The use of sugammadex in a patient with myasthenia gravis

Comparison between Sugammadex and Neostigmine after Video-Assisted Thoracoscopic Surgery-Thymectomy in Patients with Myasthenia Gravis: A Single-Center Retrospective Exploratory Analysis

This single-center retrospective exploratory analysis evaluated the effects of sugammadex compared with neostigmine on postoperative recovery in patients with myasthenia gravis (MG) who underwent video-assisted thoracoscopic surgery (VATS)-thymectomy. This retrospective study included 180 patients with MG, aged >18 years, who received sugammadex (sugammadex group, n = 83) or neostigmine-glycopyrrolate (neostigmine group, n = 88) after VATS-thymectomy between November 2007 and December 2020. Inverse probability of treatment weighting (IPTW) adjustment was performed to balance the baseline characteristics between the two groups. The primary outcome was the length of postoperative hospital stay, and the secondary outcomes were the incidence of postoperative mortality and complications, as well as the postoperative extubation and reintubation rates, in the operating room after VATS-thymectomy; the outcomes were compared between the two groups. After IPTW adjustment, the sugammadex group showed a significantly shorter median postoperative hospital stay than the neostigmine group (4 (2, 4) vs. 5 (3, 6) days, respectively; p = 0.003). There were no significant differences between the two groups in the incidences of postoperative complications (including postoperative myasthenic crisis, nerve palsy, atelectasis, and pleural effusion). Patients with MG following VATS-thymectomy who received sugammadex showed a significantly shorter postoperative hospital stay than those who received neostigmine.

Anesthetic management of a patient with subclinical myasthenia gravis who underwent a thymectomy: a case report

Background

Some individuals with subclinical myasthenia gravis (MG) are positive for serum anti-acetylcholine receptor antibodies, without neurological symptoms. There are no anesthetic management guidelines for subclinical MG. We report the anesthetic management of a patient with subclinical MG who underwent a thymectomy.

Case presentation

A 57-year-old female with subclinical MG was scheduled for an extended thymectomy. Anesthesia was induced and maintained with mainly propofol and remifentanil. We administrated the minimum amount of rocuronium with reference to train-of-four (TOF) monitoring when a neuromuscular relaxant is needed. Although the prolonged effect of rocuronium was observed, the TOF ratio had already recovered to 100% before the tracheal extubation. Postoperative analgesia was performed by a continuous epidural infusion of levobupivacaine.

Conclusion

We reported the anesthetic management of a patient with subclinical MG who underwent a thymectomy. Further research is necessary to clarify subclinical MG patients' sensitivity to rocuronium.

[Deep neuromuscular blockade : Benefits and risks]

Neuromuscular blockade (TOF count = 0) can improve tracheal intubation and microlaryngeal surgery. It is also frequently used in many surgical fields including both nonlaparoscopic and laparoscopic surgery to improve surgical conditions and to prevent sudden muscle contractions. Currently there is a controversy regarding the need and the clinical benefits of deep neuromuscular blockade for different surgical procedures. Deep neuromuscular relaxation improves laparoscopic surgical space conditions only marginally when using low intra-abdominal pressure. There is no outcome-relevant advantage of low compared to higher intra-abdominal pressures, but worsen the surgical conditions. Postoperative, residual curarisation can be avoided by algorithm-based pharmacological reversing and quantitative neuromuscular monitoring.

Anesthesia in a patient with Charcot-Marie-Tooth disease with pneumothorax: a case report

A 21-year-old man underwent wedge resection for treatment of pneumothorax. This patient had been diagnosed with Charcot-Marie-Tooth disease (CMTD) and had a history of surgical treatment of scoliosis, pneumothorax, foot deformity, and arm dislocation. Additionally, the patient showed signs of muscle weakness and atrophy in the upper and lower extremities.

