Anesth Analg 2000;90:224
© 2000 International Anesthesia Research Society
CASE REPORTS
The Prolonged Effect of a Muscle Relaxant in a Patient with Chronic Inflammatory Demyelinating Polyradiculoneuropathy
Koji Hara, MD,
Kouichiro Minami, MD, PhD,
Katsuhiro Takamoto, MD,
Munehiro Shiraishi, MD, and
Takeyoshi Sata, MD, PhD
Department of Anesthesiology, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
Address correspondence and reprint requests to Koji Hara, MD, Department of Anesthesiology, University of Occupational and Environmental Health, School of Medicine, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu, 807-8555, Japan. Address e-mail to kojihara{at}med.uoeh-u.ac.jp
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Introduction
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In 1975, Dyck et al. (1) first described chronic in- flammatory demyelinating polyradiculoneuropathy (CIDP). This disease is characterized as a predominantly symmetric sensorimotor neuropathy with a relapsing, chronic monophasic, or steadily progressive course, without the presence of an associated causal disease (2). Patients with this disease often have symptoms such as paresthesia and weakness of the proximal and distal muscles, including the respiratory muscles. No reports mention the anesthetic management of patients with CIPD. We found that vecuronium had a prolonged effect in a patient with CIDP during general anesthesia. In this report, we discuss the problems of anesthetic management for patients with CIDP.
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Case Report
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A 77-yr-old, 59-kg man, 173 cm tall, with early stage gastric cancer and gallstone, was scheduled for partial gastrectomy and cholecystectomy. At the age of 76 yr, he had complained of progressive paresthesia and muscle weakness in his extremities and his condition was diagnosed as CIDP, according to the criteria of an Ad Hoc Subcommittee of the American Academy of Neurology AIDS Task Force. These criteria are based on the four features: clinical, physiologic, pathologic, and cerebrospinal fluid studies (3). On admission to our hospital, he was unable to walk without a walker. His respiratory function was adequately preserved: % vital capacity and the ratio of forced expiratory volume in 1 s to forced vital capacity were 90% and 88%, respectively. Liver and renal functions were normal.
The patient was not premedicated preoperatively. To assess the effect of the muscle relaxant, skin electrodes were attached to the wrist before the induction of anesthesia. Neuromuscular monitoring was performed using an electromyograph (Relaxograph; Datex, Helsinki, Finland) to record the contractions of the adductor pollicis muscle to train-of-four (TOF) supramaximal stimulation (2 Hz) of the ulnar nerve every 20 s (Figure 1). Anesthesia was induced with 50 mg propofol. After control twitch height became stable, 6 mg vecuronium was administered IV. Onset time (time from injection to achieve a maximal depression of T1) of vecuronium was approximately 2 min. His trachea was intubated uneventfully 3 min after the injection. Anesthesia was maintained by using nitrous oxide (60%) and isoflurane (1%–1.5%) in oxygen. His body temperature remained between 36.7° and 36.3°C during the operation. No electrolyte abnormalities were seen. When the T1% (a percentage of prevecuronium control) recovered to over 40%, approximately 110 min after the first vecuronium injection, 1 mg vecuronium was administered. Because the T1% recovered to 50% 140 min after the second dose, a third injection of 1 mg vecuronium was given. After the partial gastrectomy, the cholecyst was manually explored for the gallstone. Because the gallstone was not detected, cholecystectomy was abandoned and the operation ended unexpectedly early 15 min after a third injection. After the operation, we started controlled ventilation using 0.6% isoflurane in oxygen. It took 50 min for spontaneous respiration. After anesthesia was discontinued, neostigmine 1 mg and atropine 0.5 mg were administered IV. At this time, T1% and the TOF ratio were 40% and 25%, respectively. After another 10 min, T1% and the TOF ratio returned to 100%, and the endotracheal tube was removed. Considering possible recurarization, the patient was transferred to the recovery room and observed overnight. The postoperative course was uneventful.
