Anesthetic Considerations in A Patient With Bulbar Onset Myasthenia Gravis (MG) For Paraesophageal Hiatal Hernia Repair: A Case Report And Brief Review Of Literature.

Abstract

Introduction: Myasthenia Gravis (MG) poses a huge challenge for any anesthetist in different terms of management. These patients require special terms of care in the pre, peri and post operative period. In this study we are addressing the anesthetic considerations for an MG patient with variable clinical symptoms and several medical conditions during general anesthesia (GA).

Aim and Objectives: The main aim of this case report is to present our approach for GA in an MG patient taking into consideration the peri-operative care and challenges. We also describe how an interprofessional team manages MG during GA, briefly provide an explanation for the pathophysiology of the disease, examine the risk factors and clinical outcomes and summarize peri-operative evaluation of the disease.

Conclusion:

MG is an autoimmune neuromuscular junction disorder, characterized by skeletal muscle weakness that worsens with activity. Respiratory muscle function, medications, and medical history are important factors in assessing the risk of postoperative respiratory failure. Neuromuscular blocking agents (NMBAs) should be avoided as possible in such patients. A clear understanding of the disease allows for an individualized anesthetic approach.

Case presentation:

A middle-aged female patient with bulbar onset MG, controlled asthma and suspected allergy to fentanyl was posted electively for laparoscopic paraesophageal hiatal hernia repair under GA. Preoperative evaluation was done and the patient was cleared from neurology side. American Society of anesthesiologists (ASA) basic standard monitoring was applied. A test dose of remifentanil was administered. During induction, she received remifentanil, ketamine, propofol and lidocaine intravenously (IV). Desflurane and continuous remifentanil infusion were used for GA maintenance. The emergence from GA was uneventful. Postoperative analgesia was covered with paracetamol, ketorolac and meperidine. Patient was transferred to post anesthesia care unit (PACU) post operatively for observation. On the 6th day postoperatively, she was discharged home safely.

Key words: myasthenia gravis, Bulbar manifestation, General Anesthesia, neuromuscular monitoring, sugammadex