CMTD is genetically associated with motor and sensory neuropathy and reportedly has an association with malignant hyperthermia or a delayed muscle relaxation mechanism. In the present case, total intravenous anesthesia was performed with a combination of propofol and remifentanil, and rocuronium was administered as a neuromuscular blocking agent. Surgery was performed without delayed muscle relaxation or any other specific intraoperative adverse events.

Anesthetic Management of Total Aortic Arch Replacement in a Myasthenia Gravis Patient under Deep Hypothermic Circulatory Arrest

The anesthetic management of myasthenia gravis patients undergoing cardiac or aortic surgery under cardiopulmonary bypass, especially with deep hypothermic circulatory arrest, is challenging. We describe a case of successful anesthetic management of a myasthenia gravis patient undergoing total arch replacement with deep hypothermic circulatory arrest under neuromuscular monitoring and complete reversal of the action of neuromuscular blocking drugs by sugammadex. The present case suggests that patients with well-controlled myasthenia gravis might be safely managed in cardiac or aortic surgery under cardiopulmonary bypass with deep hypothermic circulatory arrest.

Intensive Care Management of the Neuromuscular Patient

Neuromuscular emergencies are a distinct group of acute neurological diseases with distinct characteristic presentations. Patients who suffer from this group of diseases are at immediate risk of losing protection of their native airway as well as aspirating orogastric contents. This is secondary to weakness of the muscles of the oropharynx and respiratory muscles. Although some neuromuscular emergencies such as myasthenia gravis or Guillain-Barré syndrome are well understood, others such as critical illness myopathy and neuropathy are less well characterized. In this chapter, we have discussed the pathophysiology, diagnostic evaluation, and management options in patients who are admitted to the intensive care unit. We have also emphasized the importance of a thorough understanding of the use of pharmacological anesthetic agents in this patient population.

Myasthenia Gravis and Thymoma Surgery: A Clinical Update for the Cardiothoracic Anesthesiologist

Myasthenia gravis (MG) is a rare neuromuscular disorder characterized by skeletal muscle weakness. Patients with MG who have thymoma and thymic hyperplasia have indications for thymectomy. The perioperative care of patients with MG scheduled for thymus resection should be focused on optimizing their neuromuscular function, identifying factors related to postoperative mechanical ventilation, and avoiding of triggers associated with myasthenic or cholinergic crisis. Minimally invasive surgical techniques, use of regional analgesia, and avoidance or judicious administration of neuromuscular blocking drugs (NMBs) is recommended during the perioperative period. If NMBs are used, sugammadex appears to be the drug of choice to restore adequately the neuromuscular transmission. In patients with postoperative myasthenic crisis, plasma exchange or intravenous immune globulin and mechanical support is recommended.

Electroconvulsive Therapy for Depression Comorbid With Myasthenia Gravis: A Case Report and Review of the Literature

OBJECTIVES

Myasthenia gravis (MG) is a rare but well-described autoimmune disease, which is sometimes comorbid with psychiatric illness. There have been several case reports describing the use of electroconvulsive therapy (ECT) for the treatment of core psychopathology in the context of MG. We sought to review the available published data on ECT in MG and add another case example to the literature.

METHODS

We performed a PubMed search for relevant articles or case reports in English describing ECT in MG and summarized findings.

RESULTS

We identified 7 published cases meeting our inclusion criteria in varying detail with different psychiatric presentations and different anesthetic and ECT technique approaches. In addition, we add our own case.

CONCLUSIONS

Based on the literature and our own clinical experience, ECT seems to be a safe option for the treatment of core psychopathology with comorbid MG as long as appropriate precautions are in place, particularly when choosing an anesthetic approach.

Case report of a patient with myasthenia gravis requiring a caesarean section

RS is a 28-year old lady who presented in her first pregnancy to the High-Risk Obstetric Clinic for review in view of her medical history of myasthenia gravis. She was diagnosed with myasthenia gravis (MG) as a teenager, and underwent thymectomy soon after diagnosis. At the time of presentation to the clinic, RS was taking pyridostigmine and azathioprine for her MG.

