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(Nakamura) Inaba A, Ishida Y, Toba Y. Lower extremity peripheral nerve block for total knee arthroplasty in a patient with chronic inflammatory demyelinating polyneuropathy: A case report. Medicine (Baltimore) 2024; 103:e37601. [PMID: 38552098 PMCID: PMC10977536 DOI: 10.1097/md.0000000000037601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/23/2024] [Indexed: 04/02/2024] Open
Abstract
RATIONALE Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune disorder that affects the peripheral nerves, leading to weakness and sensory symptoms. CIDP is a rare disease, and few studies have reported on anesthetic management in patients with this condition, especially the peripheral nerve block (PNB). Therefore, a safe and standardized anesthetic approach remains to be established. This case report aims to address this gap in evidence by documenting our experience with PNB in a patient with CIDP undergoing surgery. It contributes significantly to expanding the range of anesthetic options and enhancing perioperative outcomes for patients with CIDP. PATIENT CONCERNS A 58-year-old woman diagnosed with CIDP was scheduled to undergo left total knee arthroplasty due to osteonecrosis. We anticipated postoperative pain and aggravation of neurological symptoms. DIAGNOSIS CIDP. INTERVENTIONS To manage the postoperative pain, we planned a combination of general anesthesia (GA) and lower extremity PNBs, viz. the tibial and femoral nerve blocks, supplemented with intravenous patient-controlled analgesia. An initial dose of fentanyl 50 µg was administered as analgesia. The tibial and femoral nerves were identified using a peripheral nerve stimulator in conjunction with an ultrasonic echo device while the patient was conscious, to minimize the risk of nerve injury. The tibial and femoral nerve blocks were performed with 20 mL of ropivacaine (0.25%) and dexamethasone 2.2 mg, respectively. Subsequently, we administered fentanyl and ketamine and initiated continuous infusion of remifentanil. Thereafter, propofol 120 mg was administered intravenously over a span of 1 minute, followed by continuous infusion at 4 mg/kg/h. Upon confirming loss of consciousness, we induced GA using a supraglottic airway device without using muscle relaxants. For postoperative analgesia, we administered acetaminophen 1000 mg. OUTCOMES The patient experienced no pain immediately after surgery, and good analgesia was achieved subsequently without worsening of sensory symptoms during rehabilitation. LESSONS We achieved effective anesthetic management in a patient with CIDP by combining GA with nerve stimulation and ultrasound-guided PNB. It is crucial to devise a personalized anesthesia plan that focuses on the patients' safety and comfort while minimizing risk in patients with CIDP.
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Affiliation(s)
- Aka (Nakamura) Inaba
- Department of Anesthesiology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
- Department of General Internal Medicine, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Yoshiaki Ishida
- Department of Anesthesiology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Yoshie Toba
- Department of Anesthesiology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
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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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Sahni N, Batra A. Anesthetic management of a case of chronic inflammatory demyelinating polyneuropathy undergoing major abdominal surgery. J Anaesthesiol Clin Pharmacol 2022; 38:158-159. [PMID: 35706648 PMCID: PMC9191804 DOI: 10.4103/joacp.joacp_143_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 10/28/2019] [Accepted: 02/01/2020] [Indexed: 11/12/2022] Open
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Kohle F, Kuwabara S, Lehmann HC. Chronic inflammatory demyelinating polyneuropathy and pregnancy: systematic review. J Neurol Neurosurg Psychiatry 2021; 92:473-478. [PMID: 33563801 DOI: 10.1136/jnnp-2020-325321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 11/04/2022]
Abstract
Pregnancy largely affects disease activity and clinical course in women with immune-mediated neurological disorders. Chronic inflammatory demyelinating polyneuropathy (CIDP) is rare but the most common chronic immune-mediated neuropathy; however, the effects of pregnancy on CIDP have never been investigated except case reports or series. We here provide a systematic review of the literature from 1 January 1969 to 30 June 2020 that revealed 24 women with CIDP, who had onset or relapse during pregnancy. Of these, 17 (71%) developed CIDP during the first pregnancy, and 8 (47%) had a relapse during subsequent pregnancies. Of the 17 patients, in whom the CIDP subtypes were determined, all of them had typical CIDP. First-line treatments for CIDP, such as corticosteroids, immunoglobulin and plasma exchange were efficacious and safe. We suggest that pregnancy can trigger typical CIDP in some women, and women with CIDP have a higher risk of relapse during pregnancy. The onset or relapse of CIDP during pregnancy is a rare but challenging constellation for physicians.
