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Bhat A, Dean J, Aboussouan LS. Perioperative Management in Neuromuscular Diseases: A Narrative Review. J Clin Med 2024; 13:2963. [PMID: 38792504 PMCID: PMC11122304 DOI: 10.3390/jcm13102963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/04/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Patients with neuromuscular diseases are particularly vulnerable in the perioperative period to the development of pulmonary and cardiac complications, or medication side effects. These risks could include hypoventilation, aspiration pneumonia, exacerbation of underlying cardiomyopathy, arrhythmias, adrenal insufficiency, prolonged neuromuscular blockade, issues related to thermoregulation, rhabdomyolysis, malignant hyperthermia, or prolonged mechanical ventilation. Interventions at each of the perioperative stages can be implemented to mitigate these risks. A careful pre-operative evaluation may help identify risk factors so that appropriate interventions are initiated, including cardiology consultation, pulmonary function tests, initiation of noninvasive ventilation, or implementation of preventive measures. Important intraoperative issues include positioning, airway and anesthetic management, and adequate ventilation. The postoperative period may require correction of electrolyte abnormalities, control of secretions with medications, manual or mechanical cough assistance, avoiding the risk of reintubation, judicious pain control, and appropriate medication management. The aim of this review is to increase awareness of the particular surgical challenges in this vulnerable population, and guide the clinician on the various evaluations and interventions that may result in a favorable surgical outcome.
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Affiliation(s)
| | | | - Loutfi S. Aboussouan
- Respiratory and Neurological Institutes, Cleveland Clinic, Cleveland, OH 44195, USA; (A.B.); (J.D.)
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2
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Krall JTW, Chakravartty A, Caress JB, Files DC. Identification and Management of Acute Neuromuscular Respiratory Failure in the ICU. Chest 2023; 164:1454-1461. [PMID: 38070961 DOI: 10.1016/j.chest.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/22/2023] [Accepted: 09/12/2023] [Indexed: 12/18/2023] Open
Abstract
Respiratory failure is a common and potentially life-threatening complication of neuromuscular diseases. Prompt recognition and accurate diagnosis of new or worsening chronic neuromuscular disease have important clinical management and prognostic implications. In this article, we present an approach to the acute presentation of undifferentiated neuromuscular respiratory failure in the ICU and guidance for determination and respiratory management of the underlying disorder.
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Affiliation(s)
- Jennifer T W Krall
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, NC.
| | - Akash Chakravartty
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - James B Caress
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - D Clark Files
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, NC
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3
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Van S, Lam V, Patel K, Humphries A, Siddiqi J. Propofol-Related Infusion Syndrome: A Bibliometric Analysis of the 100 Most-Cited Articles. Cureus 2023; 15:e46497. [PMID: 37927719 PMCID: PMC10624560 DOI: 10.7759/cureus.46497] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Propofol-related infusion syndrome (PRIS) is a rare, yet life-threatening sequelae to prolonged administration of the anesthetic propofol in mechanically intubated patients. The condition is characterized by progressive multi-system organ failure and eventual mortality; of note, the predominant characteristics of PRIS involve but are not limited to cardiovascular impairment and collapse, metabolic and lactic acidosis, rhabdomyolysis, hyperkalemia, and acute renal failure. While potent or extended doses of propofol have been found to be the primary precipitating factor of this condition, others such as age, critical illness, steroid therapy, and hyperlipidemia have been discovered to play a role as well. This bibliometric analysis was done to reflect the current relevance and understanding of PRIS in recent literature. The SCOPUS database was utilized to conduct a search for articles with keywords "propofol infusion syndrome" and "propofol syndrome" from February 24, 2001, until April 16, 2023, with parameters for article title, citation number, citation per year, author, institution, publishing journal, and country of origin. PRIS was first defined in 1990, just a year after its approval by the Food and Drug Administration for use as a sedative-hypnotic. Since then, interest in PRIS slowly rose up to 13 publications per year in 2013. Seven papers on the topic were published in Critical Care Medicine, six in Neurocritical Care, and four in Anesthesia. The most common institutions were Mayo Clinic, Northeastern University, and Tufts Medical Center. To our knowledge, this is the first bibliometric analysis to evaluate the most influential publications about PRIS. A majority of the research is case-based, possibly owing to the rarity of the condition. Our research suggests that confounding factors outside the precipitating dosage of propofol may be implicated in the onset and progression of PRIS. This study could therefore bring renewed interest to the topic and lead to additional research focused on fully understanding the pathophysiology of PRIS in order to promote the development of novel diagnostics and treatment.
