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D’Ambrosio ES, Gonzalez-Perez P. Cancer and Myotonic Dystrophy. J Clin Med 2023; 12:1939. [PMID: 36902726 PMCID: PMC10004154 DOI: 10.3390/jcm12051939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/05/2023] Open
Abstract
Myotonic dystrophy (DM) is the most common muscular dystrophy in adults. Dominantly inherited CTG and CCTG repeat expansions in DMPK and CNBP genes cause DM type 1 (DM1) and 2 (DM2), respectively. These genetic defects lead to the abnormal splicing of different mRNA transcripts, which are thought to be responsible for the multiorgan involvement of these diseases. In ours and others' experience, cancer frequency in patients with DM appears to be higher than in the general population or non-DM muscular dystrophy cohorts. There are no specific guidelines regarding malignancy screening in these patients, and the general consensus is that they should undergo the same cancer screening as the general population. Here, we review the main studies that investigated cancer risk (and cancer type) in DM cohorts and those that researched potential molecular mechanisms accounting for DM carcinogenesis. We propose some evaluations to be considered as malignancy screening in patients with DM, and we discuss DM susceptibility to general anesthesia and sedatives, which are often needed for the management of cancer. This review underscores the importance of monitoring the adherence of patients with DM to malignancy screenings and the need to design studies that determine whether they would benefit from a more intensified cancer screening than the general population.
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van den Bersselaar LR, Heytens L, Silva HCA, Reimann J, Tasca G, Díaz‐Cambronero Ó, Løkken N, Hellblom A, Hopkins PM, Rueffert H, Bastian B, Vilchez JJ, Gillies R, Johannsen S, Veyckemans F, Muenster T, Klein A, Litman R, Jungbluth H, Riazi S, Voermans NC, Snoeck MMJ. European Neuromuscular Centre consensus statement on anaesthesia in patients with neuromuscular disorders. Eur J Neurol 2022; 29:3486-3507. [PMID: 35971866 PMCID: PMC9826444 DOI: 10.1111/ene.15526] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/05/2022] [Accepted: 08/11/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Patients with neuromuscular conditions are at increased risk of suffering perioperative complications related to anaesthesia. There is currently little specific anaesthetic guidance concerning these patients. Here, we present the European Neuromuscular Centre (ENMC) consensus statement on anaesthesia in patients with neuromuscular disorders as formulated during the 259th ENMC Workshop on Anaesthesia in Neuromuscular Disorders. METHODS International experts in the field of (paediatric) anaesthesia, neurology, and genetics were invited to participate in the ENMC workshop. A literature search was conducted in PubMed and Embase, the main findings of which were disseminated to the participants and presented during the workshop. Depending on specific expertise, participants presented the existing evidence and their expert opinion concerning anaesthetic management in six specific groups of myopathies and neuromuscular junction disorders. The consensus statement was prepared according to the AGREE II (Appraisal of Guidelines for Research & Evaluation) reporting checklist. The level of evidence has been adapted according to the SIGN (Scottish Intercollegiate Guidelines Network) grading system. The final consensus statement was subjected to a modified Delphi process. RESULTS A set of general recommendations valid for the anaesthetic management of patients with neuromuscular disorders in general have been formulated. Specific recommendations were formulated for (i) neuromuscular junction disorders, (ii) muscle channelopathies (nondystrophic myotonia and periodic paralysis), (iii) myotonic dystrophy (types 1 and 2), (iv) muscular dystrophies, (v) congenital myopathies and congenital dystrophies, and (vi) mitochondrial and metabolic myopathies. CONCLUSIONS This ENMC consensus statement summarizes the most important considerations for planning and performing anaesthesia in patients with neuromuscular disorders.
