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Ziegler B, Ofner S, Lischent J, Perndorfer J, Diem A, Laimer M, Prodinger C, Treff F. [Anesthesiological aspects in patients with epidermolysis bullosa]. Anaesthesist 2022; 71:467-474. [PMID: 35175387 DOI: 10.1007/s00101-022-01096-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 11/25/2022]
Abstract
Epidermolysis bullosa causes blistering due to altered structural proteins of the dermoepidermal junction, resulting in scarring and strictures of the skin and mucous membranes. Affected individuals typically require frequent surgical interventions due to burdensome symptoms and complications of the disease. The anesthesiological management of these patients is inherently challenging. This review article summarizes the relevant features of this patient cohort and provides practical recommendations for care.
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Affiliation(s)
- B Ziegler
- Univ.Klinik f. Anästhesiologie, perioperative Medizin und allgemeine Intensivmedizin, LKH Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Österreich.
| | - S Ofner
- Univ.Klinik f. Anästhesiologie, perioperative Medizin und allgemeine Intensivmedizin, LKH Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Österreich
| | - J Lischent
- Univ.Klinik f. Anästhesiologie, perioperative Medizin und allgemeine Intensivmedizin, LKH Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Österreich
| | - J Perndorfer
- Univ.Klinik f. Anästhesiologie, perioperative Medizin und allgemeine Intensivmedizin, LKH Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Österreich
| | - A Diem
- Univ. Klinik f. Dermatologie und Allergologie, LKH Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Österreich.,EB Haus Austria, LKH Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Österreich
| | - M Laimer
- Univ. Klinik f. Dermatologie und Allergologie, LKH Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Österreich.,EB Haus Austria, LKH Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Österreich
| | - C Prodinger
- Univ. Klinik f. Dermatologie und Allergologie, LKH Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Österreich
| | - F Treff
- Univ.Klinik f. Anästhesiologie, perioperative Medizin und allgemeine Intensivmedizin, LKH Salzburg, Müllner Hauptstr. 48, 5020, Salzburg, Österreich
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Brooks Peterson M, Strupp KM, Brockel MA, Wilder MS, Zieg J, Bruckner AL, Kaizer AM, Szolnoki JM. Anesthetic Management and Outcomes of Patients With Epidermolysis Bullosa: Experience at a Tertiary Referral Center. Anesth Analg 2021; 134:810-821. [PMID: 34591805 DOI: 10.1213/ane.0000000000005749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Epidermolysis bullosa (EB) is a group of rare epithelial disorders caused by abnormal or absent structural proteins at the epidermal-dermal junction. As a result, patients experience blisters and wounds from mild shearing forces. Some forms of EB are complicated by resultant scarring and contractures. The perioperative anesthetic management of patients with EB is complex and requires a systems-based approach to limit harm. We reviewed our experience with providing general anesthesia to patients at our tertiary EB referral center, including adverse events related to anesthetic care, outcomes in the immediate perioperative period, and details of anesthetic management. METHODS We retrospectively reviewed the charts of all patients with EB anesthetized at the Children's Hospital Colorado between January 2011 and December 2016. A subset of pediatric anesthesiologists cared for all patients using a standardized clinical care pathway. Patient demographics, detailed anesthetic methods, immediate perioperative outcomes, and adverse events were characterized. RESULTS Over a 6-year period, 37 patients underwent 202 general anesthetics. Most patients (75.7%) had dystrophic EB (DEB). Female patients comprised 48.6%. The majority (56.7%) traveled >50 miles to receive care, and many (35.1%) traveled >150 miles for their care. Common adaptations to care included avoidance of electrocardiogram leads (88.6%) and temperature probes (91.6%). Nasal fiberoptic intubation (n = 160) was performed, or natural airway/mask (n = 27) was maintained for most patients. Supraglottic devices were not used for airway management during any of the anesthetics. Anesthesia preparation time was longer (average 25.8 minutes [standard deviation {SD} = 12.7]) than our average institutional time (14 minutes). Succinylcholine was never used, and nondepolarizing muscle relaxants were used in only 1.5% of patient encounters. Blood was transfused in 16.3% of cases and iron infused in 24.8%. Average length of stay in the postanesthesia care unit was comparable to our institutional average (average 40.1 [SD = 28.6] vs 39 minutes). New skin or mucosal injury occurred in 8 encounters (4%), and desaturation occurred in 43 cases (21.3%). There were no major adverse events. CONCLUSIONS By using a specialized team and a standardized clinical care pathway, our institution was able to minimize adverse events caused by the anesthetic and surgical care of patients with EB. We recommend natural airway or nasal fiberoptic airway management, meticulous avoidance of shear stress on the skin, and a multidisciplinary approach to care. Supportive therapy such as perioperative blood transfusions and iron infusions are feasible for the treatment of chronic anemia in this population.
