Print Email  

Surgery and Anesthesia

Surgery & Anesthesia

When a patient with Duchenne muscular dystrophy has general anesthesia, a number of issues should be considered.

Considerations for Surgery & Anesthesia

  • If possible, go to a medical center with expertise in the anesthetic management of people living with Duchenne.
  • Cardiac (heart) and respiratory (lung) abnormalities should be identified and optimally treated before any surgery/procedure involving anesthesia.
  • Tell the anesthesiologist that you/your child has muscular dystrophy.
  • Discuss the anesthesia plan with the anesthesiologist before any surgery/procedure that involves anesthesia.
  • People with Duchenne should NOT receive succinylcholine.
    • Succinylcholine is sometimes used in emergencies to relieve breathing difficulties in anesthetized patients, but when administered to patients with any kind of ongoing muscle atrophy, no matter the underlying cause, succinylcholine can cause severe, life-threatening (and sometimes fatal) increases in blood potassium. Learn more.
  • If possible, inhalational anesthetic gases should be avoided.
    • People with Duchenne are at risk of developing rhabdomyolysis, the breakdown of skeletal muscle tissue that may cause the release of myoglobin that can damage the kidneys, and hyperkalemia, the release of too much potassium into the bloodstream, which can result in life-threatening heart rhythms. Rhabdomyolysis has been reported with inhaled anesthesia (except nitrous oxide which is safe) but not with IV anesthesia. Learn more.
  • Review guidelines on Safe and Unsafe Anesthetics for people with Duchenne.
  • Patients should be monitored closely when receiving any anesthesia.

Safe and Unsafe Anesthetics

These recommendations have been reviewed and approved by the Professional Advisory Council of the Malignant Hyperthermia Association of the U.S. (MHAUS). Discuss risks and benefits of planned anesthetic medications (agents) with your anesthesiologist.

NEVER USE

Never Use

Depolarizing Muscle Relaxants

Succinylcholine (Suxamethonium)

 

People with Duchenne should not receive succinylcholine! Succinylcholine is sometimes used in emergencies to relieve breathing difficulties in anesthetized patients, but when administered to patients with any kind of ongoing muscle atrophy, no matter the underlying cause, succinylcholine can cause severe, life-threatening (and sometimes fatal) increases in blood potassium.

Instead of succinylcholine there are other commonly available muscle relaxants (e.g., any non-depolarizing neuromuscular blocker) that can be used in emergency situations if necessary (see the “Safe” list section below). It is possible, however, that there exists a rare situation (such as life-threatening airway obstruction that requires immediate treatment) where an anesthesiologist may be justified in administering succinylcholine to a patient with Duchenne whose life is in imminent danger.

AVOID IF POSSIBLE

Avoid if Possible

Inhaled Anesthetic Agents

Desflurane, Enflurane, Halothane, Isoflurane, Sevoflurane

 

People with Duchenne are at risk of developing rhabdomyolysis (the breakdown of skeletal muscle tissue that may cause the release of myoglobin that can damage the kidneys) and hyperkalemia (the release of too much potassium into the bloodstream), which can result in life-threatening heart rhythms. There are known cases of serious (and sometimes fatal) muscle breakdown (rhabdomyolysis) in Duchenne patients when exposed to inhalation anesthetic gases even when succinylcholine was avoided. Therefore, we recommend, that when possible, inhalational anesthetic gases should be avoided or used sparingly in people with Duchenne (unless the benefit/risk ratio favors their use in certain circumstances).

Why not just completely avoid inhalational gas anesthesia in all Duchenne patients? Inhalation anesthesia may be suggested for the following reasons:

  • Prior to IV catheter insertion to:
    • Reduce the pain of an IV insertion: inserting the IV can be painful, and it is sometimes more difficult to find veins in patients with decreased muscle mass.
    • Reduce the pain of IV propofol: the IV anesthetic agent, propofol, is painful when it starts going into a patient’s vein.
  • There may be rare situations where IV anesthesia is not available, or is considered an inferior anesthetic choice based on the patient’s specific clinical situation.

SAFE TO USE (WITH CLOSE MONITORING)
All intravenous (IV) anesthetic agents are considered to be safe to use with close monitoring.  

Safe to Use

Barbiturates/Intravenous Anesthetics

Diazepam (valium), Etomidate (Amidate), Ketamine (Ketalar), Methohexital (Brevital), Midazolam (Versed), Propofol (Diprivan), Thiopental (Pentothal)

Inhaled Non-Volatile General Anesthetic

Nitrous Oxide

Local Anesthetics

Amethocaine, Articaine, Bupivicaine, Etidocaine, Lidocaine (Xylocaine), Levobupivacaine, Mepivicaine (Carbocaine), Procaine (Novocain), Prilocaine (Citanest), Ropivacaine, Benzocaine (caution re: methemoglobinemia risk), Ropivacaine

Narcotics (Opioids)

Alfentanil (Alfenta), Codeine (Methyl Morphine), Fentanyl (Sublimaze), Hydromorphone (Dilaudid), Meperidine (Demerol), Methadone, Morphine, Naloxone, Oxycodone, Remifentanil, Sufentanil (Sufenta)

Muscle Relaxants

Arduan (Pipecuronium), Curare (The active ingredient is d-Tubocurarine), Metocurine, Mivacron (Mivacurium), Neuromax (Doxacurium), Nimbex (Cisatracurium), Norcuron (Vecuronium), Pavulon (Pancuronium), Tracrium (Atracurium), Zemuron (Rocuronium)

Anticonvulsants

Gabapentin (Neurontin), Topiramate (Topamax)

Anxiety Relieving Medications

Ativan (Lorazepam), Centrax, Dalmane (Flurazepam), Halcion (Triazolam), Klonopin, Librax, Librium (Chlordiazepoxide), Midazolam (Versed), Paxipam (Halazepam), Restoril (Temazepam), Serax (Oxazepam), Tranxene (Clorazepate), Valium (Diazepam)

 

Dental Dilemmas

  • Dentistry generally can, and should, be performed with the minimal amount of anesthesia possible while providing the patient maximal physical and emotional comfort.
  • Local anesthetics, nitrous oxide, and an oxygen “wash out” are safe for most patients with Duchenne, especially patients who are ambulatory with normal pulmonary function (normal breathing).
  • Patients with Duchenne who have pulmonary dysfunction (abnormal breathing) should consider receiving dental care requiring general anesthesia in a hospital or surgery center staffed with an anesthesiologist, and equipped to monitor intra-operative respiratory functioning and to manage potential respiratory and cardiac emergencies.
  • Learn more about dental care considerations in Duchenne.

Related links

Emergency Care Information
Care Guidelines

Connects
Facebook YouTube Twitter
How We Help



Our family-centered approach is at the heart of everything we do. Learn more.

Quick Links

Fund Research

Quick Links
PPMD Sites

new amazon banner small inner pages

Let's seize this moment.

  DAYS   HOURS   MINUTES   SECONDS
REMAINING!
 

There has never been so much momentum in the Duchenne community. Help us keep moving forward by donating to fund CRISPR/Cas9 gene‑editing technology. Every gift to PPMD is being doubled until we raise $250,000—but we have to reach this goal by 12/31!

]]