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Affiliation(s)
- Sophie Van
- Anesthesiology, California University of Science and Medicine, Colton, USA
| | - Vicky Lam
- Anesthesiology, California University of Science and Medicine, Colton, USA
| | - Kisan Patel
- Physical Medicine and Rehabilitation, California University of Science and Medicine, Colton, USA
| | - Andrew Humphries
- Anesthesiology, California University of Science and Medicine, Colton, USA
| | - Javed Siddiqi
- Neurological Surgery, Riverside University Health System Medical Center, Moreno Valley, USA
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4
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Sales F, Cruz ARS, Maldonado F, Cunha M. Perioperative Management of Lewis-Sumner Syndrome. Cureus 2023; 15:e36297. [PMID: 37073183 PMCID: PMC10106104 DOI: 10.7759/cureus.36297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2023] [Indexed: 03/19/2023] Open
Abstract
Lewis-Sumner syndrome (LSS) is a rare immune-mediated neuromuscular disorder. It shares some clinical and pathological features with chronic inflammatory demyelinating polyneuropathy (CIDP). We report on the anaesthetic management of a patient with LSS. There are several concerns when anaesthetizing patients with demyelinating neuropathies, the main ones being the post-operative worsening of symptoms and respiratory depression related to muscle relaxants. In our experience, the rocuronium effect was prolonged and an even lower dosage (0.4 mg/kg) was sufficient for intubation and maintenance. Sugammadex allowed total reversion of neuromuscular block and no respiratory complications occurred. In conclusion, the combination of lower dose rocuronium and sugammadex was safely used in a patient with LSS.
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5
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Palha Ribeiro A, Tomas AS, Oliveira C. Primary Lateral Sclerosis: Can Rocuronium Be an Option? Cureus 2023; 15:e35773. [PMID: 37025717 PMCID: PMC10071450 DOI: 10.7759/cureus.35773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/08/2023] Open
Abstract
Primary lateral sclerosis (PLS) is a neurodegenerative motor neuron disorder that is characterized by corticospinal and corticobulbar dysfunction. In this disease, muscle relaxants in general anesthesia should be used with extreme caution. A 67-year-old woman with a history of PLS was scheduled for laparoscopic gastrostomy due to long-term dysphagia. In the preoperative assessment, she presented a tetrapyramidal syndrome with generalized muscle weakness. A priming dose of 5 mg of rocuronium was administered and the train-of-four (TOF) ratio (T4/T1) after 60 seconds was 70% so induction was followed with fentanyl, propofol, and additional 40 mg of rocuronium. After 90 seconds when T1 was lost, the patient was intubated. During surgery, the TOF ratio increased progressively until 65%, 22 minutes after a final bolus of 10 mg of rocuronium. Prior to emergence, 150 mg of sugammadex was given and neuromuscular block reversal was evidenced with a TOF ratio > 90%. As it was decided to perform the surgery laparoscopically, general anesthesia with a neuromuscular blockade was necessary. Since it is reported that patients with motor neuron diseases show an increased sensibility to non-depolarizing muscle relaxants (NDMR), these agents should be used cautiously. Adversely to what studies document, no augmented responsiveness was shown in TOF monitoring, so the standard dose of 0.6 mg/kg of rocuronium was safely given. A final bolus of NDMR was administered after 54 minutes, demonstrating a similar pharmacokinetics profile in terms of duration of action as reported in several studies (45-70 minutes). In addition, a full and rapid neuromuscular blockade recovery with 2 mg/kg of sugammadex was seen, as previously demonstrated in a case series.