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Affiliation(s)
- Melissa Brooks Peterson
- From the Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Kim M Strupp
- From the Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Megan A Brockel
- From the Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Matthew S Wilder
- Department of Dermatology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jennifer Zieg
- From the Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.,Department of Anesthesiology and Critical Care, Rady Children's Hospital, San Diego, California.,Department of Dermatology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.,Department of Biostatistics and Informatics, University of Colorado-Anschutz Medical Campus, Aurora, Colorado.,Department of Anesthesiology, Nemours Children's Hospital, University of Central Florida, Orlando, Florida
| | - Anna L Bruckner
- Department of Dermatology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Alexander M Kaizer
- Department of Biostatistics and Informatics, University of Colorado-Anschutz Medical Campus, Aurora, Colorado
| | - Judit M Szolnoki
- Department of Anesthesiology, Nemours Children's Hospital, University of Central Florida, Orlando, Florida
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Anesthesia management in dystrophic epidermolysis bullosa: A case report. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.872798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Epidermolysis bullosa (EB) is a group of rare, inherited diseases characterized by skin fragility and multiorgan system involvement that presents many anesthetic challenges. Although the literature regarding anesthetic management focuses primarily on the pediatric population, as life expectancy improves, adult patients with EB are more frequently undergoing anesthesia in nonpediatric hospital settings. Safe anesthetic management of adult patients with EB requires familiarity with the complex and heterogeneous nature of this disease, especially with regard to complications that may worsen during adulthood. General, neuraxial, and regional anesthetics have all been used safely in patients with EB. A thorough preoperative evaluation is essential. Preoperative testing should be guided by EB subtype, clinical manifestations, and extracutaneous complications. Advanced planning and multidisciplinary coordination are necessary with regard to timing and operative plan. Meticulous preparation of the operating room and education of all perioperative staff members is critical. Intraoperatively, utmost care must be taken to avoid all adhesives, shear forces, and friction to the skin and mucosa. Special precautions must be taken with patient positioning, and standard anesthesia monitors must be modified. Airway management is often difficult, and progressive airway deterioration can occur in adults with EB over time. A smooth induction, emergence, and postoperative course are necessary to minimize blister formation from excess patient movement. With careful planning, preparation, and precautions, adult patients with EB can safely undergo anesthesia.
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Ramsali MV, Puduchira KG, Maganti SP, Vankaylapatti SD, Pasupuleti S, Kulkarni D. Anesthetic management and outcomes of patients with Steven-Johnson Syndrome-A retrospective review study. J Anaesthesiol Clin Pharmacol 2021; 37:119-123. [PMID: 34103835 PMCID: PMC8174442 DOI: 10.4103/joacp.joacp_46_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 01/16/2020] [Accepted: 03/06/2020] [Indexed: 11/04/2022] Open
Abstract
Background and Aims: Steven-Johnson Syndrome (SJS) is a rare and severe form of erythema exudative multiforme. Multisystem involvement in SJS and the suspicion of precipitation of the disease with exposure to anesthetic drugs makes anesthesia a challenging task. The concerns during anesthesia are the mucosal lesions and special care that is required to prevent injury to the oropharynx and larynx during airway management and also the drugs used for anesthesia. In the literature, very few isolated case reports or case series are available. Here, we have analyzed the cases of SJS coming for ophthalmic anesthesia, taking into consideration factors like mode of presentation, precipitating factors, associated diseases, types of anesthesia, anesthetic modifications, and various drugs used during anesthesia. Material and Methods: The electronic medical records of 497 cases of SJS who required interventions like ophthalmic examination or surgery (either under local or general anesthesia) over a period of 18 months were analyzed retrospectively. The records were reviewed to obtain the concerned details like anesthesia-inducing agents, muscle relaxants, inhalational agents, and analgesics. The problems concerned with monitoring and intubation were also noted. The data were analyzed and presented as frequency and percentage. Results: Patient age ranged between 9 months and 72 years. Many surgeries were conducted under general anesthesia (441) although a few required local (peribulbar block) anesthesia (56). The drugs administered for general anesthesia were sevoflurane, isoflurane, propofol, thiopentone, vecuronium, and atracurium and those administered for pain management were fentanyl, tramadol, butorphanol, and paracetamol. The patients who were sensitive to nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol were not administered the same. None of the patients reacted adversely to the different drugs used for anesthesia. Conclusion: Identifying the precipitating factors, understanding the pathophysiology and its implications for anesthesia will help in successfully managing anesthesia in the rare cases of SJS.