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Affiliation(s)
- Felix Kohle
- Neurology, Medical Faculty of the University of Cologne, Koln, Nordrhein-Westfalen, Germany
| | - Satoshi Kuwabara
- Neurology, Chiba University Graduate School of Medicine, Chiba, Japan
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Anesthetic management of a patient with chronic inflammatory demyelinating polyneuropathy by combination of total intravenous and regional anesthesia. JA Clin Rep 2019; 5:19. [PMID: 32025994 PMCID: PMC6967004 DOI: 10.1186/s40981-019-0241-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 03/04/2019] [Indexed: 11/30/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIPD) is a rare acquired immune-mediated progressive and relapsing disorder that causes peripheral neuropathy lasting more than 2 months. We report the successful anesthetic management of a 66-year-old man with CIPD undergoing the laparoscopic Hartmann procedure. We induced and maintained total intravenous anesthesia (TIVA) using propofol, remifentanil, and ketamine without muscle relaxants. We performed ultrasound-guided transversus abdominis plane and rectus sheath blocks with 60 ml of 0.25% levobupivacaine for achieving good surgical conditions. For postoperative analgesia, we intravenously administered fentanyl (200 μg) and acetaminophen (1000 mg). The patient was uneventfully extubated in the operating room after confirming adequate spontaneous breathing. The postoperative course was uneventful without any respiratory complications such as respiratory depression, aspiration pneumonia, or progression of CIPD symptoms.
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Abstract
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.
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Affiliation(s)
- Alan Romero
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, 75390-9068, USA
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Galán Gutiérrez JC, Sopena Zubiria A, Avello Taboada R. [Peripheral nerve block ultrasound guided in a patient with chronic inflammatory demyelinating polyneuropathy]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 61:113-4. [PMID: 23485202 DOI: 10.1016/j.redar.2012.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 12/06/2012] [Accepted: 12/08/2012] [Indexed: 10/27/2022]
Affiliation(s)
- J C Galán Gutiérrez
- Servicio de Anestesiología y Reanimación, Hospital Universitario Central de Asturias, Oviedo, España.
| | - A Sopena Zubiria
- Servicio de Anestesiología y Reanimación, Hospital Universitario Central de Asturias, Oviedo, España
| | - R Avello Taboada
- Servicio de Anestesiología y Reanimación, Hospital Universitario Central de Asturias, Oviedo, España
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Spinal anesthesia for cesarean section in a patient with chronic inflammatory demyelinating polyradiculoneuropathy. J Anesth 2011; 26:280-2. [PMID: 22179599 DOI: 10.1007/s00540-011-1296-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 11/21/2011] [Indexed: 12/19/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an inflammatory disorder of the peripheral nervous system with progressive or relapsing signs in more than one limb, ending in prolonged periods of disability. There are no guidelines for anesthesia in this uncommon paralyzing disease. This report features a 19-year-old woman with CIDP scheduled for an elective cesarean section who had prolonged recovery of motor function after the administration of spinal anesthesia. Although a partial neural block in both feet persisted for 1 day, we conclude that spinal anesthesia is acceptable for cesarean delivery in CIDP-patients when reasonable precautions have been taken.
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Gupta B, Agrawal P, D'souza N, Sawhney C. Anaesthetic management and implications of a case of chronic inflammatory demyelinating polyneuropathy. Indian J Anaesth 2011; 55:277-9. [PMID: 21808402 PMCID: PMC3141154 DOI: 10.4103/0019-5049.82683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 60-year-old man with chronic inflammatory demyelinating polyneuropathy (CIDP) was posted for surgery of the neck femur fracture and was successfully managed. We discuss the anaesthetic considerations during regional and general anaesthesia of this patient with CIDP. A brief review of the available literature reveals no consensus on the choice of anaesthetic management.
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Affiliation(s)
- Babita Gupta
- Department of Anaesthesia and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Pramendra Agrawal
- Department of Anaesthesia and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Nita D'souza
- Department of Anaesthesia and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Chhavi Sawhney
- Department of Anaesthesia and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Tomar GS, Sethi A, Kriplani TC, Agrawal S. Anaesthesia in a diagnosed ventricular septal defect with Guillain-Barré paediatric patient for videoassisted thoracic surgery. Indian J Anaesth 2010; 54:345-6. [PMID: 20882181 PMCID: PMC2943708 DOI: 10.4103/0019-5049.68389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Guillain-Barré syndrome with ventricular septal defect is rare finding. Delayed diagnosis, often leading to increased complications. This report describes an Guillain-Barré syndrome case and the special approaches required during anaesthesia. 4 yrs old male pt with Guillain-Barré syndrome diagnosed at time of ward admission, submitted to video-assisted thoracic surgery under uneventful general anaesthesia with sevoflurane, without neuromuscular blockers. The case highlights the frequency with which this syndrome so important for anaesthetic practice is diagnosed, adverse events, the best choice for the anaesthetic team and complications of pediatric Guillain-Barré syndrome.