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6
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A Review on the Anesthetic Management of Patients with Neuromuscular Diseases. Anesth Pain Med 2023. [DOI: 10.5812/aapm-132088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Context: Neuromuscular diseases (NMDs) are regarded as a clinically and genetically heterogeneous group of diseases characterized by weakening muscle strength and dystrophic changes in the muscle. Due to the nature of these diseases, it can be challenging for anesthesiologists to provide appropriate pain medications, symptom management, and other necessary techniques that are implemented to anesthetize the patient properly. Evidence Acquisition: This study was based on the available literature and the authors’ experience. The current study aimed to review the available anesthesia for patients suffering from NMDs. The search process resulted in the detection of relevant articles using valid keywords on electronic databases, including Embase, PubMed, Scopus, Web of Science, and Cochrane Library. Subsequently, 24 articles published between 2009 to 2022 were identified as eligible for this review. Results: When anesthetizing a patient with NMD, special attention should be paid to preoperative evaluation, medical-history taking, risk of difficult intubation or cardiac incidents, respiratory insufficiency, and frequent pulmonary infections. It is also necessary to keep in mind that these patients are at risk of prolonged paralysis, hyperkalemia, rigidity, malignant hyperthermia, cardiac arrest, rhabdomyolysis, or even death. Conclusions: Problems of anesthesia in patients with NMDs arise from the nature of the condition itself and the interaction of anesthetics and muscle relaxants with anticholinesterase drugs used in therapy. Each patient’s individual risk should be assessed before anesthesia. Therefore, it is important (and even necessary before major surgery) to perform a thorough preoperative examination to not only determine perioperative risk but also to ensure optimal perioperative follow-up.
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7
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Hudec J, Kosinova M. Anesthesia of the Patient with Zhu-Tokita-Takenouchi-Kim (ZTTK) Syndrome: A Case Report. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9060869. [PMID: 35740806 PMCID: PMC9221680 DOI: 10.3390/children9060869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/30/2022] [Accepted: 06/09/2022] [Indexed: 06/12/2023]
Abstract
Zhu-Tokita-Takenouchi-Kim (ZTTK) syndrome is an extremely rare multiorgan disorder, first described in 2015. Nowadays, about 50 patients with ZTTK syndrome have been reported, but there are no data about management during anesthesia. ZTTK syndrome patients can be indicated for surgery of musculoskeletal deformations and corrections of cardiovascular or urogenital malformations. This syndrome can be challenging for the anesthetic team based on the clinical manifestation of the syndrome. Because there are no recommendations for the management of these patients, anesthesiologists have to study typical symptoms, anatomy and possible expected changes in pathophysiology in perioperative period. One of the most dreaded anesthetic complications, the scenario "can not intubate, can not ventilate" could occur in these patients. The goal of this publication is to show options for anesthetic and perioperative management of this new rare syndrome with no published studies about management and approach in the perioperative period. The anesthetic team should choose the safest available approach. We present the first case report of anesthesia of a patient with ZTTK syndrome, a 7-year-old boy indicated for posterior neuromuscular scoliosis correction and fusion. This case describes the author's experiences with anesthetic management and mentions possible early postoperative complications. Adequate understanding of this syndrome can reduce perioperative complications and improve patient outcomes after surgery.
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Affiliation(s)
- Jan Hudec
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, 62500 Brno, Czech Republic;
- Department of Simulation Medicine, Medical Faculty of Masaryk University, 62500 Brno, Czech Republic
| | - Martina Kosinova
- Department of Simulation Medicine, Medical Faculty of Masaryk University, 62500 Brno, Czech Republic
- Department of Pediatric Anesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, 62500 Brno, Czech Republic
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8
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Abstract
Neuromuscular diseases (NMD) are a heterogeneous group of motor unit disorders. Common to all is the main clinical symptom of muscle weakness. Depending on entity and phenotype, a broad range of disorders of neuronal, junctional or myocytic structures occurs. In addition to a weakness of the skeletal musculature, NMD can also affect throat musculature, respiratory and heart muscles. The possible consequences are immobility, deformities, tendency to aspiration as well as respiratory and cardiac insufficiency. In the context of surgery and anesthesia, complications that can result from the underlying disease and its interaction with anesthesia must be anticipated and averted. This article describes along the treatment pathway how preoperative evaluation, choice of the anesthetic procedure and postoperative care can be effectively and safely tailored to the needs of patients with NMD. Concise and practical recommendations for carrying out anesthesia for the most important NMDs are presented as well as relevant external sources of practice recommendations.