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Aikawa K, Tanaka N, Morimoto Y. Anesthetic management with subcostal transversus abdominis plane block in recessive dystrophic epidermolysis bullosa for peritoneal dialysis catheter replacement: a case report. JA Clin Rep 2018; 4:37. [PMID: 32026958 PMCID: PMC6967288 DOI: 10.1186/s40981-018-0175-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 05/04/2018] [Indexed: 11/10/2022] Open
Abstract
Background Recessive dystrophic epidermolysis bullosa (RDEB) is a rare, hereditary mucocutaneous disorder that can involve renal insufficiency. If a vascular access for hemodialysis is unavailable, peritoneal dialysis can be utilized. This report describes an anesthetic management with ultrasound-guided transversus abdominis plane block (TAPB) in a patient with RDEB for peritoneal dialysis catheter replacement. Case presentation A 49-year-old woman with RDEB needed to undergo peritoneal dialysis catheter replacement. As general, neuraxial and local infiltration anesthesia can lead to serious complications; we planned anesthetic management with subcostal TAPB as the primary analgesia modality. In the operating theater, surgery was initiated after performing left-sided subcostal TAPB. The patient complained of moderate pain at some points during surgery, and the pain was controlled with intravenous or local anesthetics without serious complications. Conclusions In summary, subcostal TAPB could be a useful option for peritoneal dialysis catheter surgery in patients with RDEB.
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Affiliation(s)
- Katsuhiro Aikawa
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Nobuhiro Tanaka
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
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Bowen L, Burtonwood MT. Anaesthetic management of children with epidermolysis bullosa. BJA Educ 2017; 18:41-45. [PMID: 33456808 DOI: 10.1016/j.bjae.2017.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 01/11/2023] Open
Affiliation(s)
- L Bowen
- Department of Anaesthesia, Children's Hospital for Wales, Heath Park, Cardiff, UK
| | - M T Burtonwood
- Department of Anaesthesia, University Hospital of Wales, Heath Park, Cardiff, UK
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Özkan AS, Kayhan GE, Akbaş S, Kaçmaz O, Durmuş M. Emergency Difficult Airway Management in a Patient with Severe Epidermolysis Bullosa. Turk J Anaesthesiol Reanim 2016; 44:270-272. [PMID: 27909609 DOI: 10.5152/tjar.2016.49260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 07/20/2016] [Indexed: 11/22/2022] Open
Abstract
Epidermolysis bullosa (EB) is a rare disease characterised by vesiculobullous lesions with minimal trauma to the skin and mucous membranes. Bleeding, scar tissue, contractures, oedema and lesions that can spread throughout the body can cause a difficult airway and vascular access in patients with EB. Therefore, anaesthetic management in patients with EB is a major problem even for experienced anaesthesiologists. Herein, we report a case of difficult airway management in a patient diagnosed with severe EB who presented for emergency tracheostomy because of respiratory failure under general anaesthesia.
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Affiliation(s)
- Ahmet Selim Özkan
- Department of Anaesthesiology and Reanimation, İnönü University School of Medicine, Malatya, Turkey
| | - Gülay Erdoğan Kayhan
- Department of Anaesthesiology and Reanimation, İnönü University School of Medicine, Malatya, Turkey
| | - Sedat Akbaş
- Department of Anaesthesiology and Reanimation, İnönü University School of Medicine, Malatya, Turkey
| | - Osman Kaçmaz
- Department of Anaesthesiology and Reanimation, İnönü University School of Medicine, Malatya, Turkey
| | - Mahmut Durmuş
- Department of Anaesthesiology and Reanimation, İnönü University School of Medicine, Malatya, Turkey
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Galán Gutiérrez JC, Martínez Suárez M, Tobera Noval B, Avello Taboada R. Epidermólisis bullosa de Herlitz en el paciente pediátrico: implicaciones anestésicas. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rca.2014.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Galán Gutiérrez J, Martínez Suárez M, Tobera Noval B, Avello Taboada R. Herlitz epidermolysis bullosa in the paediatric patient: Anaesthetic implications. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rcae.2014.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Herlitz epidermolysis bullosa in the paediatric patient: Anaesthetic implications☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1097/01819236-201442020-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Karaman Ilić M, Kern J, Babić I, Simić D, Kljenak A, Majerić Kogler V. Application of the procedural consolidation concept to surgical treatment of children with epidermolysis bullosa: a retrospective analysis. Croat Med J 2011; 52:520-6. [PMID: 21853547 PMCID: PMC3160699 DOI: 10.3325/cmj.2011.52.520] [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] [Indexed: 11/27/2022] Open
Abstract
Aim To assess the efficacy of the procedural consolidation concept (PCC) at reducing the number of sessions of general anesthesia necessary for treating children with epidermolysis bullosa (EB). Methods We examined the records of children treated at Children's Hospital of Zagreb between April 1999 and December 2007. Children treated before the introduction of PCC in January 2005 (n = 39) and after (n = 48) were analyzed in order to determine the effect of PCC on the occurrence of complications, days of hospitalization, and number of hospitalizations. Results During the study period, 53 patients underwent 220 sessions of general anesthesia for a total of 743 surgical interventions per session. Before the introduction of PCC (n = 39 patients, 83 sessions), the median number of interventions per session was 2 (range 1-5), and after the introduction of PCC (n = 48 patients, 137 sessions) it was 4 (range 3-7, P < 0.001). After the introduction of PCC, the median number of complications per anesthesia session increased from 2 (range 0-10) to 3 (range 0-10) (P = 0.027), but the median number of complications per surgical procedure decreased from 1 (range 0-10) to 0.6 (range 0-2.5) (P < 0.001). PCC lengthened each anesthesia session from a median of 65 minutes (range 35-655) to 95 minutes (range 50-405), (P < 0.001). Total length of hospitalization was similar before (median 1, range 1-4) and after (median 1, range 1-3) introduction of PCC (P = 0.169). The number of hospitalization days per procedure was 3 times lower after the introduction of PCC (median 0.3, range 0.2-3) than before (median 1, range 0.75-1.7) (P < 0.001). Conclusion PCC should be considered an option in the surgical treatment of children with EB.
