Year : 2007 | Volume
: 51 | Issue : 1 | Page : 43--46
Anaesthetic Management for Laparoscopic Cholecystectomy in two patients with biopsy proven Polymyositis
Shikha Sharma1, Lakshmi Jayaraman2, Nitin Sethi3, Jayashree Sood4,
1 M.D. Asso. Consultant, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi - 110 060, India
2 M.D., Jr. Consultant, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi - 110 060, India
3 D.N.B., Sr. Resident, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi - 110 060, India
4 M.D., FFARCS, PGDHHM, Sr. Consultant and Chairperson Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi - 110 060, India
D-195 Sushant Lok, Gurgaon -122002, Haryana
Two patients aged 46 and 31 years with biopsy proven polymyositis presented for laparoscopic cholecystectomy. They gave history of fall while walking and difficulty in climbing stairs. There were clinical features of peripheral muscle weakness but no respiratory muscle involvement. They were being managed conservatively.Pre-operative investigations were within normal limits. They received no sedation preoperatively. Anaesthesia was induced with 1-1.5 mgkg-1 of propofol and ProSeal laryngeal mask airway was inserted under propofol anaesthesia in case 1 and after atracurium besylate 10 mg I.V. in case 2. Anaesthesia was maintained with a continuous infusion of propofol, bolus dose of fentanyl and nitrous oxide in oxygen. Bispectral index (BIS) was monitored and maintained between 40-60.
Anaesthesia was reversed with neostigmine 2.5 mg and glycopyrrolate 0.4 mg. BIS values returned to pre-anaesthetic level of 80-90 after 5-10 min, suggesting that use of propofol, ProSeal Laryngeal Mask Airway and atracurium besylate with peripheral nerve monitoring can be a safe means of inducing and maintaining anaesthesia in patients with polymyositis.
|How to cite this article:|
Sharma S, Jayaraman L, Sethi N, Sood J. Anaesthetic Management for Laparoscopic Cholecystectomy in two patients with biopsy proven Polymyositis.Indian J Anaesth 2007;51:43-46
|How to cite this URL:|
Sharma S, Jayaraman L, Sethi N, Sood J. Anaesthetic Management for Laparoscopic Cholecystectomy in two patients with biopsy proven Polymyositis. Indian J Anaesth [serial online] 2007 [cited 2020 Oct 22 ];51:43-46
Available from: https://www.ijaweb.org/text.asp?2007/51/1/43/61114
Polymyositis is a subacute inflammatory myopathy affecting adults and rarely, children. This disorder presents as progressive and often symmetric muscle weakness. It is also associated with various extramuscular manifestations such as pulmonary dysfunction due to thoracic muscle weakness and cardiac disturbances such as atrioventricular conduction defects, congestive heart failure and myocarditis.  In addition these patients may be on long term steroid therapy. The major concerns for the anaesthesiologist are delayed recovery from muscle relaxation, aspiration pneumonitis, arrhythmias, cardiac failure and steroid supplementation with its complications.  There are case reports in literature wherein anaesthetic management has been carried out avoiding muscle relaxants altogether either for intubation or for maintenance.  Other authors have suggested safe usage of muscle relaxants in conjuction with neuro muscular monitoring.  We present here the successful anaesthetic management of two cases of polymyositis scheduled for laparoscopic surgery. Ohta M et al  have reported anaesthetic management of two patients suffering from polymyositis, in one of which no muscle relaxation was used for endotracheal intubation and maintenance of anaesthesia. Ukei M et al  have suggested the use of neuromuscular blockers in these patients in conjunction with a peripheral neuromuscular monitor. The aim of our presentation is to highlight perioperative anaesthetic care and management of the associated complications in patients presenting with this rare entity.
A 46 year-old-female patient with muscle biopsy proven diagnosis of polymyositis had an attack of acute cholecystitis and was posted for laparoscopic cholecystectomy.