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Affiliation(s)
- Gaurav S Tomar
- Department of Anaesthesiology and Critical Care, N.S.C.B. Medical College, Jabalpur (M.P.), India
| | - Ashish Sethi
- Department of Anaesthesiology and Critical Care, N.S.C.B. Medical College, Jabalpur (M.P.), India
| | - TC Kriplani
- Department of Anaesthesiology and Critical Care, N.S.C.B. Medical College, Jabalpur (M.P.), India
| | - Shankar Agrawal
- Department of Anaesthesiology and Critical Care, N.S.C.B. Medical College, Jabalpur (M.P.), India
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Brambrink AM, Kirsch JR. Perioperative care of patients with neuromuscular disease and dysfunction. Anesthesiol Clin 2007; 25:483-509, viii-ix. [PMID: 17884705 DOI: 10.1016/j.anclin.2007.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
A variety of different pathologies result in disease phenotypes that are summarized as neuromuscular diseases because they share commonalty in their clinical consequences for the patient: a progressive weakening of the skeletal muscles. Distinct caution and appropriate changes to the anesthetic plan are advised when care is provided during the perioperative period. The choice of anesthetic technique, anesthetic drugs, and neuromuscular blockade always depends on the type of neuromuscular disease and the surgical procedure planned. A clear diagnosis of the underlying disease and sufficient knowledge and understanding of the pathophysiology are of paramount importance to the practitioner and guide optimal perioperative management of affected patients.
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Affiliation(s)
- Ansgar M Brambrink
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Sciences University, 3181 Sam Jackson Park Road, Portland, OR 97239-3098, USA.
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12
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Raeder J. Ketamine, revival of a versatile intravenous anaesthetic. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2004; 523:269-77. [PMID: 15088858 DOI: 10.1007/978-1-4419-9192-8_24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Johan Raeder
- Department of Anaesthesiology, Ullevaal University Hospital, N-0407 Oslo, Norway
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Abstract
PURPOSE OF REVIEW This report reviews the derangements of neuromuscular transmission in the different types of myopathy. RECENT FINDINGS The article covers recent literature on myopathy, whether prejunctional, junctional or postjunctional, as well as intensive care unit myopathy, and outlines the influence of myopathy on the action of both depolarizing and non-depolarizing muscle relaxants. SUMMARY The review classifies myopathy according to its cause, and sheds light on the upregulation and downregulation of endplate acetylcholine receptors. These findings are important for both clinical practice, and for research into neuromuscular transmission.
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Affiliation(s)
- Anis S Baraka
- Department of Anesthesiology, American University of Beirut Medical Center, Beirut, Lebanon.
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Schabel JE. Subarachnoid block for a patient with progressive chronic inflammatory demyelinating polyneuropathy. Anesth Analg 2001; 93:1304-6, table of contents. [PMID: 11682419 DOI: 10.1097/00000539-200111000-00055] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
IMPLICATIONS We report a case of successful administration of a spinal anesthetic to a patient with progressive chronic inflammatory demyelinating polyneuropathy (CIDP). There have been no reports of regional anesthetic management of patients with CIDP.
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Affiliation(s)
- J E Schabel
- Department of Anesthesiology, State University of New York at Stony Brook, Stony Brook, New York 11794-8480, USA
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15
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Abstract
Ketamine is a major drug for induction of patients with hypovolemia and for general anaesthesia under primitive conditions, but also has excellent properties for more generalized use in children, adults and other fragile patients. Potential beneficial effects on cardiac ischaemia and cerebral injury is presently explored, as well as the effects of ketamine as an potent analgesic drug. Combination with propofol or midazolam for sedation provides analgesia, sleep and spontaneous ventilation. The S-isomer of ketamine has a lower incidence of psychomimetic side effects in equianalgesic doses compared with the racemate or the R-isomer alone.
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Affiliation(s)
- J C Raeder
- Department of Anaesthesia, Ullevaal University Hospital, Oslo, Norway.
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