P016: MYASTHENIA GRAVIS WITH EXACERBATION IN THE PERIOPERATIVE SETTING: A CASE REPORT
Jonathan Nieves, MD; Aaron Hacker, DO; Armish Singh, MD; Imani Thornton, MD; HCA Westside Regional Medical Center
Introduction: Myasthenia gravis, an autoimmune process affecting acetylcholine nicotinic cholinergic receptors, remains a prevalent consideration in both the preoperative and postoperative setting. The associated muscle weakness and fatigue along with its multiple downtrace sequelae including effect on respiratory system, can lead to perioperative complications with direct impact of patient outcome. We describe a case of a 70 year old male presenting with postoperative myasthenia gravis exacerbation status post Robotic assisted laparoscopic radical prostatectomy with reconstruction of bladder neck and excision of pelvic mesh due to malignant neoplasm of prostate
Methods: Case Report, Anesthesia for the patient with myasthenia gravis, Morgan & Mikhail’s Clinical Anesthesiology, UpToDate were searched using following search terms: Case report, authorship, peer review, and manuscript. Relevant manuscripts were retrieved and the results used to update previous narrative to overview of the literature.
Results: Use of neuromuscular blockade over neuraxial or regional anesthetic methods increases the likelihood of Myasthenia gravis exacerbation and crisis and is associated with increased morbidity and mortality. (3)
Discussion: Review of anesthetic considerations for optimal perioperative care of patients with Myasthenia Gravis (MG) including pathophysiology, cholinergic and myasthenic crisis, and perioperative management. While most anesthetic drugs are well tolerated in patients with Myasthenia gravis, and the use of pyridostigmine on the day of surgery continues to be recommended, other risk factors must be considered. Extubating criteria including spontaneous breathing with zero residual curarization, alternative pain management approaches and reversal of nondepolarizing neuromuscular blockade agents are discussed. The use of opiates as well as benzodiazepine should be approached with caution, however. Neuromuscular blockade is ideally reached with the use of rocuronium, with Sugammadex readily available as an antagonizing agent.
Conclusion: Although the use of rocuronium and Sugammadex combination is widely accepted and practiced for patients with Myasthenia gravis, our case report emphasizes the need to have consideration for individual patient unpredictability and maintain a high clinical suspicion. Additionally the need for monitoring of neuromuscular blockade, as well as consideration of alternate anesthetic approaches in patients for whom neuromuscular blockade is not mandatory, must be considered.