Anesthetic implications of muscular dystrophies:

Regional anesthesia and muscle-wasting diseases in pediatrics: A focused educational review

The muscular dystrophies or muscle-wasting diseases include a diverse group of genetic disorders, which result in progressive degeneration of skeletal muscles, progressive muscle weakness, and comorbid multi-system involvement. Duchenne muscle dystrophy is the most common type of muscular dystrophy with a reported incidence of 1 in every 3500-6000 male live births in the United States. Given the progressive nature of these disorders, skeletal muscle weakness frequently progresses to loss of the ability to ambulate and perform functions of daily life. In addition to affecting the skeletal musculature, many muscular dystrophies have effects on both cardiac and smooth muscles. As respiratory muscles are one of the most frequently affected muscles in patients with muscular dystrophies, progressive respiratory insufficiency may occur with dependance on non-invasive forms of respiratory support. Given the progressive multi-system involvement associated with the muscular dystrophies, perioperative care and the use of general anesthetic agents and opioids may result in postoperative respiratory failure. In an effort to avoid the deleterious effects of anesthetic agents and opioids on hemodynamic and respiratory functions, regional anesthesia may be used as an adjunct to or instead of general anesthesia. This manuscript provides a literature review and educational summary regarding the use of regional anesthetic techniques in pediatric-aged patients with muscular dystrophies.

Implication of Corneal Refractive Surgery in Duchenne Muscular Dystrophy

Duchenne muscular dystrophy (DMD) is an X-linked disorder due to a dystrophin mutation and is the leading cause of muscular dystrophy. DMD presents with characteristic systemic effects, including severe muscular atrophy, cardiomyopathy, and ocular manifestations. Performing corneal refractive surgeries in patients with DMD raises concerns regarding patient positioning, risk of cataracts, and other comorbid conditions. Published reports of photorefractive keratectomy, laser-assisted in situ keratomileuses, and small incision lenticule extraction are lacking in this population. Here, we discuss a patient being evaluated for a corneal refractive surgery. This article also discusses the current understanding of DMD, known ocular manifestations, and factors to consider when evaluating a patient for potential corrective vision laser surgery.

A difficult airway approach in a merosin-deficient congenital muscular dystrophy patient: a case report

Merosin-deficient muscular dystrophy is caused by an autosomal recessive mutation on laminin-..2 gene characterized by severe progressive muscle weakness associated with neuromuscular scoliosis and restrictive lung disease. In this case report, we describe an alternative airway approach performed in a child with anticipated difficult airway and merosin-deficient muscular dystrophy. Significant anesthetic implications may increase the perioperative risk, requiring accurate knowledge to anticipate an adequate management and provide patient-safety strategies.

Mapping the current evidence on the anesthetic management of adult patients with neuromuscular disorders-a scoping review

PURPOSE

Patients with neuromuscular disorders (NMDs) are at increased risk of perioperative complications. The objective of this scoping review was to examine emerging evidence from published studies, case reports, and review articles on anesthetic management of patients with NMDs, following the methodological frame for scoping reviews.

SOURCES

We searched PubMed and EMBASE for articles published between 1 January 2000 and 14 July 2021.

PRINCIPAL FINDINGS

Three prospective and 21 retrospective studies on altered pharmacokinetics and pharmacodynamics of neuromuscular blocking agents (NMBA) in NMD patients were included. Furthermore, 168 case reports/series reporting 212 anesthetics in 197 patients were included. These studies showed that preanesthetic neuromuscular monitoring can be used for precise NMBA dosing in myasthenia gravis patients. Sugammadex was associated with fewer postoperative myasthenic crises. Perioperative complications were not associated with specific anesthetic agents. Case reports/series showed that in 32% (67/212) of anesthetics, at least one complication was reported. Unexpected intensive care unit admission was a frequently reported complication. Patients with a complicated disease course may have had a higher use of succinylcholine (unadjusted relative risk, 0.13; 95% confidence interval [CI], 0.20 to 0.86) and volatile anesthetics (adjusted odds ratio [OR], 0.38; 95% CI, 0.20 to 0.73; P = 0.004).

CONCLUSION

Evidence on the anesthetic management and perioperative complications of patients with NMDs is mainly based on small retrospective studies and case reports. Further clinical trials or large retrospective studies are required to investigate the choice of safe anesthetic agents. Main areas of interest are the potential benefits of neuromuscular monitoring and sugammadex and the risks possibly associated with volatile anesthetics and succinylcholine.

Laparoscopic cholecystectomy under total intravenous anaesthesia in a patient with myotonic dystrophy type 1 (Steinert’s disease) – a case report

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.

Facioscapulohumeral muscular dystrophy-Reproductive counseling, pregnancy, and delivery in a complex multigenetic disease

Reproductive counseling in facioscapulohumeral muscular dystrophy (FSHD) can be challenging due to the complexity of its underlying genetic mechanisms and due to incomplete penetrance of the disease. Full understanding of the genetic causes and potential inheritance patterns of both distinct FSHD types is essential: FSHD1 is an autosomal dominantly inherited repeat disorder, whereas FSHD2 is a digenic disorder. This has become even more relevant now that prenatal diagnosis and preimplantation genetic diagnosis options are available for FSHD1. Pregnancy and delivery outcomes in FSHD are usually favorable, but clinicians should be aware of the risks. We aim to provide clinicians with case-based strategies for reproductive counseling in FSHD, as well as recommendations for pregnancy and delivery.

Perioperative Pulmonary Optimization With Average Volume-Assured Pressure Support of a Pediatric Patient With Ullrich Congenital Muscular Dystrophy: A Case Report

Patients with preexisting respiratory compromise are at risk for perioperative respiratory failure. Adult literature has shown benefit with prophylactic postoperative use of noninvasive mechanical ventilation (NIMV). While pediatric literature has documented the increasing use of postoperative NIMV, there is no literature on prophylactic preoperative NIMV in patients with preexisting respiratory compromise. Further, surgical literature does not address preoperative prophylactic use of NIMV, as well as use of the newest modality of NIMV, average volume-assured pressure support (AVAPS). Here, we describe the first report of pre- and postoperative use of AVAPS in a pediatric patient with respiratory compromise from Ullrich disease.