Sensitivity to curare in patients with upper and lower motor neurone dysfunction

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.

Anesthetic management during Cesarean section in a woman with residual Arnold-Chiari malformation Type I, cervical kyphosis, and syringomyelia

Background:

Type I Arnold–Chiari malformation (ACM) has an adult onset and consists of a downward displacement of the cerebellar tonsils and the medulla through the foramen magnum. There is paucity of literature on the anesthetic management during pregnancy of residual ACM Type I, with cervical xyphosis and persistent syringomyelia.

Case Description:

A 34-year-old woman with surgically corrected ACM Type I presented for Cesarean delivery. A recent MRI demonstrated worsening of cervical xyphosis after several laminectomies and residual syringomyelia besides syringopleural shunt. Awake fiberoptic intubation was performed under generous topical anesthesia to minimize head and neck movement during endotracheal intubation. We used a multimodal general anesthesia without neuromuscular blockade. The neck was maintained in a neutral position. Following delivery, the patient completely recovered in post-anesthesia care unit (PACU), with no headache and no exacerbation or worsening of neurological function.

Conclusions:

The present case demonstrates that patients with partially corrected ACM, syringomyelia, cervical kyphosis, and difficult intubation undergoing Cesarean delivery require an interdisciplinary team approach, diligent preparation, and skilled physicians.

Epidural anesthesia for Cesarean delivery in a patient with post-traumatic cervical syringomyelia

PURPOSE

To illustrate the successful management of a patient with post-traumatic syringomyelia (PTS) and chronic pain syndrome who presented for elective Cesarean delivery under epidural anesthesia.

CLINICAL FINDINGS

A 30-yr-old gravida 3 para 1 woman, with a known diagnosis of cervical PTS secondary to a whiplash injury sustained three years earlier, presented to the labour and delivery unit at 31 weeks' gestation. She had severe pain in the cervical and lumbar spine, motor and sensory deficits in the upper extremities, tender mass in her left trapezius muscle, and history of dizziness and syncopal episodes. She was taking oxycodone 120 mg·day(-1) Magnetic resonance imaging of her spine revealed a syrinx of 2 mm in diameter extending from C4 to T1 levels with disc protrusions in the C4-C6 region. There was no evidence of Arnold-Chiari malformation or elevated intracranial pressure. On airway examination, her Mallampati score appeared normal, but there was a limitation in the range of her neck movements in all directions. An elective Cesarean delivery was planned at 39 weeks' gestation. An epidural catheter was placed using ultrasound guidance, and the procedure was performed without complications.

CONCLUSIONS

The successful management of this case suggests that epidural can be considered in women with cervical PTS presenting for a Cesarean delivery.

[Neuromuscular monitoring in patients with neuromuscular diseases. Options and needs]

The management of general anaesthesia in patients with neuromuscular disorders remains challenging. The underlying causes and clinical presentations of these rare heterogeneous diseases are highly variable and the only common feature is usually skeletal muscle weakness. The appropriate choice and dosage of muscle relaxants are important and an adequate monitoring of the neuromuscular blockade is obligatory. Neuromuscular monitoring can be complicated because of disease-induced alterations in neurophysiology; however, continuous monitoring of the neuromuscular blockade should be realized to accurately determine the recovery from the blockade. These patients very often have an increased risk for postoperative pulmonary complications, which increases further if a residual neuromuscular blockade is present.

Perioperative care of patients with neuromuscular disease and dysfunction

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.

Anaesthesia for caesarean section in a patient with syringomyelia and Arnold-Chiari type I malformation

A 37-year-old primiparous woman with syringomyelia and Arnold-Chiari type I malformation was scheduled to undergo elective caesarean section for a fetus in the breech presentation. Caesarean section was performed under general anaesthesia without complications; all we observed was an exaggerated response to atracurium. The patient was discharged home 7 days after the operation without neurological deterioration. General anaesthesia was chosen in this patient to avoid any spinal manipulation that could increase intracranial pressure or reduce intraspinal pressure and cause deterioration of neurological symptoms. Syringomyelia is a progressive myelopathy characterised by cystic degeneration within the spinal cord, which causes severe neurological deficits. The anaesthetic management is discussed.

