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Anesthetic Management for the Severely Decompensated ALS Patient:
Three Different Anesthetics During a Single Hospitalization
Courtney L. Scott (DO); Whitney W. McLeod (MD); Robert L. McClain (MD);
Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida 32224, USA
Amyotrophic Lateral Sclerosis (ALS) patients presenting for procedures requiring anesthesia introduce uncommon challenges to the anesthesiologist. With a prevalence of of approximately 1.5-2.7 per 100,000 persons, ALS is a rare disease with myriad presentations. Motor dysfunction due to upper and lower motor neuron disease leads to increased risk of aspiration and respiratory complications both at baseline and in the peri-operative period.
Case reports of anesthetic management for ALS patients are available, but recommendations for anesthetic technique are difficult to support with robust data. While our department regularly works with ALS patients with advanced disease, we less commonly provide multiple anesthetics for a single ALS patient in a short timeframe. We present one patient who required three procedures during one 28 day hospitalization,for which she successfully underwent three different anesthetic techniques.
Anesthetic plan: Maintain spontaneous ventilation with moderate sedation and place a T10/T11 thoracic epidural.
Intraoperatively: Sedation: dexmedetomidine and propofol infusions. Epidural: 2% lidocaine boluses. Airway: CPAP via face mask.
Postoperatively: Patient tolerated the procedure without obvious pain or respiratory depression and was transferred to the intensive care unit (ICU) for further observation.
Anesthetic plan: General anesthesia with endotracheal intubation
Intraoperatively: Induction: propofol, rocuronium and fentanyl. Maintanence: propofol infusion, fentanyl as needed.
Postoperatively: Taken to ICU and successfully extubated 14 hours later. She continued to have nausea and vomiting with persistent ileus
Anesthetic plan: Thoracic (T6-8) paravertebral block bilaterally
Intraoperatively: Patient required fluid and pressor boluses for hemodynamic support but did not require sedation or opioids.
Postoperatively: Patient regained bowel function and was discharged to home 10 days after gastrostomy tube placement.
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