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Fröhlich S, O’Sullivan E. Airway management in adult patients with epidermolysis bullosa dystrophica: a case series. Anaesthesia 2011; 66:842-3. [DOI: 10.1111/j.1365-2044.2011.06805.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Babić I, Karaman-Ilić M, Pustisek N, Susić S, Skarić I, Kljenak A, Cikojević D. Respiratory tract involvement in a child with epidermolysis bullosa simplex with plectin deficiency: a case report. Int J Pediatr Otorhinolaryngol 2010; 74:302-5. [PMID: 20044146 DOI: 10.1016/j.ijporl.2009.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 10/01/2009] [Indexed: 11/28/2022]
Abstract
We report a rare case of a child with epidermolysis bullosa simplex (EBS) with plectin deficiency but without muscular dystrophy, with severe lesions of the oral cavity, oropharyngeal, hypopharyngeal, laryngeal, tracheal and bronchial mucosa. Case report and a review of the world literature are used. The literature review revealed only five similar patients with EBS without muscular dystrophy complicated by respiratory involvement. This paper highlights the potentially serious complications of the EB in the form of breathing, swallowing and speech difficulties and describes the specific problems encountered in the treatment of this patient. Epidermolysis bullosa (EB) is a group of severe hereditary diseases, primarily of the skin, but which can also involve the respiratory and gastrointestinal tract mucosa. Respiratory tract involvement is usually only found in certain types of EB. The oral cavity and oropharynx are involved more frequently than the hypopharynx, larynx and trachea. Involvement of laryngeal and tracheal mucosa is generally associated with an increased morbidity and mortality, numerous complications and therapeutic difficulties, and is more common in junctional EB and dystrophic EB than in EBS. We present a rare case of a child with EBS and plectin deficiency with pronounced lesions of respiratory tract mucosa from the oral cavity to the bronchi and even extending into the trachea. Deciding on tracheotomy requires thorough consideration and should not be taken lightly.
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Affiliation(s)
- Irena Babić
- ENT Division, Department of Pediatric Surgery, Zagreb University Children's Hospital, Klaićeva 16, Zagreb, Croatia.
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García I, Manrique S, Muñoz C, López-Gil MV, Munar F, Montferrer N. [Anesthesia for cesarean section in a patient with recessive dystrophic epidermolysis bullosa]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:569-571. [PMID: 20112549 DOI: 10.1016/s0034-9356(09)70460-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Recessive dystrophic epidermolysis bullosa is inherited as a rare autosomal disorder which causes blisters to form in the skin. We describe the treatment of a 39-year-old parturient with this condition. She was scheduled for elective cesarean section at 37 weeks' gestation. The patient had widespread skin lesions, had lost fingers, and had esophageal stenosis. The cesarean was performed under spinal anesthesia without complications. Recessive dystrophic epidermolysis bullosa requires adaptation of anesthetic technique that includes control over posture and careful handling of the skin. Material for attaching monitoring devices and inserting venous lines must be adapted to the particular deformities and skin lesions present.
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Affiliation(s)
- I García
- Servicio Anestesiología y Reanimación, Hospital Vail d'Hebron. Barcelona.
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Fine JD, Mellerio JE. Extracutaneous manifestations and complications of inherited epidermolysis bullosa: part II. Other organs. J Am Acad Dermatol 2009; 61:387-402; quiz 403-4. [PMID: 19700011 DOI: 10.1016/j.jaad.2009.03.053] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Revised: 02/22/2009] [Accepted: 03/02/2009] [Indexed: 10/20/2022]
Abstract
It is well known, primarily via case reports and limited case series, that nonepithelial tissues may become injured in patients with epidermolysis bullosa. Only recently, however, have there been data generated from large, well characterized cohorts. Our objective is to provide dermatologists with a comprehensive review of each of these major extracutaneous complications, with a summary of the pertinent literature and evidence-based recommendations for surveillance, evaluation, and management. Some epidermolysis bullosa subtypes are at risk for severe injury of the bone marrow, musculoskeletal system, heart, kidney, and teeth, and for the development of squamous cell carcinoma, basal cell carcinoma, or malignant melanoma. If untreated, significant morbidity or mortality may result.
