Ondine's curse: anesthesia for laparoscopic implantation of a diaphragm pacing stimulation system

Central alveolar hypoventilation syndrome (CAHS) is a rare disease characterized by the loss of autonomic control of breathing. This condition causes hypoventilation and obstruction during sleep. Throughout their lives, these patients require ventilatory assistance by means of positive pressure ventilation to their lungs via mask, tracheotomy, or other means, such as phrenic nerve pacers. The diaphragm pacing stimulation system (DPSS) is a new treatment where electrodes are implanted into the diaphragm and cause contraction on stimulation. The DPSS has been used successfully in tetraplegic patients and patients suffering from amyotrophic lateral sclerosis (ALS). It has been shown to improve quality of life and to extend survival in patients with advanced respiratory muscle weakness. In our case, we describe the perioperative management of an adult patient with acquired CAHS who presented for laparoscopic DPSS insertion. Our patient was a 50-yr-old female who developed CAHS at age thirteen after contracting encephalitis. Since the onset of her disease, she had been managed with positive pressure ventilation to her lungs via mask. Due to her longstanding disease, she presented with pulmonary hypertension and cor pulmonale and was scheduled for laparoscopic DPSS implantation. Our anesthetic technique included a total intravenous technique with remifentanil and propofol, and her trachea was intubated without the use of muscle relaxants. The pacemakers were switched on when the patient emerged from anesthesia, which provided her with ventilatory support and allowed us to extubate her trachea. We present the successful anesthetic management of an adult patient with CAHS undergoing laparoscopic DPSS insertion.