Anesthesia for cesarean section in a patient with spinal muscular atrophy

We describe the anesthetic management for cesarean section and tubal ligation of a 23-year-old primipara with type II spinal muscular atrophy (benign Werdnig Hoffmann). She was wheelchair-bound, had severe restrictive lung disease, and severe kyphoscoliosis, with Harrington rods extending from the thoracic to the sacral spines. A general anesthetic was given. We used propofol and alfentanil for rapid-sequence induction of anesthesia. We did not use any muscle relaxants intraoperatively. Postoperative care was provided in the intensive care unit. The patient made a good recovery.

Use of rapacuronium in a child with spinal muscular atrophy

We report the case of an 18-month-old girl with spinal muscular atrophy (SMA) that received 1 mg x kg(-1) rapacuronium for laryngospasm during induction of anaesthesia. Within 15 min, we observed some diaphragmatic recovery and, after emergence from anaesthesia, the child demonstrated adequate respiratory efforts. However, the child showed diminished strength of the upper extremity muscles. Since the preoperative workup had revealed bulbar symptoms and laryngeal function could not be easily assessed, the patient was kept intubated until upper extremity strength had returned to preoperative levels. Small doses of midazolam had been given to reduce the patient's anxiety but the patient was extubated within 5 h without any complications. Train of four (TOF) monitoring of the right adductor pollicis muscle, performed during anaesthetic recovery, was equivocal. In SMA, muscle groups are differentially affected so that TOF responses may be inconclusive and not reflect the state of the upper airway muscles. To our knowledge, this is the first report of use of a nondepolarizing neuromuscular blocking agent in a child with SMA.

Cesarean section in a patient with syringomyelia

PURPOSE

To describe the anesthetic management of Cesarean section in a patient with syringomyelia.

CLINICAL FEATURES

A 27-yr-old pregnant woman with syringomyelia was scheduled to undergo elective Cesarean section. At the age of 25 yr, she had begun to experience headaches, and at the age of 26 yr, a diagnosis of syringomyelia of the upper spinal cord was made on the basis of magnetic resonance imaging findings. No symptoms other than headache were noted preoperatively. General anesthesia was used for the Cesarean section. After the administration of 1 mg vecuronium as a priming dose, 5 mg vecuronium were injected. At the onset of clinical muscle weakness, 225 mg thiamylal were promptly administered as the induction agent and the patient was intubated (timing principle with priming method) and pressure on the cricoid cartilage applied to prevent regurgitation of stomach contents. Anesthesia was maintained with oxygen, nitrous oxide and isoflurane at a low concentration. Mild hyperventilation was used throughout the procedure. Anesthesia and surgery proceeded without any problem, response to vecuronium was clinically normal and recovery was uneventful. Neurological status remained normal.

CONCLUSION

We report the safe use of general anesthesia for Cesarean section in a patient with syringomyelia. Precautions were taken to avoid increases in intracranial pressure and our patient experienced no untoward neurologic event.

Is succinylcholine appropriate or obsolete in the intensive care unit?

Muscle relaxants in intensive care unit (ICU) patients are predominantly administered to facilitate intubation. The adverse effect profile of succinylcholine is such that its use in the ICU must be considered obsolete. Suitable alternatives are the intermediately long-acting nondepolarizing relaxants, of which rocuronium is probably preferable.

Effects of feeding conditions on sensitivity to tubocurarine of nerve-muscle preparations from the mouse

1. The effects of feeding conditions on the sensitivity to the effect of tubocurarine (dTc) in vitro were compared among various nerve-muscle preparations from mice. The mice were fed under conditions that restricted or compelled their movement for 64 days and controls were fed conventionally. 2. The sensitivity to the effect of dTc differed considerably among preparations. It was much higher in the sciatic nerve-extensor digitorum longus muscle (EDL), moderately higher in the sciatic nerve-soleus muscle (SOL) and lower in the phrenic nerve-diaphragm (DPH) in control mice. 3. The order of the sensitivity was not altered by either type of conditioning. Constant restriction of movement or compelled movement did not modify the sensitivity of DPH to the effect of dTc in vitro. 4. Compulsion facilitated the sensitivity in both SOL and EDL. Restriction selectively increased the sensitivity of EDL. Both types of conditioning selectively and significantly reduced twitch development in EDL. 5. These results indicate that the sensitivity to dTc of neuromuscular transmission reflects constant states of motor activity.