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Affiliation(s)
- Jo-David Fine
- The National Epidermolysis Bullosa Registry, and Department of Medicine (Dermatology), Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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HAYNES L, ATHERTON D, ADE-AJAYI N, WHEELER R, KIELY E. Gastrostomy and growth in dystrophic epidermolysis bullosa. Br J Dermatol 2008. [DOI: 10.1046/j.1365-2133.1996.120855.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
This article is the first in a series of three focusing on the causes, clinical presentation, complications and care of adult patients affected by epidermolysis bullosa (EB), a group of rare genetic skin fragility disorders. Although the condition is rare, in some cases it presents extreme challenges both to those affected and those involved in the care of the EB patient; therefore, these articles may have relevance for other long-term disorders. While there is a wealth of information regarding the 'science' of EB there is dearth of information regarding the care of the adult EB patient, and this series of articles will endeavour to fill that gap. This article focuses mainly on those patients affected with the most severe form of EB found in the adult group, recessive dystrophic epidermolysis bullosa; with the part two looking at the care of the adult with EB from the nursing perspective, including wound management, and the experiences of a specialist EB psychotherapist being presented in the final article of the series. Readers will thus have an opportunity to gain an overall view of this difficult condition.
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Baloch MS, Fitzwilliams B, Mellerio J, Lakasing L, Bewley S, O'Sullivan G. Anaesthetic management of two different modes of delivery in patients with dystrophic epidermolysis bullosa. Int J Obstet Anesth 2008; 17:153-8. [PMID: 18308542 DOI: 10.1016/j.ijoa.2007.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 04/01/2007] [Indexed: 11/26/2022]
Abstract
Dystrophic epidermolysis bullosa is an inherited severe bullous condition characterised by extreme skin fragility and blistering in response to minor trauma. We present two obstetric cases with recessive dystrophic epidermolysis bullosa, one who underwent elective caesarean section, the other who delivered vaginally. The key points in the anaesthetic management of the obstetric patient with dystrophic epidermolysis bullosa include multidisciplinary preassessment, airway management strategies and the role of regional anaesthesia.
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Affiliation(s)
- M S Baloch
- Department of Anaesthetics, St Thomas' Hospital, London, UK.
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Hore I, Bajaj Y, Denyer J, Martinez AE, Mellerio JE, Bibas T, Albert D. The management of general and disease specific ENT problems in children with Epidermolysis Bullosa--a retrospective case note review. Int J Pediatr Otorhinolaryngol 2007; 71:385-91. [PMID: 17145082 DOI: 10.1016/j.ijporl.2006.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2006] [Revised: 11/01/2006] [Accepted: 11/01/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Epidermolysis Bullosa encompasses a group of inherited disorders characterized by excessive susceptibility of the skin and mucosa to separate from underlying tissues following mechanical trauma. Information in the literature and guidance on the management of Ear, Nose and Throat problems in such children is scarce. The aim of this study is to report the experience of an Ear, Nose and Throat department in a tertiary paediatric hospital linked to a national Epidermolysis Bullosa unit, describing how children have presented and the care that has been given including a theatre protocol aimed at reducing shearing forces. METHODS Retrospective case note review of Epidermolysis Bullosa patients referred to Otolaryngology over an 8-year period. RESULTS Reviewing notes of 307 EB patients identified 15 that had been referred to the ENT department. Four children with middle ear effusions were effectively treated by watchful waiting or grommets. Three children with otitis externa had some relief from careful microsuction but reinfection from ulcers on other parts of the children's bodies tended to occur. One child with profound sensorineural hearing loss benefited from cochlear implantation but later passed away from unrelated sepsis. One child with intrinsic rhinitis was treated with steroid and then a salt-water nasal spray. Five children had nasal crusting documented, although this was not a specific reason for referral. When severe this had been treated with topical steroids by the dermatology team. One patient with obstructive sleep aponea had tonsillectomy and examination of the post-nasal space. Of the five patients referred with glottic or supraglottic scarring, the management of four included a tracheostomy. When carried out tracheostomy sites healed well in each case. With repeated endoscopic procedures it was subsequently possible to remove the tracheostomy in the two of the children. Using a special theatre protocol no new ulcers were recorded as being precipitated by any of the procedures children underwent. CONCLUSIONS Optimal management depends on the support of a multidisciplinary team, including otolaryngologists, pediatricians, dermatologists, anaesthetists, and specialist nurses. Adherence to a protocol for theatre management can help avoid intraoperative complications.
