Anesthetic management of a patient with amyotrophic lateral sclerosis for transurethral resection of bladder tumor
We report anesthetic management of a patient with ALS who presented for transurethral resection of the bladder tumor (TURBT).\nA 45-year-old male presented with a history of hematuria for 2 weeks. Cystoscopy revealed papillary growth 1 × 0.5 cm on the left side of bladder base, extending to the left wall. He was diagnosed to have ALS four years ago, when he had developed a slow onset, progressive, asymmetric weakness of upper limbs and lower limbs with associated difficulty in walking. He was a non-smoker with no other co-morbid illnesses. Neurologically, he had spasticity of upper and lower limbs with exaggerated tendon reflexes. His motor power was grade 3 (MRC grading)[] in upper limbs and grade 4 powers in lower limbs [] and associated hand muscle weakness with widespread fasciculations. He was bradykinetic with resting tremors of all extremities. There was no evidence of bulbar dysfunction or truncal weakness.\nPreoperative examination demonstrated ineffectual cough, with borderline peak expiratory flow rate (450 L/min), and reduced breath sounds in both lung bases. Further pulmonary function test showed a restrictive pattern with low vital and total lung capacity with preserved flow rates (FVC: 60% of normal; FeV1: 58% of normal; FEV1/FVC: 96%). Blood investigations including serum electrolytes were normal (s.Na+: 134 mmol/L; s.K+: 4.9 mmol/L; s. HCO3 –20 mmol/L).\nHis regular medications which included Syndopa, Ropinirole, Clonazepam, Amitriptyline and Trihexyphenidyl were continued till the morning of surgery.\nA combination of general anaesthesia without muscle paralysis and a regional block was planned for surgery. Informed consent was obtained prior to the procedure and he was fasting to solids for 6 h and to water for 2 h. No premedication was given.\nGeneral anaesthesia was induced with propofol 2 mg/kg and fentanyl at 1 mcg/kg via a 20-gauge IV cannula. Ventilation was assisted with a mixture of air–oxygen and isoflurane. Ensuring adequate depth of anaesthesia, airway was secured with size 4 laryngeal mask airway (LMA). Anaesthesia was maintained on 50-50 mixture of air–oxygen with isoflurane on spontaneous respiration.\nBilateral obturator block with 15 mL of 0.5% hyperbaric bupivacaine on each side was performed after LMA insertion. A nerve stimulator was used for eliciting adductor response between current of 0.4-0.6 mA. No drug interactions were observed. Surgery lasted for one hour, during which he received 400 mL of Ringer lactate solution. At end of the procedure, patient was extubated awake. He had an uneventful recovery in the post-operative period and was discharged on the third post-op day.