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Affiliation(s)
- Luuk R. van den Bersselaar
- Malignant Hyperthermia Investigation Unit, Department of AnaesthesiologyCanisius Wilhelmina Hospital NijmegenNijmegenThe Netherlands,Department of Neurology, Donders Institute for Brain, Cognition, and BehaviourRadboud University Medical CentreNijmegenThe Netherlands
| | - Luc Heytens
- Malignant Hyperthermia Research Unit, Departments of Anaesthesiology and NeurologyUniversity Hospital Antwerp, University of Antwerp and Born Bunge InstituteAntwerpBelgium
| | - Helga C. A. Silva
- Malignant Hyperthermia Unit, Department of Surgery, Discipline of Anaesthesia, Pain, and Intensive CareSão Paulo Federal UniversitySão PauloBrazil
| | - Jens Reimann
- Department of NeurologyUniversity of Bonn Medical CentreBonnGermany
| | - Giorgio Tasca
- UOC of NeurologyA. Gemelli University Polyclinic Foundation, Scientific Institute for Research and Health CareRomeItaly
| | - Óscar Díaz‐Cambronero
- Malignant Hyperthermia Unit, Department of AnaesthesiologyPerioperative Medicine Research Group, La Fe University and Polytechnic HospitalValenciaSpain
| | - Nicoline Løkken
- Copenhagen Neuromuscular CentreRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Anna Hellblom
- Department of Intensive and Perioperative CareSkåne University Hospital LundLundSweden
| | - Philip M. Hopkins
- Leeds Institute of Medical Research at St James'sUniversity of Leeds and Malignant Hyperthermia Investigation Unit, St James's University HospitalLeedsUK
| | - Henrik Rueffert
- Schkeuditz Helios Clinic, Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology, Intensive Care, Pain TherapyUniversity Hospital LeipzigLeipzigGermany
| | - Börge Bastian
- Schkeuditz Helios Clinic, Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology, Intensive Care, Pain TherapyUniversity Hospital LeipzigLeipzigGermany
| | - Juan Jesus Vilchez
- Neuromuscular Centre, La Fe Hospital UIP and ERN EURO‐NMDNeuromuscular Research Group at La Fe IIS and CIBERERValenciaSpain
| | - Robyn Gillies
- Malignant Hyperthermia Diagnostic Unit, Department of Anaesthesia and Pain ManagementRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Stephan Johannsen
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, Centre for Malignant HyperthermiaUniversity Hospital WürzburgWürzburgGermany
| | - Francis Veyckemans
- Paediatric Anaesthesia ClinicJeanne de Flandre Hospital, Lille University Hospital CentreLilleFrance
| | - Tino Muenster
- Department of Anaesthesia and Intensive Care MedicineHospital of the Order of St John of GodRegensburgGermany
| | - Andrea Klein
- Department of Paediatric NeurologyUniversity Children's Hospital UKBBBaselSwitzerland,Division of Neuropaediatrics, Development, and Rehabilitation, Department of Paediatrics, InselspitalBern University Hospital, University of BernBernSwitzerland
| | - Ron Litman
- Department of Anaesthesiology and Critical CareChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular ServiceEvelina's Children Hospital, Guy's and St Thomas' Hospital National Health Service Foundation TrustLondonUK,Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and MedicineKing's College LondonLondonUK
| | - Sheila Riazi
- Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology and Pain MedicineUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - Nicol C. Voermans
- Department of Neurology, Donders Institute for Brain, Cognition, and BehaviourRadboud University Medical CentreNijmegenThe Netherlands
| | - Marc M. J. Snoeck
- Malignant Hyperthermia Investigation Unit, Department of AnaesthesiologyCanisius Wilhelmina Hospital NijmegenNijmegenThe Netherlands
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Karras G, Nikouli E, Kiamiloglou B. Laparoscopic cholecystectomy under total intravenous anaesthesia in a patient with myotonic dystrophy type 1 (Steinert’s disease) – a case report. Folia Med (Plovdiv) 2022; 64:333-336. [DOI: 10.3897/folmed.64.e59905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/11/2021] [Indexed: 11/12/2022] Open
Abstract
Myotonic dystrophy type 1 or Steinert’s disease is an autosomal dominant multisystem disease which is characterized by consistent contracture of muscle following stimulation (myotonia). Hypothermia, shivering, mechanical or electric stimulation during surgery can precipitate episodes of myotonia which may complicate the course of anaesthesia. The present case report focuses on successful strategies for providing general anaesthesia for laparoscopic cholecystectomy in a patient affected by this genetic disorder, at a hospital which does not have the facility for postoperative ventilation.
