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