Dilemmas of an Anesthesiologist to assure a patient with Myasthenia Gravis safely walks the tightrope through the peri-operative course

Abstract

Background: Myasthenia gravis [MG] is an autoimmune disorder of neuromuscular transmission. A significant percentage of patients diagnosed with this disease benefit from thymectomy. It poses unique peri-operative challenges to the anaesthesiologists. Case: A 27 year old male diagnosed with MG-stage III, on Pyridostigmine, Azathioprine & Methylprednisolone, was posted for thoracoscopic thymectomy. This case report documents our experience about managing the patient’s ongoing treatment peri-operatively, judicious use of neuromuscular blockers assisted by neuromuscular & bis monitoring; management of intra-operative complications such as ventricular tachycardia and continuously rising end tidal carbon dioxide. Reversal of the neuromuscular blockade was guided by monitoring the train of four count / ratio.Conclusion: The perioperative concerns include-Assessment of Airway & respiratory muscle strength, implications of superior mediastinal mass, managing the neuromuscular blockers intra-operatively & identifying the risk factors to decide the need of postoperative ventilation. Neuromuscular monitoring is an absolute must.