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van den Bersselaar LR, Riazi S, Snoeck M, Jungbluth H, Voermans NC. 259th ENMC international workshop: Anaesthesia and neuromuscular disorders 11 December, 2020 and 28-29 May, 2021. Neuromuscul Disord 2021; 32:86-97. [PMID: 34916120 DOI: 10.1016/j.nmd.2021.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 02/07/2023]
Affiliation(s)
- L R van den Bersselaar
- Department of Anaesthesiology, Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands; Department of Neurology, Radboud University Medical Center, Reinier Postlaan 4, P.O. Box 9101, 6500 HB, Nijmegen 6525 GC, the Netherlands
| | - S Riazi
- Department of Anesthesiology and Pain Medicine, Malignant Hyperthermia Investigation Unit, University Health Network, University of Toronto, Toronto, Canada
| | - Mmj Snoeck
- Department of Anaesthesiology, Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - H Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, United Kingdom; Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - N C Voermans
- Department of Neurology, Radboud University Medical Center, Reinier Postlaan 4, P.O. Box 9101, 6500 HB, Nijmegen 6525 GC, the Netherlands.
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Fishman H, Hamid JS, Barrowman N, Momoli F, Maclusky I, Katz SL. Associations between polysomnography measurements and postoperative adverse respiratory events in children with neuromuscular disease. J Clin Sleep Med 2021; 17:757-765. [PMID: 33231163 DOI: 10.5664/jcsm.9026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
STUDY OBJECTIVES To determine if polysomnographic cardiorespiratory outcomes are associated with and could have the potential to predict the presence of postoperative adverse respiratory events in children with neuromuscular disease undergoing any surgical procedure. METHODS A retrospective cohort study was conducted at a tertiary pediatric institution. The study population included individuals with neuromuscular disease admitted for a surgical intervention under general anesthetic who had undergone a polysomnogram within 1 year before surgical intervention. Polysomnographic indices and postoperative adverse respiratory events were collected through chart review. Multivariable logistic regression was used to model postoperative adverse respiratory events, where PSG results were considered primary predictors. RESULTS Postoperative adverse respiratory events occurred in 25/61 (41%) of individuals and consisted mainly of desaturations requiring intervention 33 (73%), airway obstruction 15 (33%), and atelectasis (22%). Results from the unadjusted and adjusted logistic regression models indicated that saturation nadir and bulbar dysfunction individually were independent risk factors for postoperative adverse respiratory events with the highest areas under the receiver operating characteristic curve. A multivariable prediction model using these 2 risk factors provided an area under the receiver operating characteristic curve of 0.74 (95% confidence interval, 0.65-0.83). CONCLUSIONS Knowing that nocturnal oxygen saturation nadir and the presence of bulbar dysfunction are potential predictors of postoperative adverse respiratory events is useful for future counseling of families and surgical planning, in an effort to improve perioperative management and reduce adverse events.
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Affiliation(s)
- Haley Fishman
- Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, Division of Pediatric Respirology, Montreal, Quebec, Canada.,University of Montreal, Faculty of Medicine, Montreal, Quebec, Canada
| | - Jemila S Hamid
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Ian Maclusky
- University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario, Department of Pediatrics, Division of Pediatric Respirology, Ottawa, Ontario, Canada
| | - Sherri Lynne Katz
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario, Department of Pediatrics, Division of Pediatric Respirology, Ottawa, Ontario, Canada
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Fukuda M, Tachibana S, Nishihara N, Yamakage M. Remimazolam for a patient with myotonic dystrophy type 1 who underwent endoscopic retrograde cholangiopancreatography under general anesthesia: a case report. JA Clin Rep 2021; 7:17. [PMID: 33625620 PMCID: PMC7905007 DOI: 10.1186/s40981-021-00422-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Remimazolam is a benzodiazepine receptor agonist with an ultra-short-acting anesthetic effect. We used remimazolam for anesthesia in a patient with myotonic dystrophy type 1 who underwent endoscopic retrograde cholangiopancreatography (ERCP). CASE PRESENTATION A 58-year-old woman received ERCP under general anesthesia. She had impaired respiratory function due to myotonic dystrophy type I and was at a risk of respiratory complications after anesthesia. General anesthesia was induced with remimazolam 12 mg/kg/h, remifentanil 0.1 μg/kg/min and rocuronium 15 mg, followed by tracheal intubation and maintained with remimazolam 0.8-1.0 mg/kg/h. At the end of anesthesia, we injected sugammadex 150 mg and flumazenil 0.2 mg, allowing smooth and clear emergence from anesthesia. She was discharged from the hospital without any respiratory problems on postoperative day 5. CONCLUSIONS Remimazolam was safe to use for general anesthesia in a patient with myotonic dystrophy type 1 undergoing ERCP.