Postoperative Respiratory Failure in a Patient with Undiagnosed Myastenia Gravis

Myasthenia gravis (MG) is an autoimmune disease caused by the development of antibodies against the nicotinic acetylcholine receptor. There is hypersensitivity against non-depolarizing muscle relaxants in these patients. Sugammadex eliminates the effects of steroid non-depolarizing muscle relaxants, such as rocuronium and vecuronium, by selectively encapsulating their molecules. In this case report, we present a case of recurarization and respiratory failure after the use of sugammadex and rocuronium in a patient with preoperatively undiagnosed myasthenia gravis.

Feasibility of full and rapid neuromuscular blockade recovery with sugammadex in myasthenia gravis patients undergoing surgery - a series of 117 cases

Purpose

Myasthenia gravis (MG) is an autoimmune disease interfering with neuromuscular transmission. Patients are at risk of postoperative residual curarization (PORC) if nondepolarizing muscle relaxants are used. Clinically inapparent insufficient muscle strength may result in hypoventilation and postoperative bronchopneumonia. We describe a cohort of 117 cases in which sugammadex was used in MG patients undergoing surgery with muscle relaxation with rocuronium.

Methods and patients

We anesthetized 117 patients with MG using rocuronium and sugammadex as neuromuscular blockade reversal agent. One hundred five patients underwent surgical thymectomy and 12 underwent cholecystectomy (five laparotomic and seven laparoscopic). We measured time from sugammadex administration to recovery and to extubation, using the TOF-Watch^® (series of four consecutive electrical impulses [the train-of-four] >0.9). We tracked peripheral capillary oxygen saturation (SpO₂) <95%, elevation of partial pressure of carbon dioxide (pCO₂) >10% above baseline, number of reintubations within the first 48 hours, and number of pneumonias within 120 hours, postoperatively. Results were processed as average, minimum, and maximum values.

Results

The period needed to reach train-of-four of 0.9 following sugammadex administration was on average 117 seconds (minimum of 105 seconds/maximum of 127 seconds) and differed within deviation <10%. The time to extubation following sugammadex administration was on average 276 seconds (minimum of 251 seconds/maximum of 305 seconds) and differed minimally among patients as well. We observed no SpO₂ <95%, no pCO₂ elevation >10% above a baseline, no emergent reintubation within the first 48 hours, and no pneumonia diagnosed on clinical basis within 120 hours, postoperatively in all 117 patients.

Conclusion

In this cohort of MG patients undergoing surgery using rocuronium and sugammadex, we did not observe any signs of postoperative residual curarization and respiratory depression. The neuromuscular blockade recovery was reliable, predictable, and rapid.

Restoration of Train-of-Four Ratio with Neostigmine After Insufficient Recovery with Sugammadex in a Patient with Myasthenia Gravis

We present a patient with myasthenia gravis in whom sugammadex failed to restore the train-of-four ratio (TOFR) sufficiently. When the patient's TOFR count had recovered to 2, we administered 2 mg/kg of sugammadex. However, the TOFR did not recover to the preoperative value. An additional 2 mg/kg of sugammadex also had no effect. We then administered 30 μg/kg of neostigmine which restored the TOFR to more than the preoperative value. We speculate that exacerbation of myasthenia symptoms during surgery interfered with recovery of TOFR after sugammadex administration.

High-dose rocuronium for rapid-sequence induction and reversal with sugammadex in two myasthenic patients

The anesthetic management of patients affected by myasthenia gravis is usually challenging in elective surgery and even more so in emergency procedures. The difficulties involved are several-fold, ranging from the choice of an appropriate muscle relaxant (i.e. one that enables safe and rapid airway management) to neuromuscular monitoring and normal muscular recovery. Additionally, optimizing patient conditions - either pharmacologically or with plasmapheresis - before intervention is well beyond the realm of possibility. We discuss the anesthetic management of two myasthenic patients undergoing emergency surgery (for sigmoid perforation and upper gastrointestinal bleeding respectively). In both cases, we opted for rapid-sequence induction with high-dose rocuronium to prevent inhalation of gastric contents. We also report on the implication of neuromuscular monitoring. We found that the rocuronium-sugammadex combination was a useful and effective option in the emergency setting.