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9
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Cung S, Ritz ML, Masaracchia MM. Regional anesthesia in pediatric patients with preexisting neurological disease. Paediatr Anaesth 2021; 31:522-530. [PMID: 33590927 DOI: 10.1111/pan.14152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 12/01/2022]
Abstract
Preexisting neurological disease in pediatric patients presents unique challenges to the anesthesiologist. In-depth knowledge of the disease processes and awareness of sequalae that uniquely influence the risks and benefits of anesthetics are needed to make informed decisions. Because these vulnerable populations are often susceptible to perioperative airway or cardiopulmonary complications, the use of regional anesthesia can be advantageous. However, these clinical conditions already involve compromised neural tissue and, as such, create additional concern that regional anesthesia may result in new or worsened deficits. The following discussion is not intended to be a full review of each disease process, but rather provides a concise, yet thorough, discussion of the available literature on regional anesthesia in the more common, but still rare, pediatric neurological disorders. We aim to provide a framework for pediatric anesthesiologists to reengage in a healthy discussion about the risks and benefits of utilizing regional anesthesia in this vulnerable population.
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Affiliation(s)
- Stephanie Cung
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Matthew L Ritz
- Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Melissa M Masaracchia
- University of Colorado School of Medicine, Aurora, CO, USA.,Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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10
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Lai HC, Wu CY, Wu KL, Wu TS, Tseng WC, Lin BF. The relationship between the sugammadex use and postoperative reintubation in the absence of neuromuscular monitoring. JOURNAL OF MEDICAL SCIENCES 2021. [DOI: 10.4103/jmedsci.jmedsci_209_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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Mongodi S, Ottonello G, Viggiano R, Borrelli P, Orcesi S, Pichiecchio A, Balottin U, Mojoli F, Iotti GA. Ten-year experience with standardized non-operating room anesthesia with Sevoflurane for MRI in children affected by neuropsychiatric disorders. BMC Anesthesiol 2019; 19:235. [PMID: 31852450 PMCID: PMC6921558 DOI: 10.1186/s12871-019-0897-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/29/2019] [Indexed: 12/20/2022] Open
Abstract
Background Children require anesthesia for MRI to maintain immobility and reduce discomfort; clear indications about the best anesthesiologic management are lacking and each center developed its own protocol. Moreover, children with neuropsychiatric disorders more likely require sedation and are described in literature as more prone to general and respiratory complications. Aim of this study was to analyze the applicability of a sevoflurane-based approach, to describe general and respiratory complications and to identify risk factors in a pediatric neuropsychiatric population. Methods Retrospective cohort study, university Hospital (January 2007–December 2016). All the 1469 anesthesiologic records of children addressed from Neuropsychiatric Unit to undergo MRI under general anesthesia were analyzed; 12 patients equal or older than 18-year-old were excluded. We identified post-hoc nine macro-categories: static encephalopathies, metabolic/evolutive encephalopathies, epileptic encephalopathies, neuromuscular diseases, autistic spectrum disorders, migraine, psychiatric disorders, intellectual disabilities, others. A logistic regression model for events with low frequency (Firth’s penalized likelihood approach) was carried out to identify the mutually adjusted effect among endpoints (complications) and the independent variables chosen on the basis of statistical significance (univariate analysis, p ≤ 0.05) and clinical judgment. Results Of 1457 anesthesiologic records (age 4.0 (IQR 2.0 to 7.0) year-old, males 891 (61.2%), weight 17.0 (IQR 12.0 to 24.9) kg), 18 were cancelled for high anesthesiologic risk, 50 were cooperative, 1389 were anesthetized. A sevoflurane-based anesthesia was feasible in 92.3%; these patients required significantly less mechanical ventilation (8.6 vs. 16.2%; p = 0.012). Complications’ rate was low (6.2%; 3.1% respiratory). The risk for general complications increases with ASA score > 1 (OR 2.22, 95 CI% 1.30 to 3.77, p = 0.003), male sex (OR 1.73, 95% CI 1.07 to 2.81, p = 0.025), multi-drug anesthesia (OR 2.98, 95 CI% 1.26 to 7.06, p = 0.013). For respiratory complications, it increases with ASA score > 1 (OR 2.34, 95 CI% 1.19 to 4.73, p = 0.017), autumn-winter (OR 2.01, 95 CI% 1.06 to 3.78, p = 0.030), neuromuscular disorders (OR 3.18, 95 CI% 1.20 to 8.41, p = 0.020). We had no major complications compromising patients’ outcome or requiring admission to ICU. Conclusions Sevoflurane anesthesia is feasible and safe for children affected by neuropsychiatric disorders undergoing MRI. Specific risk factors for general and respiratory complications should be considered.