She gave family history of polymyositis and had progressive muscle weakness for two years with difficulty in walking and performing activities against gravity like lifting objects. She also gave history of sudden falls while walking. She had difficulty in performing day to day tasks requiring use of proximal muscles such as getting up from chair, climbing steps, lifting objects and combing hair etc. She could however perform functions like buttoning a shirt, writing etc. She had temporary loss of voice many times and recent onset dysphagia. Her sensory system was intact and tendon reflexes were preserved. She was also diagnosed as a patient of hypothyroidism one year back and was taking tablet thyroxin daily.
Her haemotological and biochemical parameters were normal with CPK of 83. Her thyroid function tests were normal. EMG was suggestive of myopathy and ECHO showed mitral valve prolapse (MVP).
After premedication with oral metaclopromide 10 mg and ranitidine 150 mg on the day of surgery, the patient was wheeled in the operating room and anaesthesia was induced with propofol 80 mg, fentanyl citrate 60 mg and midazolam 1 mg intravenously. Propofol infusion was started to achieve a BIS of 40-60. ProSeal LMA was introduced under propofol anaesthesia without the use of muscle relaxant. It was chosen as a airway device as the insertion required minimal muscle relaxation.
As soon as insufflation of the peritonal cavity was attempted with CO 2 the airway pressure rose to 35 mmHg and ventilation became difficult. The abdomen was immediately deflated and atracurium besylate 5 mg I.V. was given to achieve muscle relaxation. Peripheral neuromuscular monitor was attached to achieve a twitch response of 1. In train of four stimuli monitoring Insufflation was reattempted and was successful this time. An additional dose of 2.5 mg of atracurium besylate was given intraoperatively at twitch response of 2. The procedure lasted for about 45 min and anaesthesia was reversed with neostigmine 2.5 mg and glycopyrrolate 0.4 mg at the end of the procedure and trachea extubated at twitch response of 3. In TOF monitoring no untoward complication occurred throughout the course of surgery.
BIS returned to pre-anaesthetic level (86) after reversal of anaesthesia and patient made an uneventful recovery.
A 31 year old female with a muscle biopsy proven diagnosis of polymyositis was posted for laparoscopic cholecystectomy. She had progressive muscle weakness and lethargy for past one year with recent incidences of sudden fall while walking, feeling of unsteadiness and difficulty in climbing stairs. She had no history of dysphagia or any respiratory problem. Her thyroid function test was normal and EMG was suggestive of myopathy. Her haemogram, biochemical parameters and ECHO were within normal limits with a CPK of 200. Her sensory system was normal and tendon reflexes intact. EMG was suggestive of myopathy.
After premedication with metaclopromide 10 mg and ranitidine 150 mg on the day of surgery, the patient was taken in the operating room and a drip started. Fentanyl 60 mg and midazolam 1 mg I.V. were injected. Anaesthesia was induced with propofol 70 mg I.V. and an infusion of propofol started to achieve a BIS of 40-60. Since carboperitoneum had not been possible without the aid of muscle relaxant in Case I, atracurium 10 mg I.V. was given and ProSeal LMA introduced. Peripheral neuromuscular monitoring was done to achieve a twitch response of 1. In TOF monitor Ryle's tube was passed and stomach contents aspirated. Carboperitoneum was done to achieve an intra abdominal pressure of 12 mmHg and operation commenced. No untoward complication occurred throughout the course of surgery.
At the end of surgery, anaesthesia was reversed with neostigmine 2.5 mg and glycopyrrolate 0.4 mg. Trachea was extubated at twitch response of 3 and BIS level returned to preanaesthetic level (88) in 5 min. Diclofenac sodium 75 mg I.M. was used for postoperative analgesia. This patient too had an uneventful recovery and was discharged after 48 hours.
Inflammatory myopathies represent the largest group of acquired and potentially treatable causes of skeletal muscle weakness. They are classified into three major groups: polymyositis, dermatomyositis and inclusion body myositis. Polymyositis as a stand alone entity is a rare disease affecting adults. 
