Outcomes after major surgery in patients with myasthenia gravis: A nationwide matched cohort study

Perioperative Management in Neuromuscular Diseases: A Narrative Review

Patients with neuromuscular diseases are particularly vulnerable in the perioperative period to the development of pulmonary and cardiac complications, or medication side effects. These risks could include hypoventilation, aspiration pneumonia, exacerbation of underlying cardiomyopathy, arrhythmias, adrenal insufficiency, prolonged neuromuscular blockade, issues related to thermoregulation, rhabdomyolysis, malignant hyperthermia, or prolonged mechanical ventilation. Interventions at each of the perioperative stages can be implemented to mitigate these risks. A careful pre-operative evaluation may help identify risk factors so that appropriate interventions are initiated, including cardiology consultation, pulmonary function tests, initiation of noninvasive ventilation, or implementation of preventive measures. Important intraoperative issues include positioning, airway and anesthetic management, and adequate ventilation. The postoperative period may require correction of electrolyte abnormalities, control of secretions with medications, manual or mechanical cough assistance, avoiding the risk of reintubation, judicious pain control, and appropriate medication management. The aim of this review is to increase awareness of the particular surgical challenges in this vulnerable population, and guide the clinician on the various evaluations and interventions that may result in a favorable surgical outcome.

The role of thymectomy in myasthenia gravis: A programmatic approach to thymectomy and perioperative management of myasthenia gravis

BACKGROUND

Myasthenia gravis is a rare autoimmune disease caused by antibodies that probably originate from the thymus glands. This study examined the epidemiology of patients with MG, who underwent thymectomy over the last three decades.

METHODS

The objectives of this observational study were to investigate the clinicopathological features, treatment modalities, and prognostic factors for patients with thymic masses, over three decades at the Royal Hospital, Muscat, Oman.

RESULTS

There were 100 patients who underwent thymectomy with a mean (SD) age of 32.0 (8.6) years, of which 20% were men and 80% were women. Their follow up period, cardiac and neurology clinics, ranged from 1.5 to 12.0 years with a mean (SD) of 6.0 (3.0) years. Small percentage of MG patients had diabetes and hypertension and 10% of patients have positive family history of MG. Symptoms at the onset of the disease were ophthalmoplegia in 75%, limb weakness in 39%, bulbar symptoms in 57% and respiratory symptoms in 39% of patients. The Osserman grading was Grade I - 5%, Grade IIA - 39%, Grade IIB - 34%, and Grade III - 22%. Post thymectomy, 21% of patients had complete clinical remission, 76% of patients had significant clinical improvement and 3% had no apparent improvement in their clinical status. Histologically, hyperplasia was found in 57% and involuted thymus in 18% of patients.

CONCLUSION

Thymectomy can reduce patient's need for medication and reduce the severity of MG regardless of age, sex, severity, or length of sickness, or thymic masses. The early-onset, sever M.G, female, thymic hyperplasia benefit the most. Patients classified as Osserman Class IIA and IIB benefit most from this procedure.

Increased rate of complications in myasthenia gravis patients following hip and knee arthroplasty: a nationwide database study in the PearlDiver Database on 257,707 patients

Background and purpose - The increasing prevalence of total hip arthroplasty (THA) and total knee arthroplasty (TKA) within the growing elderly population is translating into a larger number of patients with neuromuscular conditions such as myasthenia gravis (MG) receiving arthroplasty. We compared systemic and joint complications following a THA or TKA between patients with MG and patients without MG.Patients and methods - Patient records were queried from PearlDiver (Pearl Diver Inc, Fort Wayne, IN, USA), an administrative claims database, using ICD-9/ICD-10 and Current Procedural Terminology codes. In-hospital and 90-day post-discharge rates of systemic and joint complications were compared between the 2 cohorts.Results - 372 patients with MG and 249,428 patients without MG who received a THA or TKA were included in the study. At 90 days post-discharge, MG patients exhibited exhibited between 1.6 and 15% higher rates of systemic complications, including cerebrovascular event, pneumonia, respiratory failure, sepsis, myocardial infarction, acute renal failure, anemia, and deep vein thrombosis (all p < 0.001). The same results were also found during the in-hospital time period. 90-day incidence of aseptic loosening was the only joint complication with significantly increased odds risk for the MG cohort (OR 5; 95% CI 2-12).Interpretation - Patients with MG exhibited significantly higher risk for multiple systemic complications during the index hospital stay and in the acute post-discharge setting.

Administration of Sugammadex Intraoperatively in a Patient With a Congenital Myasthenic Syndrome: A Case Report

Congenital myasthenic syndromes are a group of genetic neuromuscular disorders caused by mutations that impair synaptic transmission at the neuromuscular junction. Developing an anesthetic plan for patients with this diagnosis is difficult, as they are at risk for prolonged neuromuscular blockade. Sugammadex is an alternative to neostigmine for neuromuscular blockade reversal that does not produce muscarinic side effects, yet there is a little literature assessing sugammadex in congenital myasthenic syndromes. We present the case of a 6-year-old boy with a congenital myasthenic syndrome who received sugammadex without complication. This case provides support for clinicians to consider sugammadex in these patients.