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Affiliation(s)
- Silvia Mongodi
- Anesthesia and Intensive Care, Rianimazione 1 Fondazione IRCCS Policlinico S. Matteo, 27100, Pavia, Italy.
| | - Gaia Ottonello
- Anaesthesia and Intensive Care, Merate, DEA ASST Lecco, Lecco, Italy
| | - Raffaelealdo Viggiano
- Department of medical-surgical, diagnostic and paediatric sciences, University of Pavia, Pavia, Italy
| | - Paola Borrelli
- Department of Public Health, Experimental and Forensic Medicine, Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
| | - Simona Orcesi
- Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy.,Child Neurology and Psychiatry Unit, Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Anna Pichiecchio
- Neuroradiology department, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Umberto Balottin
- Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy.,Child Neurology and Psychiatry Unit, Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Francesco Mojoli
- Anesthesia and Intensive Care, Rianimazione 1 Fondazione IRCCS Policlinico S. Matteo, 27100, Pavia, Italy.,Department of medical-surgical, diagnostic and paediatric sciences, University of Pavia, Pavia, Italy
| | - Giorgio Antonio Iotti
- Anesthesia and Intensive Care, Rianimazione 1 Fondazione IRCCS Policlinico S. Matteo, 27100, Pavia, Italy.,Department of medical-surgical, diagnostic and paediatric sciences, University of Pavia, Pavia, Italy
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12
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Stöllberger C, Finsterer J. Myopathy and Noncompaction Detected After Malignant Hyperthermia During Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 32:e8-e9. [PMID: 29174122 DOI: 10.1053/j.jvca.2017.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Indexed: 11/11/2022]
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13
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Sung TY, Kang T, Cho CK, Kwon HU, Kang PS, Jee YS. Experience with reversal of a neuromuscular block with sugammadex in a child with Prader-Willi syndrome - A case report -. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.4.335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Tae-Yun Sung
- Department of Anesthesiology and Pain Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Taehoon Kang
- Department of Anesthesiology and Pain Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Choon-kyu Cho
- Department of Anesthesiology and Pain Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Hee Uk Kwon
- Department of Anesthesiology and Pain Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Po-Soon Kang
- Department of Anesthesiology and Pain Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Young Seok Jee
- Department of Anesthesiology and Pain Medicine, Konyang University College of Medicine, Daejeon, Korea
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14
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Paganoni S, Nicholson K, Leigh F, Swoboda K, Chad D, Drake K, Haley K, Cudkowicz M, Berry JD. Developing multidisciplinary clinics for neuromuscular care and research. Muscle Nerve 2017. [PMID: 28632945 PMCID: PMC5656914 DOI: 10.1002/mus.25725] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Multidisciplinary care is considered the standard of care for both adult and pediatric neuromuscular disorders and has been associated with improved quality of life, resource utilization, and health outcomes. Multidisciplinary care is delivered in multidisciplinary clinics that coordinate care across multiple specialties by reducing travel burden and streamlining care. In addition, the multidisciplinary care setting facilitates the integration of clinical research, patient advocacy, and care innovation (e.g., telehealth). Yet, multidisciplinary care requires substantial commitment of staff time and resources. We calculated personnel costs in our ALS clinic in 2015 and found an average cost per patient visit of $580, of which only 45% was covered by insurance reimbursement. In this review, we will describe classic and emerging concepts in multidisciplinary care models for adult and pediatric neuromuscular disease. We will then explore the financial impact of multidisciplinary care with emphasis on sustainability and metrics to demonstrate quality and value. Muscle Nerve 56: 848-858, 2017.
