CASE REPORT : A NON MUSCLE RELAXANT TECHNIQUE  FOR A MYASTHENIA GRAVIS PATIENT UNDERGOING  VIDEO-ASSISTED THORACOSCOPIC SURGERY

Marilaeta Cindryani Ra , Ratumasa; Kadek Agus Heryana Putra; Putu Bagus Arisadika

doi:10.31004/prepotif.v9i2.45656

Authors

Marilaeta Cindryani Ra , Ratumasa Anesthesiology and Intensive Care Department, Prof. Dr. I.G.N.G. Ngoerah General, Hospital/Udayana University, Denpasar, Bali, Indonesia
Kadek Agus Heryana Putra Anesthesiology and Intensive Care Department, Prof. Dr. I.G.N.G. Ngoerah General, Hospital/Udayana University, Denpasar, Bali, Indonesia
Putu Bagus Arisadika Anesthesiology and Intensive Care Department, Prof. Dr. I.G.N.G. Ngoerah General, Hospital/Udayana University, Denpasar, Bali, Indonesia

DOI:

https://doi.org/10.31004/prepotif.v9i2.45656

Keywords:

blokade neuromuscular, manajemen anestesi, myasthenia gravis, operasi toraks

Abstract

Miastenia gravis (MG) adalah kelainan autoimun kronis langka yang mengganggu transmisi neuromuskular dan ditandai dengan kelemahan otot rangka yang berfluktuasi. Penatalaksanaan anestesi pada pasien dengan MG menghadirkan tantangan yang signifikan, terutama karena sensitivitas mereka yang berubah terhadap agen anestesi dan peningkatan risiko komplikasi pernapasan pascaoperasi. Seorang pria berusia 54 tahun yang didiagnosis dengan MG dijadwalkan menjalani operasi torakoskopi berbantuan video (VATS) untuk membuat jendela perikardial dan mendapatkan biopsi, yang dipicu oleh adanya efusi perikardial melingkar sedang hingga berat. Riwayat medisnya meliputi kesulitan pernapasan dan penyakit paru restriktif, yang memerlukan pendekatan anestesi yang cermat yang menghindari penggunaan agen penghambat neuromuskular untuk mencegah risiko kelumpuhan yang berkepanjangan. Anestesi dipertahankan dengan aman menggunakan kombinasi remifentanil dan propofol, dan isolasi paru-paru dicapai secara efektif dengan pemasangan tabung endotrakeal lumen ganda. Pendekatan ini memungkinkan upaya pernapasan spontan dan kondisi intraoperatif yang stabil. Kasus ini menggambarkan pentingnya perencanaan anestesi individual pada pasien MG, dengan menekankan perlunya menghindari relaksan otot dan mempertahankan fungsi pernapasan, terutama dalam prosedur bedah toraks. Dengan menyesuaikan strategi anestesi dengan pertimbangan patofisiologi spesifik MG, hasil perioperatif yang optimal dapat dicapai pada populasi berisiko tinggi ini.

References

Ahmed, J., Khan, M., & Khan, A. (2018). Perioperative management of patients with myasthenia gravis: A review. Cureus, 10(6), e2854. https://doi.org/10.7759/cureus.2854

Chevalley, C., Spiliopoulos, A., de Perrot, M., Tschopp, J. M., & Licker, M. (2001). Perioperative medical management and outcome following thymectomy for myasthenia gravis. Canadian Journal of Anaesthesia, 48(5), 446–451.

Collins, S., Roberts, H., & Hewer, I. (2020). Anesthesia and perioperative considerations for patients with myasthenia gravis. AANA Journal, 88(6), 485–491.

Daum, P., Smelt, J., & Ibrahim, I. R. (2021). Perioperative management of myasthenia gravis. BJA Education, 21(11), 414–419.

Della Rocca, G., Coccia, C., Diana, L., Pompei, L., Costa, M. G., Tomaselli, E., Di Marco, P., Vilardi, V., & Pietropaoli, P. (2003). Propofol or sevoflurane anesthesia without muscle relaxants allow the early extubation of myasthenic patients. Canadian Journal of Anaesthesia, 50(6), 547–552.