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Figure 1. The effect of vecuronium in a patient with chronic inflammatory demyelinating polyradiculoneuropathy. Train-of-four is performed by delivering four supramaximal stimulation (2 Hz) of the left ulnar nerve at the wrist every 20 s. The contraction of the adductor pollicis muscle was recorded with a neuromuscular blockade monitor (Datex, Relaxograph). The duration of action of vecuronium was prolonged compared to normal patients.
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Discussion
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CIDP is a chronic neuropathy thought to be mediated by the immune system, although its etiology is not well known. It is a very rare disease, whose incidence is estimated to be <1:100,000 in Japan (4). The disease is distinct from Guillain-Barré syndrome, which is an acute inflammatory demyelinating polyradiculoneuropathy. In CIDP, the muscle atrophy is usually mild, while the reflexes are often depressed or absent. An autonomic nervous system disorder is rarely present.
When 0.1 mg/kg vecuronium is administered in normal patients under isoflurane anesthesia, previously reported values of the time from injection to 25% recovery of T1 are 38 ± 7 (5), 39 ± 15 (6), and 41 ± 5 (7) min (mean ± SD). In our case, the time to 25% recovery was approximately 80 min (Figure 1), suggesting a prolonged effect of vecuronium. It is well known that the effects of muscle relaxants are prolonged in conditions such as hypothermia and electrolyte abnormalities and with the use of aminoglycoside antibiotics (8). In this patient, body temperature and electrolytes were normal and antibiotics were not used during the operation. Aging also may affect the duration of vecuronium. At present, the effect of age on vecuronium-induced neuromuscular blockade remains controversial. Some investigators have shown that duration of vecuronium in elderly patients is prolonged approximately 40% as compared with young patients (9,10). In contrast, several reports indicate that there is no significant difference between young and elderly patients (11–13). Rupp et al. (14) concluded that "healthy elderly patients do not appear to represent a population distinctly different from younger adults in their pharmacokinetic/pharmacodynamic response." Because our patient had normal hepatic and renal function, there appeared to be no marked delay of elimination of the drug. Neostigmine effectively reversed the effect of vecuronium in this case. Previous reports have shown that patients with lower motor neuron lesions are hypersensitive to nondepolarizing muscle relaxants, such as d-tubocurarine (15). Of interest, patients with Guillain-Barré syndrome are susceptible to nondepolarizing muscle relaxants (16). Recently, Ifuku et al. (17) reported that the effects of vecuronium were prolonged in a patient with Crow-Fukase syndrome, which is a type of polyneuropathy. Similar findings were observed in our patient with CIDP. In our case, the recovery process monitored with a electromyograph indicated an unusual pattern, i. e., the TOF ratio returned to 100% before the T1 height recovered to control. It is unclear whether this finding arose from pathophysiology of CIDP.
Patients with CIDP tend to suffer from respiratory tract infections (2). Therefore, postoperative respiratory dysfunction may increase the risk of this complication. We recommend that any muscle relaxant be administrated carefully, in small divided doses, while monitoring the effect of the drug. A depolarizing muscle relaxant may induce cardiac arrest as a result of hyperkalemia in patients with motor neuron involvement (18,19). Therefore, succinylcholine should be avoided in such patients.
To avoid the use of muscle relaxants, regional anesthesia may be used. However, McGrady (20) reported the case of a pregnant woman with Guillain-Barré syndrome, in whom very small doses of local anesthetic were sufficient for epidural anesthesia during a caesarian delivery. The epidural anesthesia might exacerbate the syndrome. Furthermore, epidural anesthesia may trigger demyelinating neuropathy (21). Therefore, it is uncertain whether local anesthetics affect the neuronal lesions. Some patients may benefit from the use of epidural opioids (22).
In summary, we gave general anesthesia to a patient with CIDP. The effect of muscle blockade may be prolonged in patients with this disease, and such drugs should either not be used or be used with smaller doses.
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References
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Accepted for publication September 20, 1999.
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Introduction
Case Report