Coronary artery bypass grafting in a patient with myasthenia gravis

A 70-year-old male patient with myasthenia gravis required coronary artery bypass grafting due to triple-vessel disease. The anesthetic management was performed with general anesthesia using reduced doses of muscle relaxants. He was extubated four hours after surgery and the postoperative course was uneventful. Coronary artery bypass surgery in myasthenic patients can be challenging to anesthesiologists and cardiac surgeons. In this rare condition, a meticulous assessment of the patient's neurologic and cardiac status, and careful perioperative anesthetic management were needed in order to avoid life-threatening complications in both intraoperative and postoperative periods.

The use of sugammadex in a patient with Kennedy's disease under general anesthesia

Kennedy's disease (KD), also known as spinal and bulbar muscular atrophy, is a rare, X-linked recessive, neurodegenerative disorder of the lower motor neurons characterized by progressive bulbar and appendicle muscular atrophy. Here we report a case of a 62-year-old male patient with KD, weighing 70 kg and 173 cm tall, was scheduled for frontal sinusectomy due to sinusitis. General anesthesia was induced through propofol 80 mg, remifentanil 0.25 μg/kg/min and 40 mg rocuronium. We were successfully able to use a sugammadex on a patient suffering from KD in order to reverse rocuronium-induced neuromuscular blockade.

Sugammadex and reversal of neuromuscular block in adult patient with duchenne muscular dystrophy

Duchenne's muscular dystrophy (DMD) is the most common and severe form of myopathy. Patients with DMD are more sensitive to sedative, anesthetic, and neuromuscular blocking agents which may result in intraoperative and early postoperative cardiovascular and respiratory complications, as well as prolonged recovery from anesthesia. In this case report, we describe a 25-year-old male patient admitted for cholecystectomy under general anesthesia. We induced our anesthesia by oxygen, propofol, fentanyl, and rocuronium bromide. Maintenance was done by fentanyl, rocuronium bromide, sevoflurane, and O₂. We report in this case the safety use of sugammadex to antagonize the neuromuscular block and rapid recovery in such category of patients.

Safety and Efficacy of Sugammadex for Neuromuscular Blockade Reversal

Since its first human use in 2005, the γ-cyclodextrin sugammadex (Org 25969) has had the potential to become the reversal agent of choice, for rocuronium- or vecuronium-induced neuromuscular blockade. Sugammadex binds to the aminosteroid neuromuscular blocker, encapsulating it and extracting it from the neuromuscular junction, effectively ceasing activity and allowing neuromuscular transmission to recover rapidly. Phases I–III and subsequent trials have found sugammadex to be safe and effective in a wide range of doses and for the reversal of a range of depth of muscle relaxation in healthy volunteers and a variety of disease states. Sugammadex use may allow refinement of anesthetic practice and improvement in surgical conditions, through the maintenance of deep neuromuscular blockade right to the end of surgery, with subsequent rapid reversal. Debate remains about the use of sugammadex in the treatment of rocuronium anaphylaxis and airway emergencies. The high price of sugammadex currently prohibits its routine use, but if the price falls, after expiry of its patent, it may become cost-effective as a readily available agent in certain specific clinical situations. Serious adverse reactions have occurred in less than 1% of patients and are most commonly because of hypersensitivity. No deaths have been reported, but caution is advised in neonates, pediatrics, and pregnancy where data are lacking.

Monitoring of neuromuscular blockade in one muscle group alone may not reflect recovery of total muscle function in patients with ocular myasthenia gravis

PURPOSE

We report on two patients with ocular myasthenia gravis who received rocuronium, followed later by sugammadex to reverse neuromuscular blockade. Recovery was monitored simultaneously at the adductor pollicis muscle (APM) and the corrugator supercilii muscle (CSM).

