Basak ALTİPARMAK, Leyla ŞAHAN, SEMRA DEMİRBİLEK

Thoracic epidural anesthesia for severe myasthenia gravis patient undergoing laparoscopic cholesistectomy

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease characterized by different degrees of weakness and fatigue of skeletal muscles after physical exercise. It has an incidence of 2-10/100000 per year. The optimal anesthetic management of these patients is still controversial. A 69 yearold male patient with MG was scheduled for laparoscopic cholesistectomy due to gallbladder stone. Epidural puncture was performed by a 18G Tuohy needle inserted between 7th and 8th thoracic vertebrae. After the placement of epidural catheter, a combination of 40 mg bupivacaine, 100 mg prilocaine and 100 µg fentanil were applied slowly. Pneumoperitonium was applied with approximetly 12 mmHg CO2 for laparoscopic view. At the 10th minute of the surgery, a sudden deep bradicardia was observed. Following administration of one mg of atropine, heart rate of the patient turned to normal ranges within 30 seconds. In the postoperative period no respiratory or cardiac complications were detected and the patient was discharged from hospital after three days. Anesthetic management of MG patients should be individualized due to increased risk of intraoperative and postoperative complications. Their increased sensitivity to nondepolarizing muscle relaxants can lead to prolonged postoperative mechanical ventilation need. In adult patients, regional anaesthesia alone can be a good and safe method for myasthenic patients by eleminating the need for muscle relaxants and opioids in abdominal surgeries. In this case we prefer to insert a thoracic epidural catheter to control the level of blockage intraoperatively. Continuous epidural infusion allowed us to maintain postoperative analgesia without intravenous opioid agents

PDF

___

1. Stevens RD. Neuromuscular disorders and anesthesia. Current opinion in anaesthesiology. 2001;14(6):693-8.

2. Conti-Fine BM, Milani M, Kaminski HJ. Myasthenia gravis: past, present, and future. The Journal of clinical investigation. 2006;116(11):2843-54.

3. Rodriguez MA, Mencia TP, Alvarez FV, Baez YL, Perez GM, Garcia AL. Low-dose spinal anesthesia for urgent laparotomy in severe myasthenia gravis. Saudi journal of anaesthesia. 2013;7(1):90-2.

4. Tellez-Zenteno JF, Cardenas G, Estanol B, Garcia-Ramos G, Weder-Cisneros N. Associated conditions in myasthenia gravis: response to thymectomy. European journal of neurology: the official journal of the European Federation of Neurological Societies. 2004;11(11):767-73.

5. Mincewicz G, Aloszko A, Nyka W, Bilinska M, Krzykowski G, Nyka WM. [The comparison of selected spirometric parameters with functional muscles exercise evaluation in patients with myasthenia]. Polski merkuriusz lekarski: organ Polskiego Towarzystwa Lekarskiego. 2007;22(129):177-81.

6. Barbosa FT, Correia MC, Cunha RM, Cavalcanti IL. [Thoracic epidural anesthesia for mammaplasty in myasthenia gravis patient: case report]. Revista brasileira de anestesiologia. 2005;55(3):354- 60.

7. Rudzka-Nowak A, Piechota M. Anaesthetic management of a patient with myasthenia gravis for abdominal surgery using sugammadex. Archives of medical science: AMS. 2011;7(2):361- 4.

8. Koda K, Kimura H, Uzawa M, Sambe N, Sugano T, Kitamura T, Tagami M. [Desflurane anesthesia without muscle relaxant for a patient with myasthenia gravis undergoing laparoscopic high anterior resection: a case report]. Masui The Japanese journal of anesthesiology. 2014;63(10):1135-8.

9. Kiran U, Choudhury M, Saxena N, Kapoor P. Sevoflurane as a sole anaesthetic for thymectomy in myasthenia gravis. Acta anaesthesiologica Scandinavica. 2000;44(3):351-3.

10. Della Rocca G, Coccia C, Diana L, Pompei L, Costa MG, Tomaselli E, Di Marco P, Vilardi V, Pietropaoli P. Propofol or sevoflurane anesthesia without muscle relaxants allow the early extubation of myasthenic patients. Can J Anaesth. 2003;50(6):547- 52.

11. Schaller SJ, Fink H. Sugammadex as a reversal agent for neuromuscular block: an evidence-based review. Core evidence. 2013;8:57-67.

12. Iwasaki H, Takahoko K, Otomo S, Sasakawa T, Kunisawa T, Iwasaki H. Monitoring of neuromuscular blockade in one muscle group alone may not reflect recovery of total muscle function in patients with ocular myasthenia gravis. Can J Anaesth. 2013;60(12):1222-7.

13. Rangasamy V, Kumar K, Rai A, Baidya DK. Sevoflurane and thoracic epidural anesthesia for trans-sternal thymectomy in a child with juvenile myasthenia gravis. J Anaesth Clin Pharmacol. 2014;30(2):276-8.

14. Stephenson L, Tkachenko I, Shamberger R, Seefelder C. Anesthesia for patients undergoing transsternal thymectomy for juvenile myasthenia gravis. Saudi J Anaesth. 2011;5(1):25-30.

15. Mundada SD, Shah B, Atram S. Emergency cesarian section in a patient of myasthenia gravis: Is neuraxial anesthesia safe? Saudi J Anaesth. 2012;6(4):430-1.

16. Inoue S, Shiomi T, Furuya H. Severe bradycardia in a patient with myasthenia gravis during transurethral ureterolithotripsic procedure under spinal anaesthesia. Anaesth and intensive care. 2002;30(3):387.

17. Kocum A, Sener M, Bozdogan N, Turkoz A, Arslan G. Spinal anesthesia for inguinal hernia repair in 8-year-old child with myasthenia gravis. Paediatr Anaesth. 2007;17(12):1220-1.

18. Datt V, Tempe DK, Singh B, Tomar AS, Banerjee A, Dutta D, Bhandari H. Anesthetic management of patient with myasthenia gravis and uncontrolled hyperthyroidism for thymectomy. Ann Card Anaesth. 2010;13(1):49-52.

19. McGrogan A, Sneddon S, de Vries CS. The incidence of myasthenia gravis: a systematic literature review. Neuroepidemiology. 2010;34(3):171-83.

20. Said S, Cooper CJ, Alkhateeb H, Elhanafi S, Bizet J, Gosavi S, Abedin Z. Pyridostigmine-induced high grade SA-block in a patient with myasthenia gravis. Am J Case Rep. 2013;14:359-61.