Dewilde, S., Philips, G., Paci, S., Beauchamp, J., Chiroli, S., Quinn, C., et al. (2023). Patient-reported burden of myasthenia gravis: Baseline results of the international prospective, observational, longitudinal real-world digital study MyRealWorld-MG. BMJ Open, 13(1), e066445.

Dezube, A. R., Deeb, A. L., & Jaklitsch, M. T. (2021). Narrative review of surgery for myasthenia gravis. OBM Neurobiology, 5(4), 1–1.

Hien, V. V., Tu, N. H., & Thu, N. D. (2023). Propofol TCI or sevoflurane anesthesia without muscle relaxant for thoracoscopic thymectomy in myasthenia gravis patients: A prospective, observational study. BMC Anesthesiology, 23(1), 349.

Karattuparambil, J., Bains, R., & Govindaswamy, A. (2021). Anaesthesia for thoracoscopic thymectomy in myasthenia gravis: A non-muscle-relaxant technique. Journal of Cardiothoracic and Vascular Anesthesia, 35, S41–S42.

Karunarathna, I., Bandara, S., Jayawardana, A., De Alvis, K., Gunasena, P., Hapuarachchi, T., et al. (2024). Managing anesthesia in myasthenia gravis: From pre-op to post-op care. Uva Clinical Anaesthesia and Intensive Care. Retrieved from https://www.researchgate.net/publication/383053060

Rowbottom, S. (1989). Isoflurane for thymectomy in myasthenia gravis. Anaesthesia and Intensive Care, 17, 444–447.

Sanders, D. B., Wolfe, G. I., Benatar, M., Evoli, A., Gilhus, N. E., Illa, I., ... & Verschuuren, J. J. (2016). International consensus guidance for management of myasthenia gravis: Executive summary. Neurology, 87(4), 419–425. https://doi.org/10.1212/WNL.0000000000002790

Senapathi, T. G. A., Subagiartha, I. M., Nada, I. K. W., & Mahendra, I. B. P. O. (2020). Erector spinae plane block for different surgeries: A case series. Bali Journal of Anesthesiology, 4(4), 203–205. https://doi.org/10.4103/BJOA.BJOA_111_20

Sheikh, S., Alvi, U., Soliven, B., & Rezania, K. (2021). Drugs that induce or cause deterioration of myasthenia gravis: An update. Journal of Clinical Medicine, 10(7), 1537.

Sloan, D. A., & Wahidi, M. M. (2021). Anesthetic considerations in patients undergoing video-assisted thoracoscopic surgery: Focus on high-risk populations. Current Opinion in Anesthesiology, 34(1), 24–30. https://doi.org/10.1097/ACO.0000000000000960

Tosh, P., Rajan, S., Narayani, N., Babu, K. C., Kumar, N., & Paul, J. (2020). Comparison of efficacy and safety of dexmedetomidine versus propofol infusion for maintaining depth of general anesthesia when muscle relaxants are not used. Bali Journal of Anesthesiology, 4(2), 42–45. https://doi.org/10.4103/BJOA.BJOA_6_20

Urovi, S. (2023). Video-assisted thoracoscopic surgery (VATS) and multimodal anaesthetic approach in non-intubated patients. Journal of Cardiothoracic and Vascular Anesthesia, 37, 45–46.

Vanjari, V., & Maybauer, M. (2020). Anaesthetic management of myasthenia gravis in coronary artery bypass grafting. Annals of Cardiac Anaesthesia, 23(2), 209.

Wu, J., Li, N., Zhang, J., Tang, X., & Cao, X. (2023). Safety and efficacy of remifentanil-propofol combination on “muscle relaxant-free” general anesthesia for therapeutic endoscopic retrograde cholangiopancreatography: A randomized controlled trial. American Journal of Translational Research, 15(8), 5292–5303.

Yun, M., Kim, G. H., Ko, S., Han, Y. J., & Kim, W. (2022). Comparison of two-lung and one-lung ventilation in bilateral video-assisted thoracoscopic extended thymectomy in myasthenia gravis: A retrospective study. Anesthesia and Pain Medicine (Seoul), 17(2), 199–205.