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Affiliation(s)
- Masakazu Fukuda
- Department of Anesthesiology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Shunsuke Tachibana
- Department of Anesthesiology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Noriaki Nishihara
- Department of Anesthesiology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
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Tesoro S, De Robertis E, Marturano F, van den Hout HJ, De Graaff JC. Anaesthesiological approach to the floppy child. Minerva Anestesiol 2021; 87:940-949. [PMID: 33432795 DOI: 10.23736/s0375-9393.20.15011-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Children with symptoms of hypotonia (reduction of postural tone of lower limbs and trunk with or without changes in phasic tone) are frequently anaesthetized for diagnostic and therapeutic interventions. This review outlines the underlying causes and classifications, and the anaesthesiologic pre- and peri-operative management of hypotonic children. Hypotonia may have a large range of aetiologies that be categorized into central and/or peripheral hypotonia. A multidisciplinary approach towards the (differential) diagnosis of the underlying cause of the symptoms in cooperation with a paediatrician and/or paediatric neurologist is emphasized. Anaesthetic management involves the anticipation of an increased risk in difficult airway management because of macroglossia, reduced mouth opening, obesity and limited neck mobility, which increases with age. There are no specific restrictions towards the use of intravenous or inhalational anaesthetics. Short acting opioids and hypnotics, avoiding neuromuscular blockade, and locoregional techniques are preferred. Most patients are sensitive to the cardiac and depressive effects of anaesthetics and all dystrophic myopathies are considered at risk of malignant hyperthermia. Depolarizing neuromuscular blockers are contraindicated. The use of a peripheral nerve stimulator is recommended to detect the severity of muscle relaxation before extubating. Accurate control and management of IV fluids, electrolytes and temperature is mandatory. Adequate postoperative pain treatment is essential to limit stress and metabolic alteration. Preferably a locoregional technique is used to reduce the increased risk of respiratory depression. A multidisciplinary preoperative approach taking into account the differential diagnosis of the underlying disease of the floppy child is recommended.
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Affiliation(s)
- Simonetta Tesoro
- Division of Anaesthesia, Analgesia, and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Edoardo De Robertis
- Division of Anaesthesia, Analgesia, and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy -
| | - Federico Marturano
- Division of Anaesthesia, Analgesia, and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Hannerieke J van den Hout
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jurgen C De Graaff
- Department of Anesthesia, Erasmus MC, Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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8
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Opioid use may be associated with postoperative complications in myotonic dystrophy type 1 with high-grade muscular impairment. Sci Rep 2021; 11:8. [PMID: 33431966 PMCID: PMC7801477 DOI: 10.1038/s41598-020-76217-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/22/2020] [Indexed: 12/25/2022] Open
Abstract
Individuals with myotonic dystrophy type 1 (DM1) reportedly have a higher risk of postoperative complications than those without DM1; however, factors related to perioperative complications in DM1 patients remain unclear. We aimed to identify the risk factors that may be associated with postoperative complications in DM1 patients. We reviewed medical records of 256 patients with DM1 from 1998 to 2018, among whom 42 (16.4%) had previously undergone 51 surgeries under general and regional anaesthesia. Among the 42 patients, 11 (21.5%) had 13 postoperative complications including respiratory complications, sustained hypotension, wound infection and dehiscence, artery thrombosis and occlusion, and delayed recovery from anaesthesia. There were significant inter-group differences between the non-complicated and complicated groups considering the following parameters: high-grade (≥ 3) muscular impairment rating scale (MIRS), extubation time, postoperative opioid use, and hospital length of stay. Furthermore, univariate analysis revealed that an MIRS score ≥ 3 (odds ratio [OR] 9.346, confidence interval [CI] 1.761–49.595, p = 0.009) and postoperative opioid use (OR 8.000, CI 1.772–36.127, p = 0.007) were the only statistically significant factors. Therefore, clinicians should be cautious in administering opioids, particularly in patients with a high-grade MIRS score during the perioperative period.