CLINICAL FEATURES

Two patients with ocular myasthenia gravis (case 1: 74 yr-old female, 54 kg; case 2: 71 yr-old male, 72 kg) were scheduled for surgery under general anesthesia. Neuromuscular blockade was induced with rocuronium 0.3 mg·kg(-1) after placing two separate monitors at the APM and the CSM, respectively. Additional doses of rocuronium 0.1-0.2 mg·kg(-1) were given to maintain neuromuscular blockade at fewer than two twitches at the APM during surgery. Train-of-four response at the CSM did not show recovery of the twitch after its initial disappearance. At the end of surgery, sugammadex was administered. Twitch height at the APM recovered to the control value in 12 min (case 1) and 13 min (case 2) after sugammadex administration; however, twitch height at the CSM took 26 min (case 1) and 14 min (case 2) to recover to the control value.

CONCLUSION

After rocuronium-induced paralysis in both patients with ocular myasthenia, spontaneous recovery and sugammadex-assisted recovery were slower at the CSM than at the APM. In patients without the disorder, CSM recovery is faster than APM recovery. Thus, in ocular myasthenia gravis, neuromuscular recovery at the APM may not reflect recovery of all muscles.

Sugammadex as a reversal agent for neuromuscular block: an evidence-based review

Sugammadex is the first clinical representative of a new class of drugs called selective relaxant binding agents. It has revolutionized the way anesthesiologists think about drug reversal. Sugammadex selectively binds rocuronium or vecuronium, thereby reversing their neuromuscular blocking action. Due to its 1:1 binding of rocuronium or vecuronium, it is able to reverse any depth of neuromuscular block. So far, it has been approved for use in adult patients and for pediatric patients over 2 years. Since its approval in Europe, Japan, and Australia, further insight on its use in special patient populations and specific diseases have become available. Due to its pharmacodynamic profile, sugammadex, in combination with rocuronium, may have the potential to displace succinylcholine as the "gold standard" muscle relaxant for rapid sequence induction. The use of rocuronium or vecuronium, with the potential of reverse of their action with sugammadex, seems to be safe in patients with impaired neuromuscular transmission, ie, neuromuscular diseases, including myasthenia gravis. Data from long-term use of sugammadex is not yet available. Evidence suggesting an economic advantage of using sugammadex and justifying its relatively high cost for an anesthesia-related drug, is missing.

Neuromuscular disease and anesthesia

Patients with neuromuscular disease pose many anesthetic challenges and are at greater risk for perioperative complications, including respiratory or cardiovascular dysfunction and pulmonary aspiration. Therefore, these patients require special precautions, including interdisciplinary communication between primary care physicians, neurologists, physiatrists, surgeons, and anesthesiologists. Preoperative evaluation and optimization of comorbid conditions is critical. These patients may have adverse response to neuromuscular blocking drugs and the reversal drugs (e.g., neostigmine). They should be used with caution and titrated based on objective neuromuscular monitoring. Drugs that potentiate neuromuscular blocking drugs should also be avoided or their doses limited if possible. The risk of malignant hyperthermia in certain neuromuscular diseases mandates avoidance of triggering agents such as succinylcholine and inhaled anesthetics. Patients with neuromuscular disease may also be sensitive to sedative-hypnotics and opioids, which should be used judiciously. Finally, the postoperative period requires close monitoring due to increased risk of postoperative cardiorespiratory dysfunction.

Rocuronium and sugammadex in patients with myasthenia gravis undergoing thymectomy

BACKGROUND

The use of neuromuscular blocking agents is still controversial in myasthenic patients but rocuronium could be useful after the introduction of sugammadex as a selective antagonist. The aim of the study was to evaluate the use of rocuronium-sugammadex in myasthenic patients undergoing thoracoscopic thymectomy.