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Affiliation(s)
- I Hore
- Otolaryngology Department, Great Ormond Street Hospital, London, UK.
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Toda Y, Yokoyama M, Morimatsu H, Nakatsuka H, Takeuchi M, Katayama H, Morita K. General anesthesia in a patient with dystrophic epidermolysis bullosa. J Anesth 2006; 20:138-40. [PMID: 16633776 DOI: 10.1007/s00540-006-0388-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Accepted: 01/19/2006] [Indexed: 10/24/2022]
Abstract
A 13-year-old boy with epidermolysis bullosa underwent a repair of pseudosyndactyly. He had a long history of bullae formation in the oral cavity and on the pharynx and body surface, and some were active at the time of surgery. We chose inhalational general anesthesia with tracheal intubation using sevoflurane and nitrous oxide. The trachea was successfully extubated after the surgery, and no major bulla formation was observed. General anesthesia with tracheal intubation may be chosen as anesthesia for patients with epidermolysis bullosa.
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Affiliation(s)
- Yuichiro Toda
- Department of Anesthesiology and Resuscitology, Okayama University Medical School, Okayama 700-8558, Japan
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Thangathurai D, Roffey P, Mogos M, Riad M, Bohorguez A. Mediastinal haemorrhage mimicking tamponade during en-bloc oesophagectomy. Eur J Anaesthesiol 2005; 22:555-6. [PMID: 16045149 DOI: 10.1017/s0265021505240942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Nguyen L, Minville V, Riu B, Atallah F, Fourcade O. Anaesthetic management of a patient with epidermolysis bullosa undergoing percutaneous nephrolithotomy. Eur J Anaesthesiol 2005; 22:558-60. [PMID: 16045151 DOI: 10.1017/s0265021505260945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
Epidermolysis bullosa is a family of inherited blistering skin disorders characterized by blister formation in response to mechanical trauma. Major types of epidermolysis bullosa include epidermolysis bullosa simplex, hemidesmosomal epidermolysis bullosa, junctional epidermolysis bullosa, and dystrophic epidermolysis bullosa. Current treatment for epidermolysis bullosa consists of supportive care for skin and other organ systems and entails a combination of wound management, infection support for chronic wounds, surgical management as needed, nutritional support, and preventative screening for squamous cell carcinoma in recessive dystrophic epidermolysis bullosa. The regimen must be tailored specifically to the severity and extent of skin and systemic involvement in each case. Recent studies have identified specific protein and genetic abnormalities for most epidermolysis bullosa subtypes. These new advancements in the understanding of molecular pathophysiology have provided much of the basis for current efforts to develop effective gene and protein therapy for epidermolysis bullosa.
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Affiliation(s)
- Shan Pai
- Department of Dermatology, Stanford University School of Medicine, Stanford, California 94305, USA
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Herod J, Denyer J, Goldman A, Howard R. Epidermolysis bullosa in children: pathophysiology, anaesthesia and pain management. Paediatr Anaesth 2002; 12:388-97. [PMID: 12060323 DOI: 10.1046/j.1460-9592.2002.00768.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jane Herod
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Iohom G, Lyons B. Anaesthesia for children with epidermolysis bullosa: a review of 20 years' experience. Eur J Anaesthesiol 2001; 18:745-54. [PMID: 11580781 DOI: 10.1046/j.1365-2346.2001.00916.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Epidermolysis bullosa is a rare, genetically determined disorder characterized by excessive susceptibility of the skin and mucosa to separate from the underlying tissues after mechanical trauma. Patients suffering from this disease may have multiple medical problems, but the risk of anaesthesia is attributed mainly to oropharyngeal involvement; airway management may be hazardous and preservation of mucosa and skin integrity problematical. There is a paucity of data in the literature concerning the perioperative management of children with epidermolysis bullosa. We present our experience of managing 54 general anaesthetics (and two local anaesthetics) over the past 20 years. METHODS The case notes of 16 children with epidermolysis bullosa were reviewed. The children underwent surgical procedures under local or general anaesthesia over a 20-year period. RESULTS Fifty-four general and two local anaesthetics were administered for 58 procedures in 10 children (mean age 12.6 years). Surgical procedures included oesophageal dilatation (24), insertion/revision of gastrostomy (16), dental procedures (10), hand surgery (2), skin biopsy (2) and others (4). Anaesthesia was induced by inhalation in 73.4% of patients and the airway was maintained with an endotracheal tube in 64.8%. Monitoring of anaesthesia was performed with pulse oximetry (89%), whereas electrocardiography and non-invasive blood pressure monitoring were used in 16.6% of cases each. The mean duration of anaesthesia was 64 min. Tracheal intubation was difficult in two of the five children who were intubated. Mucocutaneous blistering occurred in three children, otherwise there was no attributable morbidity. CONCLUSION With maximal skin and mucous membrane protection, anaesthesia in children with epidermolysis bullosa may be undertaken with few sequelae.
