P086: PARALYZED BY POTASSIUM SHIFT: A PEDIATRIC CASE OF PERIODIC PARALYSIS AND ANESTHETIC CONSIDERATIONS
Cecilia Nosti, MD1; Kevin Lukose, MD1; Alexa Ovalles Lacruz, BA2; Jacquelin Peck, MD3; Benjamin Houseman, MD, PhD3
1Memorial Healthcare System; 2Florida International University HWCOM; 3Envision Physician Services
Introduction: Periodic paralysis is a group of disorders characterized by recurrent episodes of skeletal muscle weakness or paralysis that typically spares respiratory muscles. The underlying pathophysiology involves skeletal muscle ion channel dysfunction, leading to impaired action potential propagation and muscle fiber excitation failure.[1] This abstract describes successful anesthetic management of a patient hypokalemic periodic paralysis (HPP) undergoing dental extraction.
Case Presentation: A nine-year-old, 35 kg male with suspected HPP presented for tooth extraction. His past medical history was notable for a history of episodic weakness following viral infections and bilateral lower extremity tremors progressing to weakness following nitrous oxide sedation for a root canal.
He was instructed to avoid glucose-rich preoperative hydration two hours prior to surgery. In the preoperative area, his preoperative potassium level was 4.1 mmol/L. Following premedication with midazolam, anesthesia was induced with intravenous propofol. Maintenance anesthesia consisted of a propofol infusion with normal saline as the carrier/hydration fluid. IV anesthesia was used due to suspicion of nitrous oxide having potentially been a trigger during the patient’s previous incident, albeit unconfirmed. Neuromuscular blockade was deemed unnecessary to facilitate the procedure, and was thus omitted. Shortly after induction spontaneuous ventilation was resumed, and hypothermia was prevented using a forced-air warmer.
The procedure proceeded uneventfully, and the patient was discharged home with full strength in all extremities.
Discussion: The perioperative management of patients with HPP requires careful planning to prevent fluctuations in potassium levels that may precipitate muscle weakness or paralysis. Several factors, including stress, hyperventilation, glucose-containing fluids, and temperature changes can precipitate potassium shifts and increase the risk of an HPP episode. [1-3]
In the preoperative period, modification of standard ERAS protocols was key to avoid a heavy glucose load. Lab testing confirmed normal electrolyte levels prior to the procedure. We avoided potassium-containing carrier fluids and ensured adequate anxiolysis to avoid triggering potassium shifts.
Intraoperatively, we utilized intravenous anesthesia due to the nature of the procedure. While vapor anesthetics are considered safe in HPP, they may have a higher risk of emergence agitation. Postoperatively, the patient was closely monitored for signs of weakness while minimizing stress and pain. Ideally, even minor procedures such as this one should be performed at a specialized facility familiar with the perioperative needs of these high risk patients.
References:
Hines, Roberta L., and Stephanie B. Jones, editors. Stoelting's Anesthesia and Co-Existing Disease. 8th ed., Elsevier, 2021. pp. 507–508
Chitra, S, and Grace Korula. “Anaesthetic management of a patient with hypokalemic periodic paralysis- a case report.” Indian journal of anaesthesia vol. 53,2 (2009): 226-9
Hofer, C et al. “Total intravenous anaesthesia in a patient with familial hypokalaemic periodic paralysis.” Anaesthesia vol. 56,11 (2001): 1082-5. doi:10.1046/j.1365-2044.2001.02268.x