Department of Anesthesiology, Fukuoka University School of Medicine, Fukuoka, Japan
*Corresponding author. E-mail: nitahara@fukuoka-u.ac.jp
Accepted for publication: July 17, 2003
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Abstract |
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Br J Anaesth 2004; 92: 4323
Keywords: anaesthetic techniques, epidural; complications, genetic disease, X-linked; complications, Kennedys disease; complications, motor neuron disease, lower
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Introduction |
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Case report |
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After detailed discussion and with the agreement of the patient, management by epidural anaesthesia was chosen. The patient was premedicated with roxatidine (H2-blocker), 75 mg, post-orally. An epidural catheter was inserted at the L34 interspace and directed 5 cm cephalad. Epidural anaesthesia was established by injecting 10 ml of mepivacaine 2% via the catheter after a test dose of 3 ml of 2% mepivacaine, achieving a sensory block extending to T10. Oxygen was administered through a facemask at 5 litre min1. An additional increment of mepivacaine 2% (5 ml) was given epidurally during the operation. Throughout this period, ECG was normal, SpO2 greater than 98%, and the patient had no respiratory discomfort. The postoperative course was uneventful, and there was no exacerbation of neurologic signs or symptoms.
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Discussion |
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The problem areas associated with anaesthetic management of patients with Kennedys disease are not fully clarified. However, patients with bulbar involvement with dysfunction of pharyngeal muscles may be predisposed to regurgitation and aspiration. General anaesthesia depresses the swallowing reflex and may further increase the risk of pulmonary aspiration.6 The use of neuromuscular blocking agents is also a major concern in anaesthetic management in a patient with motor neuron disease. Although, in Kennedys disease, it is not clear whether succinylcholine causes a hyperkalaemic response, it seems that the use of succinylcholine should be avoided because of possible unpredictable side effects. Decreased levels of acetylcholine may increase a patients sensitivity to non-depolarizing neuromuscular blocking agents in motor neuron disease.7 Taking into account the various disadvantages of general anaesthesia and the use of neuromuscular blocking agents in patients with motor neuron diseases, we chose epidural anaesthesia for our patient.
When neuraxial block is chosen, it is important to select an appropriate level as a sensory block above T6 decreases the expiratory reserve volume, leading to reduced clearance of secretions from the airway.8 We used 3 ml of mepivacaine 2% as a test dose and then followed by 10 ml. The highest anaesthetic level in our case was T10 and the patient experienced no respiratory discomfort.
Exacerbation of pre-operative neurological impairment after neuraxial block has been reported.9 However, there have been no reports of deterioration of pre-existing neurological function after epidural anaesthesia in patients with lower motor neuron diseases. Epidural anaesthesia has been successfully administered to patients with amyotrophic lateral sclerosis without neurological exacerbation or impairment of pulmonary function.10
In summary, we managed a patient with Kennedys disease by epidural anaesthesia without exacerbation of neurological signs or symptoms. Although there is no evidence that any specific anaesthetic technique or drug in particular is best for patients with this disease, we suggest that it may be successfully managed with epidural anaesthesia in the surgical procedure of an internal urethrotomy.
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Acknowledgements |
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References |
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