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9
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van den Bersselaar LR, Snoeck MMJ, Gubbels M, Riazi S, Kamsteeg EJ, Jungbluth H, Voermans NC. Anaesthesia and neuromuscular disorders: what a neurologist needs to know. Pract Neurol 2020:practneurol-2020-002633. [PMID: 33109742 PMCID: PMC8172077 DOI: 10.1136/practneurol-2020-002633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2020] [Indexed: 11/04/2022]
Abstract
Neurologists are often asked for specific advice regarding patients with neuromuscular disease who require general anaesthesia. However, guidelines on specific neuromuscular disorders do not usually include specific guidelines or pragmatic advice regarding (regional and/or general) anaesthesia or procedural sedation. Furthermore, the medical literature on this subject is mostly limited to publications in anaesthesiology journals. We therefore summarise general recommendations and specific advice for anaesthesia in different neuromuscular disorders to provide a comprehensive and accessible overview of the knowledge on this topic essential for clinical neurologists. A preoperative multidisciplinary approach involving anaesthesiologists, cardiologists, chest physicians, surgeons and neurologists is crucial. Depolarising muscle relaxants (succinylcholine) should be avoided at all times. The dose of non-depolarising muscle relaxants must be reduced and their effect monitored. Patients with specific mutations in RYR1 (ryanodine receptor 1) and less frequently in CACNA1S (calcium channel, voltage-dependent, L type, alpha 1S subunit) and STAC3 (SH3 and cysteine rich domain 3) are at risk of developing a life-threatening malignant hyperthermia reaction.
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Affiliation(s)
- Luuk R van den Bersselaar
- Anaesthesiology, Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
- Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, Netherlands
| | - Marc M J Snoeck
- Anaesthesiology, Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Madelief Gubbels
- Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, Netherlands
| | - Sheila Riazi
- Anesthesiology and Pain Medicine, Malignant Hyperthermia Investigation Unit, University of Toronto, Toronto, Canada
| | | | - Heinz Jungbluth
- Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
- Department of Basic and Clinical Neuroscience, IoPPN, King's College, London, UK
- Randall Division for Cell and Molecular Biophysics, Muscle Signalling Section, King's College, London, UK
| | - Nicol C Voermans
- Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, Netherlands
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Grijalba Ipiñazar I, Tuduri Limousin I, Reguera Fernández M, Najarro Ajuria G, Martínez Ruiz A. Anesthetic management of a child with congenital Steiner syndrome scheduled for laparoscopic bilateral orchidopexy. ACTA ACUST UNITED AC 2019; 66:381-384. [PMID: 31027758 DOI: 10.1016/j.redar.2019.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 11/18/2022]
Abstract
Congenital Steinert syndrome is a severe form of myotonic dystrophy, characterized by general hypotonia, facial diplegia, respiratory difficulty and sucking and swallowing problems presented since birth. This syndrome has an estimated incidence of 1 per 10.000 births. Mortality is close to 50% during the neonatal period. It represents a challenge for the anesthesiologist due to the great variety of intraoperative and postoperative adverse events, given by both the evolution of the disease and the susceptibility to the vast majority of the anesthetic agents. A report of a 3-year-old boy with congenital myotonic dystrophy is presented, scheduled for laparoscopic bilateral orchidopexy, performed under general anesthesia without muscular relaxation, combined with ecoguide bilateral TAP block.
