Low-dose spinal anesthesia for urgent laparotomy in severe myasthenia gravis

Laparoscopic Abdominal Surgery Under Thoracic Epidural Anesthesia in Patients with Interstitial Lung Disease: Retrospective Observational Cohort Study

BACKGROUND

Patients with interstitial lung disease who present with abdominal disease carry a perioperative risk of morbidity and mortality, including the risks of general anesthesia and postoperative pulmonary complications. We investigated the efficacy of laparoscopic surgery in such patients under epidural anesthesia.

MATERIALS AND METHODS

All patients with interstitial lung disease who underwent laparoscopic abdominal surgery were retrospectively studied. At 30 days, our primary end point was acute exacerbation of pulmonary complications. The second end point was nonpulmonary complications and 30-day hospital mortality.

RESULTS

Eighteen patients were enrolled in this study after reviewing their medical and surgical records. Our study revealed that none of the patients suffered from acute pulmonary exacerbations, and only 1 patient experienced a nonpulmonary event. There was no reported mortality. The conversion rate was low, with 1 patient necessitating conversion from laparoscopic to open surgery, which was conducted under epidural anesthesia. No conversions from epidural to general anesthesia were performed.

CONCLUSION

Epidural anesthesia is safe in a patient with interstitial lung disease, and laparoscopic surgery can be completed with low rate of conversion and, with minor complications.

Locoregional Anaesthesia for Laparotomy: A Literature Review and Subsequent Case Series Highlighting the Potential of an Alternative Anaesthetic Technique

Laparotomy is a surgical incision utilised in both emergency and elective scenarios to gain access to abdominal surgery. General anaesthesia is usually necessitated due to the substantial insult of the approach and to facilitate organ relaxation and paralysis. However, this brings with it the need for an assessment of the suitability of the anaesthetic technique, with a large number of patients having comorbidities significant enough to exclude them from surgery. Locoregional anaesthesia, provided via spinal, epidural, or a combined approach offers a means of providing anaesthesia that places a reduced level of strain on patients' cardiorespiratory function. We review the existing literature on the topic of so-called "awake laparotomy" performed with locoregional anaesthesia and present a case series including both elective and emergency procedures.

A Complicated Case of Postpartum Myasthenic Crisis

Myasthenia gravis (MG) is the most common autoimmune disorder affecting the neuromuscular junction (NMJ) of voluntary skeletal muscle. This disease is characterized by ptosis, diplopia, facial muscle weakness, bulbar muscle involvement including dysphagia and difficulty chewing, dysarthria, hypophonia, respiratory muscle fatigue, and sometimes generalized weakness. A myasthenic crisis (MC) is a complication of MG. MC is defined as severe worsening of respiratory function necessitating the need for mechanical ventilation. Precipitating factors include infection, certain drugs, pregnancy, childbirth, surgery, discontinuation of medical therapy, or even spontaneously with no inciting event. Here we present a complicated case of a 24-year-old patient with a long history of controlled who encounters many events that lead to an MC necessitating mechanical intubation, plasmapheresis, and high dose immunosuppressive therapy. She recently gave birth to a child, had an occult perforated appendicitis with multiple abscesses needing emergent exploratory laparotomy, and had an overlying COVID-19 infection. The complexity of this disease and its complications warrants careful consideration by physicians in any branch of specialty.

Regional anesthesia in pediatric patients with preexisting neurological disease

Preexisting neurological disease in pediatric patients presents unique challenges to the anesthesiologist. In-depth knowledge of the disease processes and awareness of sequalae that uniquely influence the risks and benefits of anesthetics are needed to make informed decisions. Because these vulnerable populations are often susceptible to perioperative airway or cardiopulmonary complications, the use of regional anesthesia can be advantageous. However, these clinical conditions already involve compromised neural tissue and, as such, create additional concern that regional anesthesia may result in new or worsened deficits. The following discussion is not intended to be a full review of each disease process, but rather provides a concise, yet thorough, discussion of the available literature on regional anesthesia in the more common, but still rare, pediatric neurological disorders. We aim to provide a framework for pediatric anesthesiologists to reengage in a healthy discussion about the risks and benefits of utilizing regional anesthesia in this vulnerable population.

Perianesthetic Implications and Considerations for Myasthenia Gravis

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease in which antibodies against the post-nicotinic acetylcholine receptor at the neuromuscular junction develop. Although the exact cause of MG remains unknown, the thymus is a common factor in many cases. Patients with underlying junctional disease, such as MG, have greater anesthesia-related risks because of their known predisposition toward prolonged muscle weakness. Medications given in the perioperative period, such as anesthetic agents, antibiotics, cardiovascular drugs, and corticosteroids, affect neuromuscular transmission that contributes to muscle weakness. Judicious use of neuromuscular blocking agents for patients with MG must be considered. This patient population is at high risk for respiratory failure, and therefore must be carefully assessed throughout the perioperative period to ensure that a regular spontaneous respiratory pattern is sufficient to provide adequate oxygenation. Perianesthesia providers must consider anesthetic, ventilatory, and pharmacologic implications when proposing, providing, and recovering anesthesia for the patient with MG.