Perioperative care of patients with neuromuscular disease and dysfunction

Real-time ultrasound-guided sacral plexus block combined with mild sedation for hemorrhoidectomy and hemorrhoidal artery ligation in a patient with amyotrophic lateral sclerosis: a case report

BACKGROUND

Patients with amyotrophic lateral sclerosis present perioperative challenges for clinical anesthesiologists for anesthesia-associated complications.

CASE PRESENTATION

A 54-year-old Han woman with a 2-year history of amyotrophic lateral sclerosis was scheduled for hemorrhoidectomy and hemorrhoidal artery ligation. We performed real-time ultrasound-guided sacral plexus block with dexmedetomidine under standard monitoring. The anesthesia method met the surgical demands and avoided respiratory complications during the procedures. There was no neurological deterioration after the surgery and 3 months after, the patient was discharged.

CONCLUSIONS

Real-time ultrasound-guided sacral plexus block combined with mild sedation may be an effective and safe technique in patients with amyotrophic lateral sclerosis undergoing hemorrhoidectomy and hemorrhoidal artery ligation.

An implantable soft robotic ventilator augments inspiration in a pig model of respiratory insufficiency

Severe diaphragm dysfunction can lead to respiratory failure and to the need for permanent mechanical ventilation. Yet permanent tethering to a mechanical ventilator through the mouth or via tracheostomy can hinder a patient's speech, swallowing ability and mobility. Here we show, in a porcine model of varied respiratory insufficiency, that a contractile soft robotic actuator implanted above the diaphragm augments its motion during inspiration. Synchronized actuation of the diaphragm-assist implant with the native respiratory effort increased tidal volumes and maintained ventilation flow rates within the normal range. Robotic implants that intervene at the diaphragm rather than at the upper airway and that augment physiological metrics of ventilation may restore respiratory performance without sacrificing quality of life.

The Use of Sugammadex in a Patient With Guillain-Barre Syndrome: A Case Report

Sugammadex encapsulates and inactivates rocuronium and vecuronium. It is used to reverse neuromuscular blockade from these nondepolarizing agents. The safety of sugammadex in patients with neuromuscular disease has not been established. Guillain-Barre Syndrome (GBS) is a neuromuscular disease characterized by acute inflammatory polyneuropathy. Patients with GBS may exhibit autonomic dysfunction, chronic pain, abnormal reactions to neuromuscular blocking agents, and may require postoperative mechanical ventilation. We report the successful use of sugammadex to reverse rocuronium in a patient with chronic GBS, who presented for a hemicolectomy.

Thoracic Paravertebral Block, Multimodal Analgesia, and Monitored Anesthesia Care for Breast Cancer Surgery in Primary Lateral Sclerosis

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.

Palliative Care Issues in Amyotrophic Lateral Sclerosis: An Evidenced-Based Review

As palliative care physicians become increasingly involved in the care of patients with amyotrophic lateral sclerosis (ALS), they will be asked to provide guidance regarding the use of supplements, diet, exercise, and other common preventive medicine interventions. Moreover, palliative care physicians have a crucial role assisting patients with ALS in addressing health care decisions to maximize quality of life and cope with a rapidly disabling disease. It is therefore important for palliative care physicians to be familiar with commonly encountered palliative care issues in ALS. This article provides an evidenced-based review of palliative care options not usually addressed in national and international ALS guidelines.

Perioperative respiratory management of pediatric patients with neuromuscular disease

Patients with neuromuscular disorders undergoing general anesthesia present a special set of respiratory problems for perioperative management. While there are disease-specific concerns, there are many common themes in the respiratory management of patients with neuromuscular disorders. These problems are discussed in this review. Such common perioperative concerns include upper airway obstruction, chest wall restriction, postoperative hypoventilation, inadequate airway clearance, and chronic lower airway disease. Each of these challenges has an effective management approach, and careful planning can help avoid perioperative respiratory complications.

Neuromuscular disease and anesthesia

Patients with neuromuscular disease pose many anesthetic challenges and are at greater risk for perioperative complications, including respiratory or cardiovascular dysfunction and pulmonary aspiration. Therefore, these patients require special precautions, including interdisciplinary communication between primary care physicians, neurologists, physiatrists, surgeons, and anesthesiologists. Preoperative evaluation and optimization of comorbid conditions is critical. These patients may have adverse response to neuromuscular blocking drugs and the reversal drugs (e.g., neostigmine). They should be used with caution and titrated based on objective neuromuscular monitoring. Drugs that potentiate neuromuscular blocking drugs should also be avoided or their doses limited if possible. The risk of malignant hyperthermia in certain neuromuscular diseases mandates avoidance of triggering agents such as succinylcholine and inhaled anesthetics. Patients with neuromuscular disease may also be sensitive to sedative-hypnotics and opioids, which should be used judiciously. Finally, the postoperative period requires close monitoring due to increased risk of postoperative cardiorespiratory dysfunction.

Anesthesia and perioperative medical management of children with spinal muscular atrophy

OBJECTIVE

To describe the perioperative medical care, anesthetic considerations, and the risk of postanesthetic respiratory failure in patients with pediatric spinal muscular atrophy (SMA).

METHODS

There is a retrospective chart review carried out at an urban, tertiary care pediatric hospital. All patients with ICD-9 codes corresponding to SMA diagnoses were identified, and records screened for anesthetic and perioperative medical management. Medical records were reviewed for demographic, clinical, and outcome data.

MAIN RESULTS

Twenty-five children with SMA (10 type I, 8 type II, 7 type III) accounted for 56 general and regional anesthetic cases. Twenty-one (38%) cases had preexisting ventilator dependence. Total intravenous anesthesia with nitrous oxide was provided in 14 (25%) cases, balanced anesthesia with inhalational agents and epidural or systemic opioids were used in 41 (84%) cases, and one infant received a spinal anesthesia. Intraoperative and postoperative complications occurred in 2 (4%) and 2 (4%) cases respectively. One case required an unplanned postanesthetic intensive care unit admission, and there were two late deaths with redirection of care.

CONCLUSIONS

Perioperative care can be provided for children with SMA safely and effectively with total intravenous or inhaled anesthetics along with the judicious use of opioids to improve patient comfort without increased morbidity. Further prospective studies of standardized anesthetic and perioperative respiratory medical management in this population are required to minimize the decompensation of tenuous preoperative respiratory function.