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Affiliation(s)
- G Iohom
- Department of Anaesthesia, Our Lady's Hospital for Sick Children, Dublin, Ireland
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Anaesthesia for children with epidermolysis bullosa: a review of 20 years’ experience. Eur J Anaesthesiol 2001. [DOI: 10.1097/00003643-200111000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Naehrlich L, Lang T, Schamberger U, Behrens R. Balloon dilation of an esophageal stenosis in a patient with recessive dystrophic epidermolysis bullosa. Pediatr Dermatol 2000; 17:477-9. [PMID: 11123785 DOI: 10.1046/j.1525-1470.2000.01826.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report a 13-year-old boy with recessive dystrophic epidermolysis bullosa who had dysphagia due to esophageal stenosis. A balloon dilation was successfully performed under flexible endoscopic and fluoroscopic control. The early and long-term follow-up was characterized by the disappearance of dysphagia, weight gain, and improvement of his skin lesions.
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Affiliation(s)
- L Naehrlich
- Children's Hospital, University of Erlangen-Nuremberg, Erlangen, Germany, and Children's Hospital, Coburg, Germany.
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31
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Katsambas AD. Genetic Diseases of Oral Mucosa. Oral Dis 1999. [DOI: 10.1007/978-3-642-59821-0_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ladd AL, Kibele A, Gibbons S. Surgical treatment and postoperative splinting of recessive dystrophic epidermolysis bullosa. J Hand Surg Am 1996; 21:888-97. [PMID: 8891991 DOI: 10.1016/s0363-5023(96)80210-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Digital contractures and pseudosyndactyly, common manifestations in recessive dystrophic epidermolysis bullosa, cause significant functional impairment. The deformities progress with time, although surgery may delay the progression. The role of surgical intervention, hand therapy, and the use of prolonged splinting was examined in seven children (nine hands) with recessive dystrophic epidermolysis bullosa with an average age of 5 years, 8 months (range, 1 year, 10 months to 16 years, 4 months). The technique of surgery, postoperative regimen, and splinting differ from those previously reported. Surgery includes "de-cocooning" the hand and fingers, manipulating contracted joints, and full-thickness skin grafting to dermal defects. Surgery and the postoperative regimen of rigid night splints and web-retaining gloves for day wear has allowed arrest or minimal progression of contractures in complaint patients in short-term follow-up study of an average of 17 months (range, 12-28 months). An interdisciplinary team of physicians and surgeons, therapists, and nurses makes this care regimen possible and influences family compliance.
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Affiliation(s)
- A L Ladd
- Department of Functional Restoration, Stanford University Medical Center, Palo Alto, CA 94304-2205, USA
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HAYNES L, ATHERTON D, ADE-AJAYI N, WHEELER R, KIELY E. Gastrostomy and growth in dystrophic epidermolysis bullosa. Br J Dermatol 1996. [DOI: 10.1111/j.1365-2133.1996.tb06318.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Affiliation(s)
- F J Frei
- Department of Anaesthesia, Kinderspital Basel, Universitätskliniken, Switzerland
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Yonker-Sell AE, Connolly LA. Twelve hour anaesthesia in a patient with epidermolysis bullosa. Can J Anaesth 1995; 42:735-9. [PMID: 7586115 DOI: 10.1007/bf03012674] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Epidermolysis bullosa (EB), an inherited disorder presents clinically with recurrent cutaneous blister formation with possible involvement of mucous membranes and other organs. The sequelae of this disease pose multiple challenges to the anaesthetist and operating room team. Recent literature describes several anaesthetic techniques for the short surgical procedures this patient population may undergo. We describe the anaesthetic technique employed in a 28-yr-old women with recessive dystrophic epidermolysis bullosa who underwent 12 hr reconstructive surgery followed by a review of the literature that includes a recent description of the possible association of EB with at least two distinct neuromuscular diseases. A detailed description of airway and skin management is described in addition to preoperative concerns. We conclude that a prolonged operative procedure can be undertaken successfully in this population with minimal sequelae involving skin integrity and airway management.
