MND and minor surgery

Gabrielle Morris

60yr old male with a large tender SCC on his chest.

Background:

  • Motor neurone disease
    • Diagnosed 2011
    • Bed bound, wheelchair dependent
    • Bulbar palsy, cannot lie flat (will aspirate), requires suctioning even in semi-recumbent position
    • Full PEG feeds
    • Continuous BiPAP
    • Reasonable QoL, enjoys spending time with his supportive family
  • Ex smoker
  • IHD – AMI 2015, managed medically
  • HTN

Issues

  • Should surgery proceed
    • While this gentleman has limited life expectancy the lesion is painful and growing (currently ? 5x5cm)
    • Surgeon confident the procedure can occur under LA, including the graft donor site.
    • With both patient and surgeon very motivated to do the procedure under LA and to work under challenging conditions, high likelihood of success. 
  • Advanced care planning
    • Complex discussion. Not previously documented or formalised by patient.
    • The patient would ‘like one shot at dying’ meaning if he is in a situation where he has substantially deteriorated he does not want active resuscitation.
    • However, he may consider brief periods of additional support (e.g. intubation) if he had deteriorated but not to the extent of, for example, losing consciousness, and if he had a chance to return to his current level of function and disability.
    • This is very fine distinction and requires ongoing thought from the patient between now and surgery, and further discussions between the anaesthetist and patient on the day of surgery.
  • Level of postoperative care
    • Ideally this man will have his procedure under LA and return home to his well-supported home environment. No ICU bookings made.

Discussion

Motor neurone disease

  • AKA amyotrophic lateral sclerosis
  • Progressive dx characterized by degeneration of motor neurons within cortical, brainstem and ventral cord locations.
  • Combination of upper and lower motor neurons involved.
  • Focus of care is palliative and symptom control, including respiratory and nutritional support.
  • Riluzole is an anti-glutamate medication used for symptom control

Perioperative pharmaceutical implications of MND

  • Baclofen, diazepam and dantrolene may be used for spasticity
  • Abrupt cessation of baclofen may cause an MH-like crisis.
  • Avoid depolarising neuromuscular blockers
  • Use heavily reduced non-depolarising neuromuscular blocker doses (and a PNS to guide use).
  • Consider higher doses of rocuronium and sugammadex for PNS-guided full reversal.
  • No association with MH, volatile anaesthesia safe to use.

Plan:

  • Proceed to OT under LA
  • Clinic anaesthetist to discuss with procedural anaesthetist once OT date and allocations known
  • Aim to d/c home same day
  • Further clarification of advanced care plan between procedural anaesthetist and patient