METHODS

After ethical approval, 10 myasthenic patients undergoing videothoracoscopic-assisted thymectomy were enrolled in the study. Neuromuscular block was achieved with 0.3 mg/kg rocuronium and additional doses were given according to train-of-four (TOF) monitoring or movement of the diaphragm. Sugammadex 2 mg/kg was given after surgery. Recovery time (time to obtain a TOF value > 0.9) was recorded for all subjects.

RESULT

All patients were extubated in the operating room after administration of sugammadex. Mean rocuronium dose was 48 mg and the average operation time was 62 min. Recovery time after sugammadex administration was 111 s (min 35; max 240).

CONCLUSIONS

A rapid recovery of neuromuscular function was found in myasthenic patients receiving rocuronium when sugammadex was used for reversal. This combination could be a rational alternative for myasthenic patients for whom neuromuscular blockade is mandatory during surgery.

Video-assisted thoracoscopic extended thymectomy in myasthenic children

Myasthenia gravis (MG) is an autoimmune disease marked by weakness of voluntary musculature. Medical and surgical therapy of adult myasthenia is well documented. There is little pediatric surgical evidence, only a few case reports being available. The aim of this paper is to verify whether the surgical and anesthesiological techniques can warrant an early and safe discharge from the operating room. The secondary aim is to assess the presence of perioperative indicators that can eventually be used as predictors of postoperative care. During the years 2006-2009, 10 pediatric patients were treated according to a surgical approach based on video assisted thoracoscopic extended thymectomy (VATET). Standard preoperative evaluation is integrated with functional respiratory tests. Anesthetic induction was made with propofol and fentanyl/remifentanyl and maintenance was obtained with sevoflurane/desflurane/propofol ± remifentanyl. A muscle relaxant was used in only one patient. Right or left double-lumen bronchial tube (Rüsch Bronchopart® Carlens) placement was performed. Six patients were transferred directly to the surgical ward while 4 were discharged to the intensive care unit (ICU); ICU stay was no longer than 24 h. Length of hospital stay was 4.4±0.51 days. No patient was readmitted to the hospital and no surgical complications were reported. Volatile and intravenous anesthetics do not affect ventilator weaning, extubation or the postoperative course. Paralyzing agents are not totally contraindicated, especially if short-lasting agents are used with neuromuscular monitoring devices and new reversal drugs. Perioperative evaluation of the myasthenic patient is mandatory to assess the need for postoperative respiratory support and also predict timely extubation with early transfer to the surgical department. Availability of new drugs and of reversal drugs, the current practice of mini-invasive surgical techniques, and the availability of post anesthesia care units are the keys to the safety and successful prognosis of patients affected by MG who undergo thymectomy.

Use of sugammadex in a patient with amyotrophic lateral sclerosis

OBJECTIVE

To report on general anesthesia management in amyotrophic lateral sclerosis.

CASE PRESENTATION AND INTERVENTION

A 47-year-old man presented with fracture of the humerus. The patient was diagnosed with amyotrophic lateral sclerosis. General anesthesia was induced with propofol, rocuronium and remifentanil. After uneventful surgical repair, TOF (train-of-four) ratio reached >0.90 at the end of operation. However, muscle strength and tidal volume were inadequate. After sugammadex 2 mg kg(-1) i.v. was given, the patient was extubated 120 s later.

CONCLUSION

This case highlights that rocuronium and sugammadex can be used safely in patients with amyotrophic lateral sclerosis undergoing surgery with general anesthesia.

Sugammadex reversal of rocuronium-induced neuromuscular blockade in two types of neuromuscular disorders: Myotonic dystrophy and spinal muscular atrophy

Neuromuscular disorders like myotonic dystrophy (dystrophia myotonica or Steinert's disease) and spinal muscular atrophy are associated with perioperative complications related to muscle weakness. These patients have an increased sensitivity to non-depolarising neuromuscular blocking agents, which can lead to postoperative residual curarization (PORC) and its associated respiratory complications. Adequate reversal of neuromuscular blockade is essential to prevent this. Sugammadex is the first selective relaxant binding agent and it reverses rocuronium- and vecuronium-induced neuromuscular block. Two cases are reported in which the patients received sugammadex to reverse a rocuronium-induced neuromuscular block. Reversal of the rocuronium-induced neuromuscular block (NMB) in both cases was fast, effective and without recurarization, and no safety concerns were observed.