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Affiliation(s)
- A E Yonker-Sell
- Medical College of Wisconsin, Department of Anesthesiology, Milwaukee 53226, USA
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Affiliation(s)
- M G Dunnill
- St John's Institute of Dermatology, St Thomas' Hospital, London, UK
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Chevaleraud E, Ragot JM, Glicenstein J. [Anesthesia for hand surgery in patients with epidermolysis bullosa]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1995; 14:399-405. [PMID: 8572406 DOI: 10.1016/s0750-7658(05)80392-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To report on the anaesthetic management with axillary block of patients suffering from recessive dystrophic epidermolysis bullosa (RDEB), undergoing repetitive surgery of the hand. STUDY DESIGN Retrospective analysis of a case series. PATIENTS Twenty-two patients, including 11 children less than 8-year-old and with a body weight under 20 kg, treated since 1988, were considered. METHODS For surgery, including usually three stages at a 7-day interval, an axillary block was placed when feasible, after oral premedication midazolam (0.1-0.2 mg.kg-1) with a 25 gauge needle in patients of less than 30 kg of body weight and 22 gauge beyond. The local anaesthetic mixture included 2% lidocaine (5-10 mg.kg-1) and 0.5% bupivacaine (2-3 mg.kg-1). A catheter for repetitive injections had not been inserted. For children less than 10-year-old a parent was present in the theater during all the course of operation. RESULTS Between 1988 and 1995, 22 patients underwent 160 operative interventions on 54 hands. Regional anaesthesia was used in 142 cases, including 140 axillary and 2 interscalene blocks. General anaesthesia was only required in 20 cases, either alone or associated with regional anaesthesia. The success rate of axillary blocks was 98%. DISCUSSION For surgery of the hand in patients with RDEB, we switched in 1988 from general anaesthesia with ketamine to axillary block, even in young children, as it is closer to the no-touch principle, which is essential to prevent from blistering. In comparison to general anaesthesia, regional anaesthesia raises neither the problems of airway and vascular access, nor those of instrumental monitoring. The main factors of success with regional anaesthesia are technical skills, expertise in the management of patients with RDEB and parental presence in the operating room which makes the procedure less stressful for children.
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Chevaleraud E, Ragot JM, Glicenstein J. [Anesthesia for hand surgery in patients with bullous epidermolysis]. ANNALES DE CHIRURGIE DE LA MAIN ET DU MEMBRE SUPERIEUR : ORGANE OFFICIEL DES SOCIETES DE CHIRURGIE DE LA MAIN = ANNALS OF HAND AND UPPER LIMB SURGERY 1995; 14:296-303. [PMID: 8679341 DOI: 10.1016/s0753-9053(05)80408-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Epidermolysis bullosa is a rare genetic disease, characterized by the formation of bullae in the skin and squamous epithelium following minimal trauma. The majority of surgical indications specific to this disease concern autosomal recessive dystrophic epidermolysis bullosa (RDEB). Hand surgery is one of the fields of surgery involved. The cicatricial course of the lesions results in retraction and pseudosyndactylization of the fingers, sometimes leading to complete destruction of the hand. Since 1988, we have treated 23 patients, including 11 children under the age of 8 years and weighing less than 20 kg. 185 procedures were performed by two anaesthetists, using regional plexus blocks in 157 cases and general anaesthesia in only 28 cases. This series is comparable in number, to that reported by the London team, which prefers general anaesthesia. Regional anaesthesia has been previously used, but only following general anaesthetic induction. Our approach, based on the experience of a hand surgery center, is in marked opposition with this standard paediatric approach. Regional anaesthetic techniques, particularly in the upper limb, present many advantages in addition to their feasibility in small children: efficacy, simplicity, postoperative analgesia, and outpatient comfort. In the context of the specificities and difficulties encountered in the management of these patients suffering from epidermolysis bullosa, the authors demonstrate the value of first-line regional anaesthesia, even in very young children (less than 3 years). The presence of a parent in the operating room is a valuable aid, which is still insufficiently used, but which should be used with conviction for the benefit of all concerned.
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Dorne R, Tassaux D, Ravat F, Pommier C, Bertrix L. [Surgery for epidermolysis bullosa in children: value of the association of inhalation anesthesia and locoregional anesthesia]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1994; 13:425-8. [PMID: 7992953 DOI: 10.1016/s0750-7658(94)80054-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Due to the cutaneous and mucosal fragility associated with epidermolysis bullosa, this disease is a source of various practical problems for the anaesthesiologist concerning the surgical posture, the monitoring of vital functions, the airways control and the vascular access, as all these procedures may worsen, sometimes dramatically, the lesions in these young patients, still in a precarious health state. Basing on published studies and their own experience, the authors have used in these patients a combined locoregional and general anaesthesia. The latter was obtained with isoflurane, administered in the non intubated and spontaneously breathing patient through a closed surgical isolation container (Vi-Drape), including the patient's head and ventilated with a ventilator generating a PEEP for long procedures. The results obtained during 9 procedures in 3 children are reported and discussed. For several shorter procedures (for example wound dressing), intramuscular ketamine was used.
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Affiliation(s)
- R Dorne
- Département d'Anesthésie-Réanimation, Centre Hospitalier Saint-Joseph et Saint-Luc, Lyon
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