Anesthesia for patients undergoing transsternal thymectomy for juvenile myasthenia gravis

Abstract

Background:Juvenile myasthenia gravis (JMG) is the rare form of myasthenia gravis presenting in childhood and adolescence. When medical management fails, thymectomy is offered for these patients. Complete resection of the thymus is best achieved through transsternal thymectomy. Anesthetic management of patients with JMG is challenging, particularly in regards to the goals of postoperative pain control, respiratory function, and extubation.Methods:We retrospectively reviewed the medical records of 13 patients, ranging in age from 6 to 22 years, who underwent transsternal thymectomy for JMG. Information on patient demographics, characteristics of their disease and treatment, anesthetic management, and postoperative course were collected.Results:All patients had undergone multiple treatment modalities and presented for surgery because of inadequate symptom control with medical management. As expected for a pediatric population, anesthesia induction was age dependent. 40% of the patients underwent an inhalation induction and 60% underwent an intravenous induction. Anesthesia was maintained with a low-dose inhalation agent in all patients, supplemented in 84% of patients with a remifentanil infusion, and in 69% of patients with an epidural infusion. Muscle relaxants were avoided in all patients. With this regimen, 92% of patients could be extubated successfully in the operating room.Conclusion:We found that avoidance of muscle relaxants and use of remifentanil with a low-dose hypnotic agent provided a stable intraoperative course, facilitated rapid emergence, and allowed early extubation in patients with JMG undergoing transsternal thymectomy. Epidural analgesia reduced the need for intra- and postoperative intravenous opioids and did not have an adverse effect on respiratory strength.

Laparoscopic Sleeve Gastrectomy in a Morbidly Obese Patient with Myasthenia Gravis: A Review of the Management

“…Yet there is a concern about respiratory depression with the use of opioids. This has led to the use of remifentanil, which has a short half-life allowing for easier titration during induction of anesthesia [ 20 ].…”

Sevoflurane and thoracic epidural anesthesia for trans-sternal thymectomy in a child with juvenile myasthenia gravis

“…No specific anesthesia technique has been proven to be superior for thymectomy. [ 1 ] Use of muscle relaxant remains the most important consideration. Succinylcholine dose requirement is increased 3-4 times[ 3 ] and phase 2 blockade can occur since the threshold for causing depolarising block is exceeded.…”

“…[ 9 ] TIVA with propofol and remifentanyl infusion has been used for thymectomy which decreased the need for muscle relaxants. [ 1 3 ] Opioids at therapeutic concentration have no effect on neuromuscular transmission but central respiratory depression is a concern. [ 8 ] Remifentanyl has been found to provide an adequate depth for intubation with good recovery and can be used as an adjunct when muscle relaxant is not used.…”

“…However, 60%-90% children show improvement following thymectomy. [ 1 2 ] Available literature on the anesthetic management of JMG is limited and mainly consists of various techniques aimed at avoiding muscle relaxant. [ 1 ] We report a child with JMG after obtaining consent from parents who successfully underwent transsternal thymectomy under sevoflurane and thoracic epidural anesthesia.…”

Peri-operative management of a child with juvenile myasthenia gravis undergoing thoracoscopic thymectomy - a case report

“…Trans-sternal and thoracoscopic thymectomies have been successfully performed in JMG with anaesthetic agents combined with remifentanyl or thoracic epidural analgesia or both without any muscle relaxants. 1,4,5 Since lung isolation with a cumbersome double lumen tube was not used, conventional endotracheal tube was easily tolerated with isofurane and remifentanyl infusion. All the other anesthetic challenges associated with one lung ventilation such as desaturation, shunting, atelectasis were minimized as surgical access was achieved by only partial lung collapse with created capnothorax.…”