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Affiliation(s)
- Sabrina Paganoni
- Harvard Medical School, Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, USA.,Neurological Clinical Research Institute (NCRI), Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Katie Nicholson
- Harvard Medical School, Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, USA.,Neurological Clinical Research Institute (NCRI), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fawn Leigh
- Harvard Medical School, Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, USA
| | - Kathryn Swoboda
- Harvard Medical School, Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, USA
| | - David Chad
- Harvard Medical School, Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, USA
| | - Kristin Drake
- Harvard Medical School, Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, USA.,Neurological Clinical Research Institute (NCRI), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kellen Haley
- Harvard Medical School, Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, USA.,Neurological Clinical Research Institute (NCRI), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Merit Cudkowicz
- Harvard Medical School, Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, USA.,Neurological Clinical Research Institute (NCRI), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James D Berry
- Harvard Medical School, Department of Neurology, Massachusetts General Hospital (MGH), Boston, Massachusetts, USA.,Neurological Clinical Research Institute (NCRI), Massachusetts General Hospital, Boston, Massachusetts, USA
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15
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Abstract
Neuromuscular diseases are syndromic disorders that affect nerve, muscle, and/or neuromuscular junction. Knowledge about the management of these diseases is required for anesthesiologists, because these may frequently be encountered in the intensive care unit, operating room, and other settings. The challenges and advances in management for some of the neuromuscular diseases most commonly encountered in the operating room and neurointensive care unit are reviewed.
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Affiliation(s)
- Veronica Crespo
- Department of Anesthesiology, Duke University, Erwin Road, Durham, NC 27710, USA
| | - Michael L Luke James
- Department of Anesthesiology, Duke University, Erwin Road, Durham, NC 27710, USA; Department of Neurology, Duke University, Erwin Road, Durham, NC 27710, USA.
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16
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Shapiro F, Athiraman U, Clendenin DJ, Hoagland M, Sethna NF. Anesthetic management of 877 pediatric patients undergoing muscle biopsy for neuromuscular disorders: a 20-year review. Paediatr Anaesth 2016; 26:710-21. [PMID: 27111691 DOI: 10.1111/pan.12909] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND The objectives are to review the anesthetic management and anesthetic-related adverse events in patients undergoing muscle biopsy for a broad spectrum of neuromuscular disorders (NMD). AIM The study aims to assess the hypothesis that perceived awareness of potential anesthesia-induced hyperkalemia and MH in patients with NMD reduces the frequency of such events. METHODS A 20-year retrospective review of 877 consecutive patients undergoing muscle biopsy to establish diagnoses of NMD has been performed. Patients were categorized prebiopsy into six groups: M (myopathy and muscular dystrophy), MM (mitochondrial or metabolic myopathy), N (neurodegenerative, peripheral neuropathy or spinal muscular atrophy disorder), D (dermatomyositis), C (cardiomyopathy), or S (seizure disorder). Data were collected for demographics, anesthetic management, pre- and postoperative anesthesia-induced muscle injury, postbiopsy histopathologic diagnosis, and concordance comparisons between pre- and postbiopsy diagnoses. RESULTS There were 513 males (58.5%) and 364 females (41.5%) (1.4:1) with 137 individuals (15.6%) operated on under 1 year of age and two-thirds by 6 years of age. NMD diagnosis was reached in 409 (46.6%) while 468 (53.4%) had no specific pathology. No patients exhibited signs of anesthesia-induced muscle injury (malignant hyperthermia, rhabdomyolysis, cardiac arrest, or postoperative deterioration of weakness). MM was the largest group pre biopsy (367, 41.8%). Anesthetic agents were: nitrous oxide in 657 (74.9%); volatile agents in 139 (15.8%); intravenous agents in 836 (95.3%) (primarily propofol, midazolam, and fentanyl); nondepolarizing muscle relaxants in 404 (46.1%); and regional anesthesia in 112 (12.8%) [most commonly spinal anesthesia in 80 (71.4%)]. Comparing preoperative diagnostic category with postoperative diagnosis, there was a concordance of 78% (319/409) between the two for cases with a definitive diagnosis and 89.7% (787/877) for all cases. CONCLUSIONS In this retrospective study, no patient exhibited signs or symptoms of hyperkalemia or MH probably because the incidence is very low and becomes even less likely due to the selection of the various anesthetic agents and strategies administered.
