2025 FSA Podium and Poster Abstracts

Introduction: Autonomic autoimmune ganglionopathy (AAG) is a rare disease characterized by autonomic failure often attributed to autoantibodies against ganglionic nicotinic acetylcholine receptors.1 These patients frequently experience symptomatic orthostatic hypotension, fainting, bradycardia, decreased gastrointestinal motility, urinary bladder dysfunction, and dry eyes and mouth.2 This disease process is of particular importance for patients undergoing anesthesia due to the administration of a variety of medications that can affect acetylcholine receptors, including neuromuscular blocking drugs and their reversal agents along with medications that can cause significant changes in hemodynamic parameters such as heart rate and blood pressure.

Case Presentation: Our case report discusses the anesthetic management of a 63-year-old male with AAG and GERD who presented to the hospital for elective cystoscopy with instillation of Coaptite. His symptoms secondary to AAG include orthostatic hypotension, sialorrhea, neurogenic bladder, vasomotor rhinitis, nyctalopia, peripheral neuropathy and gastroparesis. He is on biweekly infusions of IVIG for symptomatic management of his AAG. His other home medications include rosuvastatin, prednisone, famotidine and cymbalta. On preoperative interview the patient states he has frequent nausea with early satiety and a feeling of food stuck in his esophagus. In addition, the patient states he has a history of delayed emergence from previous procedures involving anesthesia. Given his active symptoms and medical history the decision was made to secure the airway with endotracheal intubation using video laryngoscopy with a rapid sequence induction technique. Induction was performed with lidocaine, fentanyl, succinylcholine and propofol. The patient was ventilated with pressure support ventilation and there were no immediate intraoperative complications. After confirmation of adequate qualitative train of four twitches and generation of sufficient tidal volume, the patient was extubated with no immediate complications. The patient was taken to the post anesthesia recovery unit (PACU) in hemodynamically stable condition. Shortly after arrival to PACU the anesthesiology team was called to the bedside for concerns of respiratory distress with desaturation and altered mental status. On examination, the patient had coarse breath sounds with audible inspiratory stridor. A nasal cannula was placed, racemic epinephrine was given and a chest x-ray was ordered. There was no evidence of superficial trauma to the airway, CXR was unremarkable and symptoms improved after one treatment with racemic epinephrine. The patient was closely observed in the PACU and eventually discharged in stable condition with no further events.

Discussion: While AAG is a rare disease unlikely to be encountered routinely in the intraoperative setting, it is important for anesthesiologists to be aware of potential complications that can occur. The approach to airway management and induction should be carefully considered given the potential for complications. The anesthesiologist can benefit from having appropriate resuscitative medications prepared prior to induction including vasopressors, bronchodilators and reversal agents to avoid complications related to airway inflammation, hyperreactivity and prolonged drug effect. Overall, the management of patients with autoimmune acetylcholine receptor disease can be challenging, adequate preparation through all phases of intraoperative care can ensure safe and improved outcomes for these patients.