Haddad Daniel, Hanna Adeeb J, Russo Lori
Medicine, Rowan University School of Osteopathic Medicine, Stratford, USA.
Anesthesiology, North American Partners in Anesthesia (NAPA), Hackensack Meridian Ocean Medical Center, Brick, USA.
Cureus. 2022 Jul 27;14(7):e27366. doi: 10.7759/cureus.27366. eCollection 2022 Jul.
Recent literature suggests that the use of sugammadex for the reversal of neuromuscular blocking agents (NMBAs) reduces the risk of postoperative myasthenic crisis (MC) in patients with myasthenia gravis (MG), particularly after thymectomy, but studies are lacking on emergency surgeries. We achieved successful intraoperative reversal of neuromuscular blockade (NMB) using a combination of sugammadex and neostigmine (with glycopyrrolate). However, MC was not avoided and reintubation was required on postoperative day 1. A 65-year-old male with a longstanding history of MG presented to the emergency department with complaints of abdominal pain, diarrhea, vomiting, chills, and fatigue for three days. A computed tomography (CT) scan of the abdomen showed acute appendicitis, for which he underwent a laparoscopic appendectomy on hospital day 1. The patient received successful general anesthesia with a rapid sequence induction using a smaller than average dose of rocuronium, given his history of MG. At the conclusion of the case, sugammadex followed by neostigmine/glycopyrrolate and a subsequent dose of sugammadex were given, with reversal of NMB. The patient was successfully extubated but required reintubation on postoperative day 1 for hypercapnic respiratory failure. Our case report on this patient with MG yields two topics that have not been extensively examined. First, dual therapy with sugammadex and neostigmine/glycopyrrolate may provide significant clinical benefit over individual therapy for NMBA reversal, given that their mechanisms of action are different and particularly when sugammadex is given prior to neostigmine/glycopyrrolate. Second, anesthesia literature is lacking on MG patients undergoing emergency surgeries. While sugammadex has been promising in medically optimized non-emergent surgeries, we discuss here a case where sugammadex failed to prevent MC in the emergency surgery setting and a look into what may provide patients with the best chance for avoiding postoperative MC.
近期文献表明，使用舒更葡糖钠逆转神经肌肉阻滞剂（NMBAs）可降低重症肌无力（MG）患者术后肌无力危象（MC）的风险，尤其是胸腺切除术后，但缺乏关于急诊手术的研究。我们使用舒更葡糖钠和新斯的明（加格隆溴铵）联合用药，成功实现了术中神经肌肉阻滞（NMB）的逆转。然而，未能避免MC的发生，术后第1天需要再次插管。一名有MG病史的65岁男性因腹痛、腹泻、呕吐、寒战和疲劳3天就诊于急诊科。腹部计算机断层扫描（CT）显示急性阑尾炎，患者于住院第1天接受了腹腔镜阑尾切除术。鉴于其MG病史，患者使用低于平均剂量的罗库溴铵进行快速顺序诱导，成功接受了全身麻醉。手术结束时，给予舒更葡糖钠，随后给予新斯的明/格隆溴铵，并再次给予舒更葡糖钠剂量，NMB得以逆转。患者成功拔管，但术后第1天因高碳酸血症呼吸衰竭需要再次插管。我们关于该MG患者的病例报告产生了两个尚未得到广泛研究的主题。首先，舒更葡糖钠与新斯的明/格隆溴铵联合治疗在逆转NMB方面可能比单一治疗具有显著的临床益处，因为它们的作用机制不同，特别是在舒更葡糖钠先于新斯的明/格隆溴铵给药时。其次，麻醉学文献中缺乏关于接受急诊手术的MG患者的内容。虽然舒更葡糖钠在经过医学优化的非急诊手术中前景良好，但我们在此讨论一例舒更葡糖钠在急诊手术中未能预防MC的病例，并探讨什么可能为患者提供避免术后MC的最佳机会。