Anesthesia and myasthenia gravis

Myasthenia gravis (MG) is a disease affecting the nicotinic acetylcholine receptor of the post-synaptic membrane of the neuromuscular junction, causing muscle fatigue and weakness. The myasthenic patient can be a challenge to anesthesiologists, and the post-surgical risk of respiratory failure has always been a matter of concern. The incidence and prevalence of MG have been increasing for decades and the disease is underdiagnosed. This makes it important for the anesthesiologist to be aware of possible signs of the disease and to be properly updated on the optimal perioperative anesthesiological management of the myasthenic patient. The review is based on electronic searches on PubMed and a review of the references of the articles. The following keywords were used: myasthenia gravis AND neuromuscular blocking agents, myasthenia gravis AND sevoflurane, myasthenia gravis AND epidural, myasthenia gravis AND neuromuscular blockade reversal and myasthenia gravis AND pyridostigmine. The articles included were from reviews and clinical trials written in English. MG patients can easily be anesthetized without need for post-surgery mechanical ventilation whether it is general anesthesia or peripheral nerve block. Volatile anesthesia or the use of an epidural for the patient makes it possible to avoid the use of neuromuscular blocking agents, and when used, it should be in smaller doses and the patient should be carefully monitored. This review shows that with thorough pre-operative evaluation, continuing the daily pyridostigmine and careful monitoring the MG patient can be managed safely.

Myasthenia gravis: two case reports and review of the literature

BACKGROUND AND OBJECTIVES

Myasthenia gravis (MG) is an autoimmune neurologic disease that affects the postsynaptic portion of the neuromuscular junction. It represents a challenge for anesthesiologists due to the diversity of disease manifestations and possibility of postoperative respiratory complications. The objective of this study was to demonstrate the importance of adequate monitoring of the neuromuscular blockade (NMB) due to the multiple presentations of MG.

CONTENTS

In this paper we report two cases of patients with MG. The first patient presented with the classical sensitivity to the neuromuscular blocker (NMB) and the second had a similar response to that of a normal patient. The literature review will be restricted to disease characteristics, while the description of its pathophysiology will focus on its reactions to NMB.

CONCLUSIONS

We suggest that, due to the multiple presentation and treatment of MG, neuromuscular transmission monitors are fundamental when using NMB.

Anaesthetic considerations in paediatric myasthenia gravis

Myasthenia gravis is of particular interest to anaesthetists because of the muscle groups affected, the pharmacology of the neuromuscular junction, and interaction of both the disease and treatment with many anaesthetic drugs. Anaesthetists may encounter children with myasthenia either to facilitate treatment options or to institute mechanical ventilation in the face of a crisis. This paper reviews the literature pertaining to the pathophysiology and applied pharmacology of the disease and explores the relationship between these and the anaesthetic management. In addition to illustrating the tried-and-tested techniques, some newer management options are explored.

Anaesthetic management of a patient with myasthenia gravis for abdominal surgery using sugammadex

We report a case of a patient with tumor of the caecum with coexistent myasthenia gravis (a form according to Osserman II A), requiring general anesthesia for abdominal surgery. To reverse the neuromuscular block induced by vecuronium was used sugammadex.

