Restless legs syndrome

 

tl;dr avoid the following:

Drugs

·      Missed doses

·      Anti-dopaminergic drugs

Medical

·      Iron deficiency

·      Uraemia

General care

·      Immobility

·      Sleep deprivation

 

The disease:

Cause

Primary:

·      Dopamine dysfunction

Secondary:

·      Iron deficiency

·      Uraemia

·      Rheumatic disease

·      Pregnancy

·      Medications

Epidemiology

·      Affects 10% of population

·      Peak age 65 years

·      Women > men (2x)

·      Common in pregnancy

·      May be triggered or exacerbated peri-op

Presentation

·      Urge to move one’s legs

·      Unpleasant sensation deep within the legs

·      Exacerbated by inactivity +++

·      Relieved by movement

·      Worse at night

Significance

·      Profound effect on QOL

 

Treatment:

Dopamine agonist

·      Only if severe

·      Use as infrequently as possible

·      Non-ergoline: pramipexole, rotigotine

·      Ergoline: cabergoline, pergolide (but fibrosis of heart valves, pericardium lungs, retroperitoneum)

Gabapentinoids

·      Effective!

Opioids

·      Mechanism unknown

Benzodiazepines

·      For sleep initiation and maintenance

 

Peri-op considerations:

Things to avoid

·      Immobility (esp long time on table without anaesthesia)

·      Missed tablets

·      Sleep deprivation

Things to pursue

·      Early mobilisation

Drugs to give

·      Regular medications

·      +/- L-DOPA via NGT

·      +/- parenteral apomorphine (dopamine agonist)

·      +/- rotigotine patch

Drugs to avoid

Anti-DA, anti-HT and anti-opioid:

·      Metoclopramide

·      Droperidol

·      Tramadol

·      Naloxone

·      Tricyclic antidepressants

·      Antihistamines

·      Most antipsychotics

·      Most antidepressants

Unclear whether neuraxial anaesthesia is good or bad.

 

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