Anaesthesia for thymectomy in adult and juvenile myasthenic patients

Successful Neuromuscular Blockade Reversal Using Sugammadex and Neostigmine Failed to Prevent Myasthenic Crisis After Emergency Surgery: A Case Report

Recent literature suggests that the use of sugammadex for the reversal of neuromuscular blocking agents (NMBAs) reduces the risk of postoperative myasthenic crisis (MC) in patients with myasthenia gravis (MG), particularly after thymectomy, but studies are lacking on emergency surgeries. We achieved successful intraoperative reversal of neuromuscular blockade (NMB) using a combination of sugammadex and neostigmine (with glycopyrrolate). However, MC was not avoided and reintubation was required on postoperative day 1.

A 65-year-old male with a longstanding history of MG presented to the emergency department with complaints of abdominal pain, diarrhea, vomiting, chills, and fatigue for three days. A computed tomography (CT) scan of the abdomen showed acute appendicitis, for which he underwent a laparoscopic appendectomy on hospital day 1. The patient received successful general anesthesia with a rapid sequence induction using a smaller than average dose of rocuronium, given his history of MG. At the conclusion of the case, sugammadex followed by neostigmine/glycopyrrolate and a subsequent dose of sugammadex were given, with reversal of NMB. The patient was successfully extubated but required reintubation on postoperative day 1 for hypercapnic respiratory failure.

Our case report on this patient with MG yields two topics that have not been extensively examined. First, dual therapy with sugammadex and neostigmine/glycopyrrolate may provide significant clinical benefit over individual therapy for NMBA reversal, given that their mechanisms of action are different and particularly when sugammadex is given prior to neostigmine/glycopyrrolate. Second, anesthesia literature is lacking on MG patients undergoing emergency surgeries. While sugammadex has been promising in medically optimized non-emergent surgeries, we discuss here a case where sugammadex failed to prevent MC in the emergency surgery setting and a look into what may provide patients with the best chance for avoiding postoperative MC.

Mapping the current evidence on the anesthetic management of adult patients with neuromuscular disorders-a scoping review

PURPOSE

Patients with neuromuscular disorders (NMDs) are at increased risk of perioperative complications. The objective of this scoping review was to examine emerging evidence from published studies, case reports, and review articles on anesthetic management of patients with NMDs, following the methodological frame for scoping reviews.

SOURCES

We searched PubMed and EMBASE for articles published between 1 January 2000 and 14 July 2021.

PRINCIPAL FINDINGS

Three prospective and 21 retrospective studies on altered pharmacokinetics and pharmacodynamics of neuromuscular blocking agents (NMBA) in NMD patients were included. Furthermore, 168 case reports/series reporting 212 anesthetics in 197 patients were included. These studies showed that preanesthetic neuromuscular monitoring can be used for precise NMBA dosing in myasthenia gravis patients. Sugammadex was associated with fewer postoperative myasthenic crises. Perioperative complications were not associated with specific anesthetic agents. Case reports/series showed that in 32% (67/212) of anesthetics, at least one complication was reported. Unexpected intensive care unit admission was a frequently reported complication. Patients with a complicated disease course may have had a higher use of succinylcholine (unadjusted relative risk, 0.13; 95% confidence interval [CI], 0.20 to 0.86) and volatile anesthetics (adjusted odds ratio [OR], 0.38; 95% CI, 0.20 to 0.73; P = 0.004).

CONCLUSION

Evidence on the anesthetic management and perioperative complications of patients with NMDs is mainly based on small retrospective studies and case reports. Further clinical trials or large retrospective studies are required to investigate the choice of safe anesthetic agents. Main areas of interest are the potential benefits of neuromuscular monitoring and sugammadex and the risks possibly associated with volatile anesthetics and succinylcholine.

Drugs That Induce or Cause Deterioration of Myasthenia Gravis: An Update

Myasthenia gravis (MG) is an autoimmune neuromuscular disorder which is characterized by presence of antibodies against acetylcholine receptors (AChRs) or other proteins of the postsynaptic membrane resulting in damage to postsynaptic membrane, decreased number of AChRs or blocking of the receptors by autoantibodies. A number of drugs such as immune checkpoint inhibitors, penicillamine, tyrosine kinase inhibitors and interferons may induce de novo MG by altering the immune homeostasis mechanisms which prevent emergence of autoimmune diseases such as MG. Other drugs, especially certain antibiotics, antiarrhythmics, anesthetics and neuromuscular blockers, have deleterious effects on neuromuscular transmission, resulting in increased weakness in MG or MG-like symptoms in patients who do not have MG, with the latter usually being under medical circumstances such as kidney failure. This review summarizes the drugs which can cause de novo MG, MG exacerbation or MG-like symptoms in nonmyasthenic patients.