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Affiliation(s)
- I Grijalba Ipiñazar
- Servicio de Anestesiología, Reanimación y Terapeútica del Dolor, Hospital Universitario de Cruces, Barakaldo (Vizcaya), España.
| | - I Tuduri Limousin
- Servicio de Cirugía Pediátrica, Hospital Universitario Cruces, Barakaldo (Vizcaya), España
| | - M Reguera Fernández
- Servicio de Anestesiología, Reanimación y Terapeútica del Dolor, Hospital Universitario de Cruces, Barakaldo (Vizcaya), España
| | - G Najarro Ajuria
- Servicio de Anestesiología, Reanimación y Terapeútica del Dolor, Hospital Universitario de Cruces, Barakaldo (Vizcaya), España
| | - A Martínez Ruiz
- Servicio de Anestesiología, Reanimación y Terapeútica del Dolor, Hospital Universitario de Cruces, Barakaldo (Vizcaya), España
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11
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Myotonic Dystrophy and Anesthetic Challenges: A Case Report and Review. Case Rep Anesthesiol 2019; 2019:4282305. [PMID: 31016049 PMCID: PMC6446115 DOI: 10.1155/2019/4282305] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/06/2019] [Accepted: 03/06/2019] [Indexed: 11/21/2022] Open
Abstract
Providing anesthesia to patients with myotonic dystrophy (DM) can be very challenging due to the multisystemic effects of the disease and extreme sensitivity of these patients to sedatives, opioids, and anesthetic agents. Other factors such as hypothermia, shivering, or mechanical or electric stimulation during surgery can precipitate myotonia which is difficult to abolish and can lead to further complications. Generally, local or regional anesthesia is preferred to avoid the complications associated with general anesthesia in this group. However there are several case reports of successful use of general anesthesia (with or without volatile agents and with or without opioids). These general anesthetic cases led to postoperative admission to the regular floor or ICU. We present a case of a woman with a history of DM who underwent robotic assisted laparoscopic hysterectomy under general anesthesia and was discharged home on the same day.
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12
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Teixeira J, Matias B, Ferreira I, Taleço T, Duarte JS. Sugammadex is changing the paradigm in neuromuscular blockade in patients with myotonic dystrophy. J Perioper Pract 2019; 29:337-340. [PMID: 30888938 DOI: 10.1177/1750458919838412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Myotonic dystrophy type 1 is a rare neuromuscular disease that represents a challenge to anaesthetic management. Most of the literature does not recommend the usage of neuromuscular blocking agents, if general anaesthesia is needed in these patients. Depolarising neuromuscular blocking agents like suxamethonium are contraindicated, and there might be an increased sensitivity to non-depolarising agents like rocuronium with greater risk of postoperative residual neuromuscular blockade and consequent respiratory failure. Reversing neuromuscular blockade is also problematic as neostigmine can induce myotonic crisis, impairing normal ventilation. We discuss the use of sugammadex for neuromuscular blockade reversal, from a clinical case of a patient with myotonic dystrophy type 1 for laparoscopic cholecystectomy. The patient had a general anaesthesia with neuromuscular blockade with rocuronium. After the surgical procedure, neuromuscular blockade was safely reversed with sugammadex, guided by neuromuscular monitoring without any perioperative complications.
