ANKLE BLOCK AN ALTERNATIVE OF ANESTHETIC MANAGEMENT OF MYASTHENIA GRAVIS (CASE REPORT)
Journal
Macedonian Journal of Anaesthesia
Date Issued
2018-12
Author(s)
Burmuzoska M
Josifov A
Abstract
Myasthenia gravis (MG) is a chronic autoimmune disease characterized by a decrease in
acetylcholine receptors at the neuromuscular junction, secondary to destruction or inactivation
by circulating antibodies. In patients with MG, perioperative issues remain unclear, especially the
use of regional anesthetic techniques, while the perioperative and postoperative complications
are numerous. Preoperative evaluation is crucial for choosing the modality.
CASE REPORT:
A 52 years old female patient with 16 years history of myasthenia gravis was admitted for
Lisfranc amputation. Preoperative examination was made, and many comorbidities were noted
(Myocardial infarction with stenting, CVI, Diabetes mellitus type II, many respiratory infections).
The severity was estimated by Osserman classification as type III B, a severe stadium
with ptosis, respiratory dysfunction and generalized weakness. According to all preoperative
evaluations, treatment regiment and in collaboration with the surgeon, it was decided to apply
regional anesthesia. Ankle block was administered, with 25 ml 0.5% Bupivacaine. Good perioperative
analgesia was provided.
DISCUSSION AND CONCLUSION:
The potential for respiratory compromise in patients with myasthenia gravis requires the
anesthesiologist to be familiar with the underlying disease state, as well as the interaction of
anesthetic and nonanesthetic drugs. When possible, regional anesthetic techniques are preferred
by many anesthesiologists. Ester anesthetics, which are metabolized by cholinesterase, may
present particular problems in patients taking anticholinesterases. That’s why regional and local
anesthesia should be performed using reduced doses of amide (rather than ester)
acetylcholine receptors at the neuromuscular junction, secondary to destruction or inactivation
by circulating antibodies. In patients with MG, perioperative issues remain unclear, especially the
use of regional anesthetic techniques, while the perioperative and postoperative complications
are numerous. Preoperative evaluation is crucial for choosing the modality.
CASE REPORT:
A 52 years old female patient with 16 years history of myasthenia gravis was admitted for
Lisfranc amputation. Preoperative examination was made, and many comorbidities were noted
(Myocardial infarction with stenting, CVI, Diabetes mellitus type II, many respiratory infections).
The severity was estimated by Osserman classification as type III B, a severe stadium
with ptosis, respiratory dysfunction and generalized weakness. According to all preoperative
evaluations, treatment regiment and in collaboration with the surgeon, it was decided to apply
regional anesthesia. Ankle block was administered, with 25 ml 0.5% Bupivacaine. Good perioperative
analgesia was provided.
DISCUSSION AND CONCLUSION:
The potential for respiratory compromise in patients with myasthenia gravis requires the
anesthesiologist to be familiar with the underlying disease state, as well as the interaction of
anesthetic and nonanesthetic drugs. When possible, regional anesthetic techniques are preferred
by many anesthesiologists. Ester anesthetics, which are metabolized by cholinesterase, may
present particular problems in patients taking anticholinesterases. That’s why regional and local
anesthesia should be performed using reduced doses of amide (rather than ester)
Subjects
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