The use of Rocuronium in a Patient with Cystic Fibrosis and End-Stage Lung Disease Made Safe by Sugammadex Reversal

While the pharmacology of sugammadex has been extensively reviewed, there is limited literature regarding its use in specific clinical settings. Several case reports describe its use in patients with the potential for postoperative respiratory dysfunction; in the settings of myasthenia gravis, Duchenne muscular dystrophy and myotonic dystrophy. We describe the use of sugammadex in a patient with severe bronchiectasis related to cystic fibrosis who required neuromuscular block for percutaneous endoscopic gastrostomy insertion. The use of rocuronium for neuromuscular block was preferred in order to avoid the potential complications associated with the use of suxamethonium. However, we wished to ensure complete neuromuscular block reversal for this short duration procedure in this high-risk patient and also to avoid the side-effects of traditional reversal agents. We therefore planned in advance to use sugammadex for neuromuscular block reversal, and this approach proved successful. Overall, the combination of rocuronium and sugammadex improved perioperative surgical and anaesthetic management in this patient.

Myasthenia gravis and pregnancy: anaesthetic management--a series of cases

BACKGROUND AND OBJECTIVE

Myasthenia gravis is an autoimmune neuromuscular disease, usually affecting women in the second and third decades. The course is unpredictable during pregnancy and puerperium. Myasthenia gravis can cause major interference in labour and partum and exacerbations of the disease frequently occur. The aim of this series of cases is to analyse retrospectively the anaesthetic management of myasthenia gravis patients and complications during the peripartum period.

MATERIALS AND METHODS

Retrospective, single centre study from clinical files of female myasthenia gravis patients who delivered between 1985 and 2007 at Hospital de Santo António, Porto, Portugal.

RESULTS

Seventeen myasthenia gravis patients delivered between 1985 and 2007 in Hospital Santo António. Two women were not included in the study as they had a spontaneous abortion in the first trimester. Four patients presented exacerbations of the disease during pregnancy, no exacerbation occurred in eight patients and three patients presented their first symptoms of myasthenia gravis during pregnancy (without diagnosis at time of delivery). Concerning the eight patients without exacerbations of the disease during pregnancy, pregnancy was brought to term in 87.5% of the cases; five women were submitted to nonurgent caesarean section (62.5%); and epidural block was performed in six patients (75%). No complications related to anaesthesia occurred in the peripartum period. Concerning the four patients with exacerbations of the disease, pregnancy was brought to term in three cases (75%); three women were submitted to nonurgent caesarean section (75%); and epidural block was performed in three patients (75%). One patient underwent an uncomplicated thymectomy under general anaesthesia during pregnancy and, in the postpartum period, there was a myasthenic crisis in another patient. Concerning the three patients without a myasthenia gravis diagnosis at partum, one woman already being followed for presenting muscular weakness had a vaginal delivery under epidural block, without complications; another patient, presenting discrete supine dyspnoea, was submitted to elective caesarean section under spinal block and developed severe dyspnoea that required mechanical ventilation and ICU admission; and in the remaining case, a woman presenting mild blurred vision was submitted to general anaesthesia, which resulted in delayed emergence, muscular weakness and respiratory failure. Pregnancy went full term in all cases (100%). No newborn had a myasthenic crisis.

CONCLUSION

Myasthenia gravis can interfere slightly with pregnancy and partum, although exacerbations of the disease occur frequently. Strict surveillance and therapeutic optimisation are crucial. In women with controlled disease, caesarean section should be carried out only if there are obstetric reasons. Locoregional anaesthesia is preferred, mainly epidural block. A good multidisciplinary cooperation, specific precautions and surveillance can certainly contribute to an improved outcome in myasthenia gravis patients during the peripartum period.

[Anesthesia with neuromuscular diseases]

Among the neuromuscular diseases (NMDs) over 800 individual entities have been identified. The vast majority of these diseases occur very seldom but all NMDs together add up to a prevalence of 1:1,500. Accordingly the conclusion "seldom diseases are common" seems to be appropriate. The scope of NMDs is very wide varying from the affection of single muscle groups to the complete musculature, from slowly progressive to fulminant progressive forms, from perinatal to the adult manifestation as well as number, course and character of associated comorbidities. Due to the wide heterogeneity concerning NMDs it is of great importance for anesthesiologists to be knowledgeable on relevant comorbidities as well as indications and contraindications for the various anesthetics.