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14
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Surgical treatment of obesity in DM1 – a case report and a review of the literature. Neuromuscul Disord 2015; 25:414-7. [DOI: 10.1016/j.nmd.2015.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 01/13/2015] [Accepted: 02/09/2015] [Indexed: 11/22/2022]
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15
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Schilling L, Forst R, Forst J, Fujak A. Orthopaedic Disorders in Myotonic Dystrophy Type 1: descriptive clinical study of 21 patients. BMC Musculoskelet Disord 2013; 14:338. [PMID: 24289806 PMCID: PMC4219587 DOI: 10.1186/1471-2474-14-338] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 11/26/2013] [Indexed: 01/20/2023] Open
Abstract
Background Myotonic Dystrophy Type 1 (DM1) is the most common form of hereditary myopathy presenting in adults. This autosomal-dominant systemic disorder is caused by a CTG repeat, demonstrating various symptoms. A mild, classic and congenital form can be distinguished. Often the quality of life is reduced by orthopaedic problems, such as muscle weakness, contractures, foot or spinal deformities, which limit patients’ mobility. The aim of our study was to gather information about the orthopaedic impairments in patients with DM1 in order to improve the medical care of patients, affected by this rare disease. Methods A retrospective clinical study was carried out including 21 patients (11 male and 10 female), all diagnosed with DM1 by genetic testing. All patients were seen during our special consultations for neuromuscular diseases, during which patients were interviewed and examined. We also reviewed surgery reports of our hospitalized patients. Results We observed several orthopaedic impairments: spinal deformities (scoliosis, hyperkyphosis, rigid spine), contractures (of the upper extremities and the lower extremities), foot deformities (equinus deformity, club foot, pes cavus, pes planovalgus, pes cavovarus, claw toes) and fractures. Five patients were affected by pulmonary diseases (obstructive airway diseases, restrictive lung dysfunctions). Twelve patients were affected by cardiac disorders (congenital heart defects, valvular heart defects, conduction disturbances, pulmonary hypertension, cardiomyopathy). Our patients received conservative therapy (physiotherapy, logopaedic therapy, ergotherapy) and we prescribed orthopaedic technical devices (orthopaedic custom-made shoes, insoles, lower and upper leg orthoses, wheelchair, Rehab Buggy). We performed surgery for spinal and foot deformities: the scoliosis of one patient was stabilized and seven patients underwent surgery for correction of foot deformities. Conclusions An orthopaedic involvement in DM1 patients should not be underestimated. The most common orthopaedic impairments are contractures, foot deformities and spinal deformities. Contractures are typically located distally in the lower extremities, but can also occur in the hip or shoulder joints. Foot deformities could be treated with orthopaedic custom-made shoes, orthoses or insoles. Surgery is indicated for severe foot deformities or contractures.
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Affiliation(s)
- Lisa Schilling
- Department of Orthopaedic Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Rathsberger Str, 57, Erlangen D-91054, Germany.
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Veyckemans F, Scholtes JL. Myotonic dystrophies type 1 and 2: anesthetic care. Paediatr Anaesth 2013; 23:794-803. [PMID: 23384336 DOI: 10.1111/pan.12120] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2012] [Indexed: 01/19/2023]
Abstract
Myotonic dystrophy is classified as one of the myotonic syndromes although myotonia is only a minor characteristic of it. It is, in fact, also a multisystem disease with cardiac, digestive, ocular, and endocrine abnormalities. Two subgroups are currently identified with many similarities: DM1 refers to classic dystrophia myotonica (Steinert disease), while DM2, formerly called proximal myotonic myopathy has a later onset. The congenital form is present only in DM1. The genetic causes of DM1 and 2 are different but end up in a similar way of altering RNAm processing and splicing of other genes. The anesthetic risk is increased in case of DM1 type. This review summarizes current knowledge concerning the pathophysiology and anesthetic management of this disease in children and adults.
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Affiliation(s)
- Francis Veyckemans
- Anesthesiology, Université catholique de Louvain Medical School, Cliniques universitaires St Luc, Brussels, Belgium.