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Affiliation(s)
- Frederic Shapiro
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Umeshkumar Athiraman
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - David J Clendenin
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Monica Hoagland
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Navil F Sethna
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
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Thoracic Paravertebral Block, Multimodal Analgesia, and Monitored Anesthesia Care for Breast Cancer Surgery in Primary Lateral Sclerosis. Case Rep Anesthesiol 2016; 2016:6301358. [PMID: 27200193 PMCID: PMC4856887 DOI: 10.1155/2016/6301358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 02/21/2016] [Accepted: 04/11/2016] [Indexed: 11/18/2022] Open
Abstract
Objective. Primary lateral sclerosis (PLS) is a rare idiopathic neurodegenerative disorder affecting upper motor neurons and characterized by spasticity, muscle weakness, and bulbar involvement. It can sometimes mimic early stage of more common and fatal amyotrophic lateral sclerosis (ALS). Surgical patients with a history of neurodegenerative disorders, including PLS, may be at increased risk for general anesthesia related ventilatory depression and postoperative respiratory complications, abnormal response to muscle relaxants, and sensitivity to opioids, sedatives, and local anesthetics. We present a case of a patient with PLS and recent diagnosis of breast cancer who underwent a simple mastectomy surgery uneventfully under an ultrasound guided thoracic paravertebral block, multimodal analgesia, and monitored anesthesia care. Patient reported minimal to no pain or discomfort in the postoperative period and received no opioids for pain management before being discharged home. In patients with PLS, thoracic paravertebral block and multimodal analgesia can provide reliable anesthesia and effective analgesia for breast surgery with avoidance of potential risks associated with general anesthesia, muscle paralysis, and opioid use.
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Bauer E, Mahida JB, Boomer LA, Lutmer JE, Minneci PC, Deans KJ, Elmaraghy CA. Outcomes following neuromuscular blockade in patients receiving tracheostomies. Int J Pediatr Otorhinolaryngol 2016; 84:101-5. [PMID: 27063762 DOI: 10.1016/j.ijporl.2016.02.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/19/2016] [Accepted: 02/26/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this study is to determine whether the use of neuromuscular blockade agents (NMBAs) in pediatric patients following tracheostomy is associated with increased rates of complications or a prolonged length of stay. METHODS This was a single-center retrospective chart review of pediatric patients undergoing tracheostomy placement between 2010 and 2013 who were admitted to the pediatric or neonatal intensive care units and did or did not receive NMBA within 7 days post-procedure. RESULTS Out of 114 included patients, 26 (23%) received NMBAs during the postoperative period. Patients receiving NMBAs were more likely to have cardiac disease and preoperative respiratory failure but less likely to have neurologic disease. Patients receiving NMBAs had a longer median postoperative length of stay (33 vs. 23 days, p=0.043) and were more likely to have postoperative ileus (12% vs. 3%, p=0.037). CONCLUSION In patients undergoing tracheostomy placement, use of NMBAs is associated with prolonged postoperative hospital courses. NMBAs are not associated with a higher likelihood of postoperative complications.
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Affiliation(s)
- Eric Bauer
- The Ohio State University College of Medicine, Columbus, OH, United States
| | - Justin B Mahida
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States; Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Laura A Boomer
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Jeffrey E Lutmer
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States; Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States; Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States; Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Charles A Elmaraghy
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States; Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, United States.
