AJA Asian Journal of Anesthesiology

Advancing, Capability, Improving lives

Letter to the Editor
Volume 51, Issue 1, Pages 49
Satoshi Shimizu 1 , Seishou Kawashima 1 , Katsuhiro Seo 1
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Outline



To the Editor,

Progressive supranuclear palsy (PSP) is a rare neurodegenerative disease. Its principal clinical features are gait instability, supranuclear gaze palsy, truncal dystonia with a cervical backward tilt, pseudobulbar palsy, Parkinsonism, and cognitive impairment. The incidence of this disease is approximately 6 per 100,000 persons.12 So far, only a few anesthetic cases with PSP have been reported.

A 70-year-old male with rapidly progressive cyanosis due to severe arteriosclerosis obliterans was scheduled for an elective above-knee amputation. He had recently been diagnosed with PSP. Treatment with antiparkinson and antidepressant agents had not yet been initiated. Blood examination revealed elevated white blood cell count (17,300/μL), C-reactive protein (24.6 mg/dL), and creatine phosphokinase (9973 IU/L). Chest radiography, electrocardiography, and transthoracic echocardiography were normal. Computed tomography of the head revealed diffuse cerebral atrophy. Physical examination showed neck rigidity. General anesthesia, which was selected because of the patient's cognitive dysfunction, was induced with propofol (150 mg), and maintained with sevoflurane in O2 (2%) and fentanyl (a total of 200 μg). Owing to difficult airway management, we used a size 4.0 ProSeal laryngeal mask airway to convey the anesthetic gas. A gastric tube was then inserted through the drain tube of the ProSeal laryngeal mask airway to empty the stomach, in order to minimize the risk of pulmonary aspiration during anesthesia. We did not use muscle relaxants and allowed the patient to breathe spontaneously. Fentanyl (50 μg) was administered intermittently to maintain the respiratory rate at 10–15 times per minute. The Bispectral Index was monitored as an indicator of proper sedation. Emergence from anesthesia was not delayed, and postoperative pain was controlled adequately. Surgical duration was 35 minutes, and the duration of anesthesia was 1 hour and 13 minutes.

Several considerations are required for PSP patients undergoing general anesthesia. First, tools for alternative techniques for the management of potentially difficult airway, such as a laryngeal mask airway, a fiberoptic or video laryngoscope, or a surgical airway, must be prepared. Sakai and Sumikawa2 reported an anesthetic case of a PSP patient, who was eventually tracheotomized because of severe neck deformity. Second, as pseudobulbar palsy may cause postoperative aspiration with subsequent pneumonia, clear emergence from anesthesia is favorable. Monitoring the Bispectral Index may be helpful for avoiding excessive sedation. Third, because PSP affects the function of the central nervous system, effects of the anesthetics may be altered. Our patient showed no significant sensitivity to the anesthetics; however, the degree of sensitivity may vary if the disease is more advanced or the surgical procedure is more invasive. Also, antiparkinson or antidepressant drugs and anesthetics may have significant interactions.3 Considering the potential problems described above, regional anesthesia may provide some advantages over general anesthesia in avoiding these potential problems. Adequate analgesia provided by regional anesthesia may help avoid the symptoms of confusion and disorientation. However, regional anesthesia may not always be appropriate for those who are uncooperative. Finally, some specific considerations are required for patients taking antiparkinson drugs. Because levodopa has a short half-life (1–3 hours), even a brief interruption of dosing during a long procedure may lead to an exacerbation of skeletal muscle rigidity.3 Also, levodopa may cause severe perioperative hypotension.4

In conclusion, we report the setting of general anesthesia in a patient with PSP. We used a laryngeal mask for its potential in the management of difficult airway. Careful monitoring of the Bispectral Index was helpful for the appropriate titration of sedation, and ensuring a clear emergence from general anesthesia to avoid postoperative aspiration was imperative.


References

1
L.I. Golbe
Progressive supranuclear palsy
Curr Treat Options Neurol, 3 (2001), pp. 413-477
Article  
2
K. Sakai, K. Sumikawa
Anesthetic management of a patient with progressive supranuclear palsy
J Anesth, 20 (2006), pp. 312-313
3
L.J. Mason, T.T. Cojocaru, D.J. Cole
Surgical intervention and anesthetic management of the patient with Parkinson's disease
Int Anesthesiol Clin, 34 (1996), pp. 133-150
4
L.I. Goldberg
Levodopa and anesthesia
Anesthesiology, 34 (1971), pp. 1-3

References

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