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Nursing surveillance moderates the relationship between staffing levels and pediatric postoperative serious adverse events: A nested case–control study. Int J Nurs Stud 2013; 50:905-13. [DOI: 10.1016/j.ijnurstu.2012.11.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 11/20/2012] [Accepted: 11/20/2012] [Indexed: 11/15/2022]
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Joh JH, Kim JY, Baek SH, Song JG, Lee YM, Kim JU. Total intravenous anesthesia in a 10-month-old patient with congenital myotonic dystrophy undergoing endoscopic third ventriculostomy -A case report-. Korean J Anesthesiol 2012; 63:169-72. [PMID: 22949987 PMCID: PMC3427812 DOI: 10.4097/kjae.2012.63.2.169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 09/09/2011] [Accepted: 09/19/2011] [Indexed: 11/10/2022] Open
Abstract
Myotonic dystrophy is a rare genetic disorder characterized by muscle atrophy and weakness. Surgical treatment of this condition poses various problems for the anesthesiologist. We describe the anesthetic management of a 10-month-old infant with congenital myotonic dystrophy, who was scheduled for endoscopic third ventriculostomy under general anesthesia. Anesthesia was induced with thiopental sodium, fentanyl, and vecuronium, and thereafter maintained via continuous infusion of propofol and remifentanil. The train-of-four ratio was monitored throughout the operation, and muscle relaxation was reversed with pyridostigmine and glycopyrrolate at the end of the procedure. We show that total intravenous anesthesia using propofol and remifentanil is a satisfactory anesthetic technique in very young patients with congenital myotonic dystrophy.
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Affiliation(s)
- Jung Hwa Joh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
PURPOSE OF REVIEW The heterogeneous nature of neuromuscular disorders (NMDs) continues to promote slow but steady advances in diagnosis, classification, and treatment. This review focuses on the updates in the general management and treatment of NMDs, with emphasis on key updates in muscular dystrophy, myotonic dystrophy, mitochondrial myopathy, spinal muscular atrophy, and hereditary neuropathies. RECENT FINDINGS Current research shows that improvements in morbidity and mortality in various NMDs may be possible. Key components include advances in identification and classification of individual NMDs; attention to anesthetic and surgical risks; aggressive pulmonary care; and implementations of a proactive, multidisciplinary, standard-of-care approach. Innovative molecular and pharmaceutical therapeutic options are being investigated in many of these disorders, but unfortunately no new intervention has borne out. SUMMARY Important advances were made in the last year in the field of neuromuscular disease. However, because of their heterogeneous nature and rarity, diagnosis and treatment of these disorders either as a single disorder or as a group continue to be both a clinical and a research challenge. It is of utmost importance that clinicians and researchers be aware of these disorders to aid in identification and treatment.
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Nivoche Y, Bruneau B, Dahmani S. [Suxamethonium and myotonic dystrophy type 1]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:571. [PMID: 22677059 DOI: 10.1016/j.annfar.2012.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Sensitivity to rocuronium-induced neuromuscular block and reversibility with sugammadex in a patient with myotonic dystrophy. Case Rep Anesthesiol 2012; 2012:107952. [PMID: 22606401 PMCID: PMC3350161 DOI: 10.1155/2012/107952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 02/07/2012] [Indexed: 12/16/2022] Open
Abstract
We report a patient with myotonic dystrophy who showed prolonged rocuronium-induced neuromuscular blockade, although with a fast recovery with sugammadex. During general anesthesia with propofol and remifentanil, the times to spontaneous recovery of the first twitch (T1) of train of four to 10% of control values after an intubating dose of rocuronium 1 mg/kg and an additional dose of 0.2 mg/kg were 112 min and 62 min, respectively. Despite the high sensitivity to rocuronium, sugammadex 2 mg/kg administered at a T1 of 10% safely and effectively antagonized rocuronium-induced neuromuscular block in 90 s.
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Abstract
Myotonic dystrophy (MD) is a rare genetic disorder with multisystem involvement characterised by myotonia and progressive muscle weakness and wasting. These patients pose significant challenges to the anaesthesiologist in view of the muscular and extramuscular involvement and sensitivity to anaesthetic drugs. The literature is replete with reports of postanaesthetic respiratory and cardiovascular complications in these patients. But an ideal anaesthetic technique in MD patients remains to be determined. Rapid recovery is desirable to reduce postoperative respiratory complications. Though there are a few case reports of maintenance of anaesthesia with isoflurane and sevoflurane, there are scanty reports of use of desflurane in these patients. We present successful management of a patient with MD for laparoscopic cholecystectomy using a carefully titrated desflurane-based anaesthesia and discuss the perioperative considerations.
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Affiliation(s)
- Ranju Gandhi
- Department of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India
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