We had a patient with myasthenia gravis who came for transthroacic removal of his thymus. Because the disease is an autoimmune disorder the thymus can be removed to help control symptoms relating to MG. In MG, antibodies bind to acetylcholine receptors decreasing the number of functional acetylcholine receptors that results in an increased sensitivity to nondepolarizing muscle relaxants (NDMRs) and a resistance to succinylcholine. Often times we don't paralyze these patients because they already have muscle weakness and combined with volatile agent are adequately relaxed for laryngoscopy. I presume this was the assumption my attending was working under when he decided to allow my preceptor to intubate without providing muscle relaxant. We were also placing a double-lumen tube (DLT) which made the situation even more risky. While advancing the DLT past the vocal cords the patient began to bite down on the laryngoscope. The attending told her to leave it in but she felt it was best to try to pull it out, which she did. Unfortunately the patient lost about 1mm of tooth from the top of his lower incisor. Looking back on the mishap I wonder what things we could have done differently. Would putting in a bite block before laryngoscopy be wise or would it just get in the way? Would using an LTA kit have helped dampen those reflexes since the patient didn't start biting until she past the DLT past the vocal cords? Did we find out enough about the patients severity of the disease before the procedure? Could we have given sux or a NDMR? Baby Miller suggests that we can.
Measurement of neuromuscular function in patients with myasthenia gravis treated with pyridostigmine demonstrates resistance to the effects of succinylcholine. The ED95 is approximately 2.6 times normal. Because the dose of succinylcholine commonly administered to normal patients (1.0–1.5 mg/kg) represents three to five times the ED95, it is likely that adequate intubating conditions can be achieved in patients with myasthenia gravis using these doses. The mechanism for the resistance to succinylcholine is unknown, but the decreased number of acetylcholine receptors at the postsynaptic neuromuscular junction may play a role.
What do you think is the best approach? Is there anything you would have done differently? Comment below.
I had this case once with Dr. Kelly and he used the same "no MR" technique. The pt was an otherwise young healthy guy other than the MG...so he was able to tolerate a large dose of propofol (almost 3 mg/kg) and then masked for a few minutes with 1.1 MAC of volatile anesthestic, and a lidocaine to blunt the airway reflex. In my case, it worked like a charm. He was intubated with a regular ETT however.
ReplyDelete...Personally , I would probably attempt to use NDMR. Use the old "titrate to effect" theme. And in the case of your situation, I would have tried to relax the patient (whether it had been with a blast of propofol or some NDMR)before removing the blade...seems like it would work...But what do I know?!
I was diagnosed with Myasthenia Gravis in 2014, 2 years after they removed a tumor on my thymus. It's been an okay road. Had one flare which put me in the hospital 4 years ago and this previous year I have been in and out of the hospital trying to see which treatment can get me back feeling 100% again. Pyridostigmine bromide just makes me nauseous all day and didn't help my droopy eye or swallowing so I need to try something else which was natural herbs recommendation from multivitamincare. org This herbal treatment has successfully cure my MG and am 100% free ,I completed the herbal treatment program last year December and am very delighted i came across their website.it starts in the eyes and face then bulgar muscles , without treatment or the proper dosages of treatment it goes on to my limbs and then neck and breathing muscles but I can happily say that am free from MG after taking my chances to try natural herbs ,my neurologist was surprise after my result of being totally cured with herbal cure from the org.
DeleteSeveral myasthenia gravis drugs including neostigmine, pyridostigmine, cyclosoprinetc are recommended but they have severe side effects. Greveton, herbal product offered by Herbs Solutions By Nature is the best treatment available for improving quality of life. Thymectomy is also sometimes done but it is a highly invasive surgical procedure.
ReplyDeleteMy Myasthenia Gravis (MG) symptoms started at the age of 51, I have had countless plasma exchanges as my veins are bad. I also needed Hickman lines inserted. I have been on azathioprine, mycophenolate (CellCept), methotrexate and none have worked. I'm currently done with my herbal remedy I purchased from multivitamincure which has totally cured my condition with a surprise after almost four months of their usage, I was discouraged and never thought I would be myasthenia gravis (MG) free today,to me the best way to get rid of this condition is multivitamincure herbal recommendation because all medications I used never worked include mycophenolate (CellCept),contact the multivitamincare .org today Call Us (or SMS): +1 (956) 758-7882 to learn more about Myasthenia Gravis (MG) herbal remedies options.
DeleteAmazing blog ! Myasthenia gravis, a muscle disease is also treated with Huperzine. It can also be used in increasing alertness and energy.But it should be used when suggested by doctors
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ReplyDeleteI had myasthenia gravis since 2015. I got medically discharged out of the Army, a job I loved well. My heart had 5 myasthenic crises, 3 being severe enough to be ventilated or require CPAP (continuous positive airway pressure) helmet. I have had countless plasma exchanges as my veins are bad. I also needed Hickman lines inserted. I have been on azathioprine, mycophenolate (CellCept), methotrexate and none have worked. I'm currently done with my herbal remedy I purchase from totalcureherbsfoundation .com which has totally cured my condition with a surprise after almost four months of their usage, I was discouraged and never thought I would be myasthenia gravis (MG) free ,to me the best to get rid of this condition is totalcureherbsfoundation com treatment because all medications I used never worked include mycophenolate (CellCept)
ReplyDeleteI was diagnosed with Myasthenia Gravis in 2014, 2 years after they removed a tumor on my thymus. It's been an okay road. Had one flare which put me in the hospital 4 years ago and this previous year I have been in and out of the hospital trying to see which treatment can get me back feeling 100% again. Pyridostigmine bromide just makes me nauseous all day and didn't help my droopy eye or swallowing so I need to try something else which was natural herbs recommendation from multivitamincare. org This herbal treatment has successfully cure my MG and am 100% free ,I completed the herbal treatment program last year December and am very delighted i came across their website.it starts in the eyes and face then bulgar muscles , without treatment or the proper dosages of treatment it goes on to my limbs and then neck and breathing muscles but I can happily say that am free from MG after taking my chances to try natural herbs ,my neurologist was surprise after my result of being totally cured with herbal cure from the org.
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