2026 FSA Podium and Poster Abstracts

Introduction/Background: Duchenne muscular dystrophy (DMD) is a progressive X-linked myopathy characterized by skeletal muscle degeneration, cardiomyopathy, restrictive lung disease, and susceptibility to anesthesia-related rhabdomyolysis, hyperkalemia, and cardiac arrest. Depolarizing neuromuscular blockers and volatile anesthetics are contraindicated due to these risks. Dental rehabilitation requires nasal intubation and shared airway management, adding complexity. In progressive neuromuscular diseases, oropharyngeal muscle weakness and reduced neck mobility may worsen airway characteristics over time, rendering earlier anesthetic documentation unreliable.

Methods/Case Description: A 15-year-old male (66.4 kg) with advanced, genetically confirmed DMD presented for comprehensive dental restoration under general anesthesia. He was wheelchair-dependent with DMD-associated cardiomyopathy (managed with ACE inhibitor), mild restrictive lung disease, mild obstructive sleep apnea, and chronic corticosteroid therapy.

Review of prior anesthetic records revealed progressive airway deterioration. An earlier anesthetic record documented uncomplicated direct laryngoscopy with a Cormack-Lehane grade I view using a Macintosh 3 blade (ETT 6.5, one attempt). Five weeks later, intubation was traumatic, requiring three attempts and videolaryngoscopy after failed Macintosh 3 and C-MAC attempts (ETT 6.5, Cormack-Lehane grade III).

Given the progressive nature of DMD and recent difficult airway documentation, the airway was managed as anticipated difficult in a hospital operating room. The anesthetic plan included malignant hyperthermia precautions, propofol-based total intravenous anesthesia (TIVA), non-depolarizing neuromuscular blockade with quantitative monitoring, primary videolaryngoscopic nasal intubation, and perioperative hydrocortisone stress dosing.

Results: The anesthesia machine was prepared with the removal of volatile anesthetics. Standard ASA monitors were applied. Intravenous induction was performed while maintaining the ability to assess mask ventilation. After confirming easy mask ventilation, rocuronium was administered with quantitative neuromuscular monitoring; succinylcholine was avoided.

Primary videolaryngoscopic nasal intubation achieved first-pass success with a Cormack-Lehane grade II view (ETT 5.5). Anesthesia was maintained with propofol-based TIVA and an adjunctive short-acting opioid. Multimodal analgesia included intravenous acetaminophen and ketorolac. Approximately 800 mL of lactated Ringer's solution was administered; blood loss was minimal.

Hemodynamics, end-tidal CO2, and core temperature remained stable and within normal limits. There was no hyperthermia, arrhythmia, hyperkalemia, or evidence of rhabdomyolysis. Residual neuromuscular blockade was reversed with sugammadex before awake extubation. The patient recovered without respiratory compromise and was discharged per institutional protocol.

Discussion/Conclusion: This case underscores cumulative anesthetic risk in advanced DMD with cardiomyopathy, restrictive lung disease, chronic steroid therapy, and evolving airway difficulty. Trigger-free TIVA with quantitative neuromuscular monitoring mitigates risks of anesthesia-related rhabdomyolysis and hyperkalemia

In progressive neuromuscular disease, the most recent and highest-risk airway documentation should guide anesthetic planning, even when bedside examination is reassuring. Progressive oropharyngeal muscle weakness contributes to worsening airway characteristics in DMD, as demonstrated by this patient's rapid deterioration from grade I to grade III laryngoscopy within five weeks. 

Hospital-based management provides appropriate resources for medically complex adolescents undergoing shared-airway procedures, with access to advanced airway equipment and critical care support as needed, where office based management may not . Comprehensive risk stratification and proactive airway planning enabled safe perioperative management in this high-risk patient.