Anaesthesia for patients with arthrogryposis multiplex congenita: what is the risk of malignant hyperthermia?

Perioperative care of the child with arthrogryposis

BACKGROUND

Arthrogryposis multiplex congenita (AMC) is a congenital symptom complex characterized by multiple joint contractures. AMC results from fetal akinesia due to extrinsic factors (oligohydramnios) or primary neurogenic or myopathic conditions of the fetus.

METHODS

We retrospectively reviewed our perioperative experience in 12 patients with AMC.

RESULTS

Intraoperative issues noted in our patients included difficulties with peripheral IV placement (n = 3), difficult tracheal intubation (n = 4), and intraoperative hyperthermia (n = 4). Difficulties with peripheral IV placement were more common in younger patients (2.3 +/- 0.6 vs 9.2 +/- 3.5 years). Although easy bag-valve-mask ventilation was present in all 12 patients, difficulty with tracheal intubation was noted in four patients. In these four patients, the airway was secured using an LMA (n = 3) or a facemask (n = 1). The patients in whom difficulties with tracheal intubation were encountered were older than patients in whom no difficulties were noted (11.0 +/- 2.9 vs 5.8 +/- 3.9 years). Four patients developed intraoperative temperatures > or =37 degrees C; however, there was no evidence of hypercarbia or tachycardia suggestive of malignant hyperthermia. Postoperative issues included stridor (n = 2) and postoperative atelectasis (n = 3).

CONCLUSIONS

The perioperative care of patients with AMC should consider not only the physical manifestations of the disease process, but also the implications of the underlying neuromuscular disease. The most common perioperative issues included difficulties with airway management, problematic intravenous access, and intraoperative hyperthermia.

Interscalene brachial plexus block for shoulder surgery in a patient with arthrogryposis multiplex congenita

A five-year-old child with severe arthrogryposis multiplex congenita and malnutrition underwent surgery for chronic osteomyelitis of the head of the left humerus. The child had typical features of arthrogryposis multiplex congenita, including a difficult airway. Propofol was used for induction and maintenance. Spontaneous respiration was maintained with a nasal airway. Analgesia was provided with an interscalene brachial plexus block placed using a nerve stimulator. No opioid was given. The child had an uneventful recovery with good postoperative analgesia. The anaesthetic implications of arthrogryposis multiplex congenita are discussed.

Intraoperative convulsions in a child with arthrogryposis

A case of intraoperative convulsions occurring in a child with arthrogryposis multiplex congenita is presented. Arthrogryposis and the anaesthetic management of children with this condition is discussed. Factors which may have contributed to the convulsions are considered.

Hypermetabolism in arthrogryposis multiplex congenita

Two patients who developed hypermetabolic reactions during anaesthesia and surgery and who were suffering from arthrogryposis multiplex congenita are reported and it is proposed that the reaction is distinct from malignant hyperthermia and independent of the anaesthetic agents used. The implications for anaesthetists involved in the management of patients with arthrogryposis multiplex congenita are discussed.