ALS and General Anesthesia

I had a case with a patient who was newly diagnosed with ALS.  They had recently had a fall and was coming in for a TEE (for pre-Watchman workup), AV node ablation, and pacemaker placement.  There was some mild lower extremity weakness.  Upper extremity strength seemed to be 5/5.  The patient recently passed a swallow evaluation.  The plan was for a GA.

What is ALS?

als-whats-is-ALS-info
From http://walkforals.ca/what-is-als/

ALS Association: What is ALS?

ALS Association: Signs and Symptoms

 

Considerations in ALS patients for GA:

 

My plan:

  • Induction: propofol, remifentanil. I avoided paralytics.
  • Pain control: remifentanil, local anesthetic by surgeon.
  • Emergence: deep, patient breathing on their own
  • Dropoff in PACU: patient wide awake and comfortable.