Surveys of post-operative pain management in a teaching hospital in Rwanda - 2013 and 2017

Background: Postoperative pain management (POPM) appeared to be weak in Rwanda. Aims: The aim of this study was to compare POPM measures in a teaching hospital between 2013 and 2017. Methods: A two-phase observational study in 2013 and 2017. was conducted. Participants were recruited prior to major surgery and followed for two postoperative days. A numerical rating scale (0-10) was administered to all participants in both years, and the International Pain Outcomes questionnaire was administered in 2017. Recruitment, consent, and data collection were performed in participants' preferred language. Results: One hundred adult participants undergoing major general, gynecologic, orthopedic, or urologic surgery were recruited in 2013 and 83 were recruited in 2017. Fourteen percent of participants in 2013 and 46% in 2017 scored their worst pain as severe (>6; P < 0.001). This was despite improved preoperative recognition of patients at high risk for severe postoperative pain (those with chronic pain or preoperative pain); 27% and 0% of these patients were not documented in 2013 and 2017, respectively (P = 0.006). Other measures of improved planning included "any preoperative discussion of POPM" (P < 0.001) and "discussion of POPM options" (P = 0.002). Preemptive analgesia use increased (3% of participants in 2013 and 54% in 2017; P < 0.001). Incidence of participants having no postoperative analgesic at all decreased from 25% in 2013 to 5% in 2017 (P < 0.001). Conclusions: Though severe postoperative pain incidence did not improve from 2013 to 2017, POPM improved by a number of measures. These changes may be attributed to pain research conducted there having raised awareness.

Inhospital Complications of Patients With Neuromuscular Disorders Undergoing Total Joint Arthroplasty

INTRODUCTION

Orthopaedic surgeons are wary of patients with neuromuscular (NM) diseases as a result of perceived poor outcomes and lack of data regarding complication risks. We determined the prevalence of patients with NM disease undergoing total joint arthroplasty (TJA) and characterized its relationship with in-hospital complications, prolonged length of stay, and total charges.

METHODS

Data from the Nationwide Inpatient Sample from 2005 to 2014 was used for this retrospective cohort study to identify 8,028,435 discharges with total joint arthroplasty. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify 91,420 patients who had discharge diagnoses for any of the NM disorders of interest: Parkinson disease, multiple sclerosis, cerebral palsy, cerebrovascular disease resulting in lower extremity paralysis, myotonic dystrophy, myasthenia gravis, myositis (dermatomyositis, polymyositis, and inclusion-body myositis), spinal muscular atrophy type III, poliomyelitis, spinal cord injury, and amyotrophic lateral sclerosis. Logistic regression was used to estimate the association between NM disease and perioperative outcomes, including inpatient adverse events, length of stay, mortality, and hospital charges adjusted for demographic, hospital, and clinical characteristics.

RESULTS

NM patients undergoing TJA had increased odds of total surgical complications (odds ratio [OR] = 1.21; 95% confidence interval [CI], 1.17 to 1.25; P < 0.0001), medical complications (OR = 1.41; 95% CI, 1.36 to 1.46; P < 0.0001), and overall complications (OR = 1.32; 95% CI, 1.28 to 1.36; P < 0.0001) compared with non-NM patients. Specifically, NM patients had increased odds of prosthetic complications (OR = 1.09; 95% CI, 0.84 to 1.42; P = 0.003), wound dehiscence (OR = 5.00; 95% CI, 1.57 to 15.94; P = 0.0002), acute postoperative anemia (OR = 1.20; 95% CI, 1.16 to 1.24; P < 0.0001), altered mental status (OR = 2.59; 95% CI, 2.24 to 2.99; P < 0.0001), urinary tract infection (OR = 1.45; 95% CI, 1.34 to 1.56; P < 0.0001), and deep vein thrombosis (OR = 1.27; 95% CI, 1.02 to 1.58; P = 0.021). No difference of in-hospital mortality was observed (P = 0.155).

DISCUSSION

Because more patients with NM disease become candidates of TJA, a team of neurologists, anesthesiologists, therapists, and orthopaedic surgeon is required to anticipate, prevent, and manage potential complications identified in this study.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Understanding the burden of refractory myasthenia gravis

Myasthenia gravis (MG) is an autoantibody-mediated disease that compromises the acetylcholine receptors or associated structures of the postsynaptic membrane of the neuromuscular junction. This leads to impaired neuromuscular transmission and subsequent fluctuating fatigability and weakness of ocular, bulbar, and limb skeletal muscles. Over the past few decades, there have been significant advances in our understanding of the disease pathophysiology and improvements in prognosis due to intensive care medicine and immunomodulation. Despite this, an estimated 10–20% of patients with MG do not achieve an adequate response, are intolerant to conventional treatment, or require chronic treatment with intravenous immunoglobulins or plasma separation procedures. Such patients are regarded as having MG that is ‘refractory’ to treatment and may represent a distinct clinical subgroup. Because the majority of patients with MG have well-controlled disease, the burden of illness in the minority with refractory disease is poorly understood and may be underestimated. However, clinically these patients are liable to experience extreme fatigue, considerable disability owing to uncontrolled symptoms, and frequent myasthenic crises and hospitalizations. Both acute adverse effects and an increased risk of comorbidity from treatment regimens may contribute to reduced quality of life. As yet, little is known concerning the impact of refractory MG on mental health and health-related quality of life. This review aims to highlight the burden of disease and unmet needs in patients with refractory MG.