Use of sugammadex in patients with neuromuscular disorders: a systematic review of case reports

Background

Sugammadex is a modified gamma-cyclodextrin that acts by selectively encapsulating free amino-steroidal neuromuscular relaxants. Several case reports have been published on the use of sugammadex in patients with neuromuscular disorders that include neuromuscular junction diseases, myopathies, neuropathies, and motor neurone disorders. The primary aim of this review is to systematically review the evidence on the use of sugammadex in patients with this heterogeneous group of diseases and provide recommendations for clinical practice.

Methods

A systematic electronic search of Medline, Embase and CINAHL databases was done until June 2019, to identify case reports describing the use of sugammadex in adult surgical patients with neuromuscular disorders.

Results

Of the 578 records identified through database searches, 43 articles were finally included for the systematic review. Of these, 17 reports were on patients with myopathy, 15 reports on myasthenia gravis, 9 reports on motor neuron diseases and 2 reports on neuropathies.

Conclusions

Majority of the articles reviewed report successful use of sugammadex to reverse steroidal muscle relaxants, especially rocuronium, in patients with neuromuscular diseases. However, with sugammadex, unpredictability in response and uncertainty regarding optimum dose still remain issues. Quantitative neuromuscular monitoring to ensure complete reversal and adequate postoperative monitoring is strongly recommended in these patients, despite the use of sugammadex.

Magnesium sulfate reduces the rocuronium dose needed for satisfactory double lumen tube placement conditions in patients with myasthenia gravis

Background

Using a minimum dose of neuromuscular blockade (NMB) to achieve intubation condition is one of the goals in anaesthesia management of patients with myasthenia gravis (MG) for thoracoscopic (VATS) thymectomy. However, tracheal intubation with double lumen tube (DLT) could be challenging if intubation condition is not optimal. This double-blind randomised controlled study was designed to investigate whether magnesium sulfate would reduce the rocuronium dose needed for DLT intubation and improve the DLT placement condition for patients with MG who were scheduled for video-assisted thoracoscopic (VATS) thymectomy.

Methods

Recruited patients were randomly assigned to receive magnesium sulfate 60 mg.kg^− 1 or normal saline (control) prior to the administration of NMB. Titrating dose of rocuronium was administered to achieve train of four (TOF) ratio less than 10% before DLT intubation. The primary outcome was the rocuronium dose required to achieve TOF ratio less than 10%. The secondary outcome was intubation condition for DLT placement.

Results

Twenty-three patients had received magnesium sulfate and 22 patients had received normal saline before rocuronium administration. The required rocuronium dose [mean (standard deviation)] were 0.10 (0.05) mg.kg^− 1 and 0.28(0.17) mg.kg^− 1 in patients who had magnesium sulfate and normal saline respectively(P < 0.0001). With a similar depth of neuromuscular blockade and depth of anaesthesia, 100% of patients in the magnesium sulfate group and 72.7% of patients in the control group showed excellent intubation condition (P = 0.027) respectively. The patients in both groups had similar emergence characteristics.

Conclusions

Magnesium sulfate is associated with a decrease in rocuronium requirement for an optimal DLT intubation condition in patients with MG for VATS thymectomy.

Trial registration

Clinical Trial Registry of China (http://www.chictr.org.cn) identifier: ChiCTR-1800017696, retrospectively registered on August 10, 2018.

Failure of reversion of neuromuscular block with sugammadex in patient with myasthenia gravis: case report and brief review of literature

Background

Myasthenia gravis (MG) is a challenge for anesthesia management. This report shows that the use of rocuronium-sugammadex is not free from flaws and highlights the importance of cholinesterase inhibitors management and neuromuscular block monitoring in the perioperative period of myasthenic patients.

Case presentation

Myasthenic female patient submitted to general balanced anesthesia using 25 mg of rocuronium. Under train-of-four (TOF) monitoring, repeated doses of sugammadex was used in a total of 800 mg without recovery of neuromuscular blockade, but TOF ratio (TOFR) was stabilized at 60%. Neostigmine administration led to the improvement of TOFR.

Conclusions

Although the use of rocuronium-sugammadex seems safe, we should consider their unpredictability in myasthenic patients. This report supports the monitoring of neuromuscular blockade as mandatory in every patient, especially the myasthenic ones.

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.