitus, anxiety, motor part of the Unified Parkinson's Disease Rating Scale score and PD duration were collected. Univariate and multivariate analysis was done between each patient characteristic and the number of antihypertensive boluses. From the 136 patients included 60 were hypertensive, of whom 32 were on angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), told to hold on the morning of surgery. Antihypertensive medications were given to 130 patients intraoperatively. Age (relative risk [RR] 1.01; 95% confidence interval [CI] 1.00-1.02; p=0.005), high Joint National Committee (JNC) class (p<0.0001), diabetes mellitus (RR 1.4; 95%CI 1.2-17; p<0.0001) and duration of PD >10 years (RR 1.2; 95%CI 1.1-1.3; p=0.001) were independent predictors for antihypertensive use. No difference was noted in the mean dose of levodopa (p=0.1) and levodopa equivalent dose (p=0.4) between the low (I/II) and high severity (III/IV) JNC groups. Addition of dexmedetomidine to propofol did not influence antihypertensive boluses required (p=0.38). Intraoperative hypertension during DBS surgery is associated with higher age group, hypertensive, diabetic patients and longer duration of PD. Withholding ACEI or ARB is an independent predictor of hypertension requiring more aggressive therapy. Levodopa withdrawal and choice of anesthetic agent is not associated with higher intraoperative antihypertensive medications.
authors.affiliation: Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA.
authors.forename: Shobana
authors.initials: S
authors.lastname: Rajan
authors.affiliation: Department of Neurosurgery, Center for Neuromodulation, Ohio State University Medical Center, Columbus, OH, USA.
authors.forename: Milind
authors.initials: M
authors.lastname: Deogaonkar
authors.affiliation: Department of Hospital Medicine and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Roop
authors.initials: R
authors.lastname: Kaw
authors.affiliation: Department of General Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
authors.forename: Eman Ms
authors.initials: EM
authors.lastname: Nada
authors.affiliation: Postgraduate School, Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru.
authors.forename: Adrian V
authors.initials: AV
authors.lastname: Hernandez
authors.affiliation: Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA.
authors.forename: Zeyd
authors.initials: Z
authors.lastname: Ebrahim
authors.affiliation: Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA. Electronic address: avitsir@ccf.org.
authors.forename: Rafi
authors.initials: R
authors.lastname: Avitsian
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000777:Anesthetics / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000008:administration & dosage*; D000978:Antiparkinson Agents / Q000627:therapeutic use; D001794:Blood Pressure; D046690:Deep Brain Stimulation; D048909:Diabetes Complications; D005260:Female; D006801:Humans; D007430:Intraoperative Care / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D019635:Neurosurgical Procedures / Q000379:methods*; D010300:Parkinson Disease / Q000150:complications / Q000628:therapy*; D012189:Retrospective Studies
chemical_list: D000777:Anesthetics; D000959:Antihypertensive Agents; D000978:Antiparkinson Agents
keywords: Anesthesia; Deep brain stimulation; Dexmedetomidine; Intraoperative hypertension; Neurosurgery; Parkinson’s disease; Propofol