MAC Anesthesia during Endoscopic Percutaneous Gastrostomy (PEG) in a Patient with Amyotrophic Lateral Sclerosis (ALS). A Case Report.

Abstract

Background: Amyotrophic lateral sclerosis (ALS) is a serious disease in which some brain and spinal cells die slowly. These nerve cells are called motor neurons and control the muscles that allow the body parts to move. Initially, the disease causes bodily fatigue and muscular weakness through degeneration of the upper and lower motor neurons, leading to loss of ability to initiate and control the voluntary bodily functions. In late stages this disease causes difficulty in the normal swelling and eating that causes the need for PEG in patients with ALS. This clinical picture increases the difficulty and the anesthetic risk used during the PEG application. Case presentation: We are describing our experience in a 56-year-old male patient, ASA III suffering from ALS and being admitted to our clinic to insert PEG. The patient presented BMI =15.6. After the patient provide informed consent, we were monitoring him for detect changes in pulse oximetry, noninvasive blood pressure, heart rate and visual assessment of ventilator activity, level of consciousness and discomfort. We used balanced propofol for moderate sedation (BPS), loading dose 1mg midazolam, 0.1 mg of fentanyl, and 5-15 mg propofol in smaller bolus dose were applied for more precise dose titration. The operation was performed after the patient lost the consciousness and had no pupil reflex. The EGD entered to the stomach. Fistula was localized after the visualization of light from the tube. Local lidocaine was applied and 1cm incision on the abdominal wall gave the possibility for application of fistula and gastro stoma placement. The patient wakes up 10 minutes after the end of the procedure without using antidotes. The patient after treatment went home in two days using gastro stoma for enteral feeding.

Keywords

• Amyotrophic lateral sclerosis
• monitored anesthesia care
• endoscopic percutaneous gastrostomy