These disorders present as progressive and often symmetric muscle weakness. Fine motor movements are affected only late in the course of polymyositis and dermatomyosins but fairly early in inclusion body myositis. Pharyngeal and neck - flexor muscles are often involved causing dysphagia or difficulty in holding up the head. In advanced, and rarely in acute cases, respiratory muscles may also be affected. Severe weakness is associated with muscle wasting if left untreated. More commonly, polymyositis occurs in association with a systemic autoimmune or connective tissue disease or with a known viral or bacterial infection.
The associated extra muscular manifestation with polymyositis are: 
Systemic symptoms such as fever, malaise, weight loss, arthralgia and Raynaud's phenomenon.Dysphagia and gastrointestinal symptoms.Cardiac disturbances including atrioventricular conduction defects, tachyarrhytmias, dilated cardiomyopathy and a low ejection fraction.Pulmonary dysfunction due to weakness of thoracic muscles and interstitial lung disease.Joint contractures, mostly in dermatomyositis and especially in children.The following points must be considered for anaesthesia of a patient with polymyositis: 
Enhanced or delayed effect of muscle relaxant.Pulmonary complications - aspiration pnuemonia and lung fibrosis.Cardiomyopathy, arrhythmia and cardiac failure.Steroid supplementation.It is generally believed that patient with polymyositis is sensitive to nondepolarising muscle relaxants and the use of antagonist drug (reversal) may cause muscle weakness and severe dysrrythmias.
Ohta M et al 3 have reported anaesthetic experience of two patients suffering from polymyositis. The first case was a 56 year old woman who underwent tympanoplasty under general anaesthesia. No muscle relaxant was used for endotracheal intubation and maintenance of anaesthesia. The second case was a 61 year old male who underwent open reduction and internal fixation for condyle fracture of the tibia under epidural block.
Ukei M et al  have reported increased duration of action of muscle relaxant in a patient with dermatomyositis. They have suggested that muscle relaxant should be given to such a patient with monitoring closely the neuromuscular function using a neuromuscular transmission monitor.
Izuta S et al  have reported the use of continuous epidural anaesthesia in a patient with mitochondrial encephalomyopathy undergoing femur head replacement.
In our case I anaesthesia was induced with midazolam 1 mg IV, fentanyl citrate 60 mg IV and propofol 60 mg IV and Proseal Laryngeal Mask Airway (PLMA) was inserted without using any muscle relaxant. Suzuki et al  have also reported the use of LMA for anaesthetic management of a patient with myotonic dystrophy as LMA insertion did not require the use of muscle relaxant.
Shibukawa K et al  used propofol along with bispectral index (BIS) in a patient with mitochondrial encephalomyopathy undergoing artificial cochlear device implantation and have suggested that propofol is safe for inducing and maintaining anaesthesia in patients with mitochondrial encephalomyopathy.
At the time of insufflation, after inserting the Verees needle in our case I, the intraabdominal pressure rose sharply to 20 cm H 2 O only after 1 liter of insufflation and the peak airway pressure also rose from a baseline value of 16 cm H 2 O to 35 cm H 2 O. This was due to an inadequate relaxation of abdominal muscles because of small dose of muscle relaxant and spontaneous respiratory efforts. Hence, we had to administer 5 mg atracurium besylate IV with peripheral neuromuscular monitor. The TOF (train of four) was maintained at 1 twitch responses throughout the duration of procedure. The patient required additional dose of 2.5 mg during the procedure. Duration of surgery was 40 min. At the end of procedure patient had three responses to train of four and a good spontaneous breathing effort and the effect of neuromuscular blockade was reversed with neostigmine 2.5 mg and glycopyrrolate 0.4 mg.
Finsterer J et al  have reported increased sensitivity to rocuronium and atracurium in patients with mitochondrial myopathy and have advised adequate monitoring of neuromuscular blockade in these patients.
Ganta et al  used atracurium for muscle paralysis in two patients with severe muscle weakness, one suffering from acute dermatomyositis and the other from acute polymyositis. They monitored nueromuscular blockade with a peripheral nerve stimulator and experienced no problem with the use of muscle relaxant.
Mair et al  have reported a normal onset time and duration of action of vecuronium but a prolonged time to recovery until antagonism with neostigmine in a patient with dermatomyositis.