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19
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Kawasaki T, Ohba S, Fujimura Y, Asahina I. Bimaxillary Osteotomy for Jaw Deformity With Facioscapulohumeral Muscular Dystrophy. J Craniofac Surg 2016; 27:776-8. [PMID: 27054436 DOI: 10.1097/scs.0000000000002549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Facioscapulohumeral muscular dystrophy (FSHD) is a subtype of muscular dystrophies which reduces the muscle strength, especially the regions of scapular, shoulder, and upper arms, progressively. According to progressive muscle weakness in FSHD, postoperative stability of patient with FSHD after orthognathic surgery is not reliably acquired same as healthy subjects. A 32-year-old woman with FSHD underwent orthodontic and orthognathic surgical treatment due to jaw deformity. She has been followed up more than 3 years after surgery and acquired skeletal stability. This patient is the first report that showed long-term skeletal stability after orthognathic surgery in patient with FSHD. This patient report suggests that it is possible to apply orthognathic surgical treatment to patients with FSHD.
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Affiliation(s)
- Takako Kawasaki
- *Department of Regenerative Oral Surgery†Department of Orthodontics and Dentofacial Orthopedics, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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20
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Alvarellos ML, McDonagh EM, Patel S, McLeod HL, Altman RB, Klein TE. PharmGKB summary: succinylcholine pathway, pharmacokinetics/pharmacodynamics. Pharmacogenet Genomics 2015; 25:622-30. [PMID: 26398623 PMCID: PMC4631707 DOI: 10.1097/fpc.0000000000000170] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | | | - Sephalie Patel
- Department of Anesthesiology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Howard L. McLeod
- DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida, USA
| | - Russ B. Altman
- Department of Genetics, Stanford University, Stanford, California, USA
- Department of Bioengineering, Stanford University, Stanford, California, USA
| | - Teri E. Klein
- Department of Genetics, Stanford University, Stanford, California, USA
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21
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Treschan TA, Malbouisson LM, Beiderlinden M. Intraoperative mechanical ventilation strategies to prevent postoperative pulmonary complications in patients with pulmonary and extrapulmonary comorbidities. Best Pract Res Clin Anaesthesiol 2015; 29:341-55. [PMID: 26643099 DOI: 10.1016/j.bpa.2015.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/20/2015] [Accepted: 08/12/2015] [Indexed: 12/26/2022]
Abstract
A variety of patient characteristics and comorbidities have been identified, which increase the risk of postoperative pulmonary complications (PPCs), including smoking, age, chronic obstructive pulmonary disease, pulmonary hypertension, obstructive sleep apnea, cardiac and neurologic diseases as well as critical illness. In contrast to the variety of conditions, evidence for specific intraoperative ventilation strategies to reduce PPC is very limited for most comorbidities. Here, we provide an overview of and discuss possible implications for the intraoperative ventilatory management of patients with comorbidities.
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Affiliation(s)
- Tanja A Treschan
- Department of Anesthesiology, Duesseldorf University Hospital, Heinrich-Heine University, Moorenstr. 5, 40225 Duesseldorf, Germany.
| | - Luiz Marcelo Malbouisson
- Divisão de Anestesiologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 155, 8th Floor, 05403-000 São Paulo, SP, Brazil.
| | - Martin Beiderlinden
- Department of Anaesthesiology, Marienhospital Osnabrück, Bischofsstraße 1, 49074 Osnabrück, Germany.
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22
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Reversal of neuromuscular blockade with sugammadex in patients with myasthenia gravis. Eur J Anaesthesiol 2014; 31:715-21. [DOI: 10.1097/eja.0000000000000153] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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23
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25
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26
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Esquinas AM. Non-invasive ventilation in Amyotrophic Lateral Sclerosis in perioperative period: a brief reflection regarding ventilatory approaches. Acta Neurol Scand 2014; 129:e24-5. [PMID: 24702472 DOI: 10.1111/ane.12241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A M Esquinas
- Intensive Care and Non Invasive Ventilatory Unit, Hospital Morales Meseguer, Murcia, Spain.
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