Anesthetic management of a patient with amyotrophic lateral sclerosis undergoing flexible ureterorenolithotripsy

case report

Abstract

Introduction: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease characterized bAmyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease characterized by motor weakness and respiratory impairment, increasing perioperative risk, particularly during anesthetic induction, ventilation, and extubation. Case Report: A 62-year-old female patient, 83 kg, ASA III, with a five-year history of ALS, an ALSFRS-R score of 10, and dependence on bilevel noninvasive ventilation (BiPAP), underwent flexible ureterorenolithotripsy with double-J stent placement. Preoperative evaluation revealed severe functional impairment and high respiratory risk. Total intravenous anesthesia with propofol and remifentanil using target-controlled infusion was performed without neuromuscular blocking agents, combined with bispectral index and trainof- four monitoring. Orotracheal intubation was successfully achieved using videolaryngoscopy (Cormack-Lehane grade I), followed by protective mechanical ventilation. The intraoperative course was uneventful, with hemodynamic stability and adequate oxygenation. At the end of the procedure, careful extubation was performed with immediate reconnection to noninvasive ventilation, and the patient was transferred to the post-anesthesia care unit under continuous monitoring without adverse events. Discussion: Anesthetic management in patients with ALS requires an individualized approach, considering reduced ventilatory reserve and unpredictable responses to neuromuscular blocking agents, highlighting the importance of strategies that preserve spontaneous ventilation and minimize respiratory depression. In this context, avoidance of neuromuscular blockers, combined with depth of anesthesia and neuromuscular monitoring, as well as early postoperative ventilatory support, proved effective in reducing the risk of respiratory complications. Conclusion: Risk anticipation, careful anesthetic titration, and immediate postoperative ventilatory planning are essential to optimize anesthetic safety in patients with advanced ALS.