Anticipating similar problem in case II as we encountered in case I a modified anaesthetic plan was followed in which 10 mg atracurium besylate was administered prior to insufflation of abdomen and the TOF was maintained at 1 twitch response throughout the procedure. Case II did not require any additional dose of muscle relaxant. The effect of neuromuscular blockade was reversed after 50 min as in case I. Both our patients had an uneventful recovery in the postoperative period and were subsequently discharged on the second postoperative day.
A total intravenous anaesthetic technique is advocated for patients with neuromuscular disorders as in myopathies like mitochondrial encephalomyopathy because inhalation anaesthetics are contraindicated as they can trigger malignant hyperthermia.  Propofol is thus a safe option as it is associated with rapid recovery at the end of surgery due to its short context sensitivity half life and its dose can be titrated using a bispectral index monitor.
Kushikata et al  have described the use of total intravenous anaesthesia with muscle relaxation titration in a patient with mitochondrial myopathy undergoing laproscopic cholecystectomy.
The use of neuromuscular blocking agents in patients with neuromuscular disease is controversial due to its prolonged duration of action. Atracurium is an intermediate acting neuromuscular blocker, which is metabolized by ester hydrolysis and non-enzymatic degradation (Hoffman elimination). Its use in titrated doses in conjunction with a peripheral neuromuscular monitor is a safe option in situations where the use of neuromuscular blockers is unavoidable.
To conclude, we suggest that for anaesthetic management of a patient with polymyositis, the sensitivity of these patients to the effect of neuromuscular blocking agents should always be kept in mind and association of polymyositis with other systemic manifestations should always kept in mind contributing to anaesthetic morbidity in the entire perioperative period.
|1||Marinos C. Dalakas. Polymyositis,dermatomyositis and inclusion body myositis. In: Isselbacher, Braunwald, Wilson et al. Harrison's Principles of Internal Medicine. Mc Graw Hill 2004: 2540-45.|
|2||Fujita A, Okutani R, Fu K. Anesthetic management for colon resection in a patient with polymyositis. Masui 1996; 45(3): 334-36.|
|3||Ohta M, Nishikwa N, Kida H, Miyao S. Anesthetic management of two patients with polymyositis. Masui 2000; 49(12): 1371-73.|
|4||Ukei M, Tosaki Y, Ogli K, Uefuji T. Anesthetic management of a patient with dermatomyositis - clinical observation of the effect of muscle relaxants. Masui 1989; 38(11): 1505-08.|
|5||Izuta S, Yaku H, Maekawa N, Obara H. Anesthetic management of a patient with mitochondrial encephalomyopathy. Masui 2000; 49(6): 649-51.|
|6||Suzuki H, Aoyagi M. Anesthetic management with a laryngeal mask airway for gastrectomy in a patient with myotonic dystrophy. Masui 2003; 52(9): 993-95.|
|7||Shibukawa K, Kawamata M, Skei S et al. The use of propofol combined with nitrous oxide and fentanyl in anesthetic management of a patient with mitochondrial encephalomyopathy. Masui 2002; 51(8): 888-89.|
|8||Finsterer J, Stratil U, Bittner R, Sporn P. Increased sensitivity to rocuronium and atracurium in mitochondrial myopathy. Can J Anaesth 1998; 45(8): 781-84.|
|9||Ganta R, Campbell IT, Mostafa SM. Anaesthesia and acute dermatomyositis / polymyositis. Br J Anaesth 1988; 60(7): 854-58.|
|10||Mair P, Mitterschiffthaler G, Hohlbock E. Nueromuscular blockade using vecuronium in dermatomyositis. Anaesthetist 1989; 38(11): 626-28.|
|11||Theil A, Ritzka M, Saur G. Anesthesia in mitochondrial encephalomyopathies. Anasthesiol Intensivmed Notfallmed Schmerzther 2001; 36(7): 437-39.|
|12||Kushikata T, Yatsu Y, Kubota T, Matsuki A. Total intravenous anesthesia with propofol, ketamine and fentanyl for a patient with mitochondrial myopathy. Masui 2004; 53(2): 178-80.|