There will be a variety of situations, both related to Duchenne (e.g. muscle biopsy, joint contracture surgery, spinal surgery or gastrostomy) and unrelated to Duchenne (e.g. acute surgical events), when surgery and/or general anesthesia may be needed. If you are having surgery, there are a number of condition-specific issues that need to be taken into account for your safety (see figure 14).

Surgery should be done in a hospital where personnel involved in the operation and after care are familiar with Duchenne and willing to work together to be sure everything goes smoothly. Stress dosing of steroids should be considered. Guidelines for stress dosing can be found in the PJ Nicholoff Steroid Protocol at  www.parentprojectmd.org/pj.

All people living with Duchenne are at risk of rhabdomyolysis. Rhabdomyolysis occurs when there is a massive amount of muscle breakdown. This muscle breakdown releases myoglobin and potassium into the blood stream. Myoglobin is dangerous to the kidneys and can cause kidney failure; potassium can be dangerous to the heart. Because of the risk of rhabdomyolysis, there are specific concerns with anaesthesia and Duchenne.

• Succinycholate will cause rhabdomyolysis and should never be used
• Avoid inhaled anesthesia; there is an increased risk of rhabdomyolysis using inhaled
  anesthesia
• IV anesthesias agents are usually safe
• Take caution using any anesthesia agents in Duchenne
• A list of anesthesias that are considered to be safe and unsafe can be found on the PPMD website at www.parentprojectmd.org/Surgery
• Remind your medical team that oxygen should be used with caution
• Care in the use of opiates, other sedating medication, and muscle relaxants is essential – they may affect your breathing rate and depth, making breathing shallower and slower