Perioperative medical management and outcome following thymectomy for myasthenia gravis

Abstract

Our data show that the severity of MG failed to predict the need for postoperative ventilation. A combined anesthetic technique was a safe and cost-effective alternative to balanced anesthesia as it provided optimal operating conditions and resulted in fewer admissions in ICU and shorter hospital stays.

Propofol or sevoflurane anesthesia without muscle relaxants allow the early extubation of myasthenic patients

“…It is a subject of debate if the determinants of postoperative mechanical ventilation are the preoperative clinical condition (such as Osserman's class), 18 or the intraoperative use of muscle relaxants. 2 In our series, none of the seven Osserman class III patients suffered from respiratory complications.…”

“…The use of muscle-relaxants in patients with MG has been associated with a higher rate of unsuccessful extubation at the end of surgery and with longer postoperative mechanical ventilation and hospital stay. 2,5 We avoided muscle relaxants in myasthenic patients because the neuromuscular effects of non-depolarizing muscle relaxants are known to be prolonged in patients with MG. 1 The speed of onset of neuromuscular block is accelerated, the degree of block is potentiated and the rate of recovery is decreased. 6 Chevalley et al described the evolution of the perioperative management of myasthenic patients undergoing thymectomy and the possibility to predict the need for systematic postoperative ventilation.…”

“…6 Chevalley et al described the evolution of the perioperative management of myasthenic patients undergoing thymectomy and the possibility to predict the need for systematic postoperative ventilation. 2 They observed that postoperative ventilatory support was more frequently required when a balanced technique was used, particularly in patients who received muscle relaxants. Our findings support the results of that article as we did not use any muscle relaxants and we extubated all patients early in the operating room.…”

“…The role of the thymus in MG has been suggested by the evidence that 10-15% of patients present a thymoma and at least 60% thymus hyperplasia or dysplasia and by the beneficial effects of thymectomy in 40 to 90% of patients. 2 The myasthenic patient represents a significant challenge for the anesthesiologist; in fact these patients are known to be unusually sensitive to non-depolarizing muscle relaxants agents, commonly used during anesthesia, 3 and for the risk of postoperative respiratory failure that may result from stress induced exacerbation of MG (myasthenic crisis) or other adverse drug interactions (antibiotics or antiarrhythmics).…”

Untitled

“…14 One study indicated that anesthesia with desflurane combined with remifentanil is safe in patients with MG. 15 Although general anesthetics may affect neuromuscular transmission, recent anesthetic approaches may be safely performed in myasthenic patients. [16][17][18][19][20][21] Our patient was adequately monitored, and no abnormal signs were seen during surgery. She had no immediate adverse effects from the anesthetics.…”