Respiratory Arrest after Postoperative Extubation in a Myasthenic Patient who Received Sugammadex to Reverse Neuromuscular Blockade
Keywords:Myasthenia gravis, Myasthenic crisis, Thymectomy, Sugammadex
Postoperative myasthenic crisis is common after thymectomy; the incidence ranges from 12 to 34%. Several factors are known to predict myasthenic crisis and increased risk necessitating postoperative mechanical ventilation, but incomplete postoperative reversal cannot be prevented perfectly. Sugammadex is a medicine that reverses neuromuscular blockade, and can be used to facilitate the return of spontaneous respiration in myasthenic patients. It was recently reported that myasthenic patients rapidly recovered neuromuscular function when sugammadex was used. An 81-year-old, 49 kg woman diagnosed with myasthenia gravis one month previously was admitted for intravenous immunoglobulin G treatment and thymectomy. After thymectomy the patient suffered a myasthenic crisis and respiratory arrest, despite administration of sugammadex to reverse the neuromuscular blockade.
This case suggests that more careful and strict evaluation and management should be conducted perioperatively in myasthenic patients, and that the recovery time (time to obtain a train-of-four [TOF] value > 0.9) and spontaneous breathing trial results should be obtained to accurately predict the success of spontaneous breathing.
O'Neill GN, â€œAcquired disorders of the neuromuscular junctionâ€, International Anesthesiology Clinics, vol 44, pp.107-21, 2006.
Sungur Ulke Z, Yavru A, Camci E, Ozkan B, Toker A, Senturk M, â€œRocuronium and sugammadex in patients with myasthenia gravis undergoing thymectomyâ€, Acta Anaesthesiol Scand, vol 57, pp.745-8, 2013.
Nozari A, Bagchi A, Saxena R, Bateman BT, Neuromuscular Disorders and Other Genetic Disorders, Miller's Anesthesia 8edn(Elsevier Saunders), Philadelphia, 2015.
Seigne RD, Scott RP, â€œMivacurium chloride and myasthenia gravisâ€, British Journal of Anaesthesia, vol 72, pp.468-469, 1994.
Wendell LC, Levine JM, â€œMyasthenic crisisâ€, Neurohospitalist, vol 1, pp.16-22, 2011.
Eisenkraft JB, Papatestas AE, Kahn CH, Mora CT, Fagerstrom R, Genkins G, â€œPredicting the need for postoperative mechanical ventilation in myasthenia gravisâ€, Anesthesiology, vol 65, pp.79-82, 1986.
Watanabe A, Watanabe T, Obama T, et al, â€œPrognostic factors for myasthenic crisis after transsternal thymectomy in patients with myasthenia gravisâ€, Journal of Thoracic and Cardiovascular Surgery, vol 127, pp.868-76, 2004.
Blichfeldt-Lauridsen L, Hansen BD, â€œAnesthesia and myasthenia gravisâ€, Acta Anaesthesiol Scand, vol 56, pp.17-22, 2012.
Kim RK, Kim SY, â€œRapid Return of Spontaneous Respiration after General Anesthesia with Sugammadex in a Patient with Myasthenia Gravisâ€, Journal of Lifestyle Medicine, vol 6, pp.43-6, 2016.
Xue L, Wang L, Dong J, et al, â€œRisk factors of myasthenic crisis after thymectomy for thymoma patients with myasthenia gravisâ€, European Journal of Cardio-Thoracic Surgery, vol 52, pp.692-7, 2017.
Yu S, Lin J, Fu X, et al, â€œRisk factors of myasthenic crisis after thymectomy in 178 generalized myasthenia gravis patients in a five-year follow-up studyâ€, International Journal of Neuroscience, vol 124, pp.792-8, 2014.
Ozel F, Altunkan AA, Azizoglu M, â€œPostoperative respiratory failure in a patient with undiagnosed myastenia gravisâ€, Turkish Journal of Anaesthesiology and Reanimation, vol 44, pp.108-10, 2016.
Kiran U, Choudhury M, Saxena N, Kapoor P, â€œSevoflurane as a sole anaesthetic for thymectomy in myasthenia gravisâ€, Acta Anaesthesiol Scand, vol 44, pp.351-3, 2000.
Kim JM, Mangold J, â€œSensitivity to both vecuronium and neostigmine in a sero-negative myasthenic patientâ€, Br J Anaesth,vol 63, pp.497-500, 1989.
Jones RK, Caldwell JE, Brull SJ, Soto RG, â€œReversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmineâ€, Anesthesiology,vol 109, pp.816-24, 2008.
Lemmens HJ, El-Orbany MI, Berry J, Morte JB, Jr., Martin G, â€œReversal of profound vecuronium-induced neuromuscular block under sevoflurane anesthesia: sugammadex versus neostigmineâ€, BMC Anesthesiol, vol 10, pp.15, 2010.
Komasawa N, Noma H, Sugi T, Sukenaga N, Kakiuchi H, â€œEffective reversal of muscle relaxation by rocuronium using sugammadex in a patient with myasthenia gravis undergoing laparoscopic cholecystectomyâ€, Masui, vol 60, pp.476-9, 2011.
Zein H, Baratloo A, Negida A, Safari S, â€œVentilator Weaning and Spontaneous Breathing Trials; an Educational Reviewâ€, Emerg (Tehran), vol 4, pp.65-71, 2016.
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