Anestesia y miastenia gravis
Anesthesia and myasthenia gravis.
Blichfeldt-Lauridsen L, Hansen BD.
Department of Anesthesiology, Sydvestjysk Sygehus Esbjerg, Denmark.louise@blichfeldtnet.dk
Acta Anaesthesiol Scand. 2012 Jan;56(1):17-22. doi: 10.1111/j.1399-6576.2011.02558.x. Epub 2011 Oct 19.
Abstract
Myasthenia gravis (MG) is a disease affecting the nicotinic acetylcholine receptor of the post-synaptic membrane of the neuromuscular junction, causing muscle fatigue and weakness. The myasthenic patient can be a challenge to anesthesiologists, and the post-surgical risk of respiratory failure has always been a matter of concern. The incidence and prevalence of MG have been increasing for decades and the disease is underdiagnosed. This makes it important for the anesthesiologist to be aware of possible signs of the disease and to be properly updated on the optimal perioperative anesthesiological management of the myasthenic patient. The review is based on electronic searches on PubMed and a review of the references of the articles. The following keywords were used: myasthenia gravis AND neuromuscular blocking agents, myasthenia gravis AND sevoflurane, myasthenia gravis AND epidural, myasthenia gravis AND neuromuscular blockade reversal and myasthenia gravis AND pyridostigmine. The articles included were from reviews and clinical trials written in English. MG patients can easily be anesthetized without need for post-surgery mechanical ventilation whether it is general anesthesia or peripheral nerve block. Volatile anesthesia or the use of an epidural for the patient makes it possible to avoid the use of neuromuscular blocking agents, and when used, it should be in smaller doses and the patient should be carefully monitored. This review shows that with thorough pre-operative evaluation, continuing the daily pyridostigmine and careful monitoring the MG patient can be managed safely.
http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2011.02558.x/pdf
Protocolo estandarizado para el manejo perioperatorio de los pacientes con miastenia gravis
A standardized protocol for the perioperative management of myasthenia gravis patients. Experience with 110 patients.
Gritti P, Sgarzi M, Carrara B, Lanterna LA, Novellino L, Spinelli L, Khotcholava M, Poli G, Lorini FL, Sonzogni V.
Department of Anesthesia and Intensive Care, Ospedali Riuniti di Bergamo, Italy. grittip@libero.it
Acta Anaesthesiol Scand. 2012 Jan;56(1):66-75. doi: 10.1111/j.1399-6576.2011.02564.x. Epub 2011 Oct 19.
Abstract
BACKGROUND: Video-assisted thoracoscopic extended thymectomy (VATET) is well established in the treatment of myasthenia gravis; however, patient selection remains controversial. Perioperative management protocol is lacking, and concerns regarding post-operative myasthenic crisis still remain. We performed a retrospective observational study evaluating the impact of the introduction of a protocol in the perioperative management of patients with myasthenia gravis who underwent VATET. METHODS: The perioperative management protocol was developed by a team of neurologists and anesthesiologists who reviewed the literature and their previous experience on myasthenia gravis patients. Respiratory, clinical, and neurological patient features were included in the protocol evaluation. A retrospective review of patients who underwent VATET before and after introduction to the protocol was finally performed. RESULTS: The medical records of 66 patients (pre-protocol group) and 44 patients (protocol group) were available for the study. In the pre-protocol group, 17 patients (26%) were admitted to intensive care unit (ICU) during the post-operative period, while three patients (6.8%) of the protocol group met the criteria for ICU post-operative admission. This resulted in a reduction of 73.5% of patients admitted to ICU (P = 0.023) and in an 80% (P = 0.002) reduction of the use neuromuscular blocking agents. Two post-operative myasthenic crises preceded by bulbar symptoms (1.8%) were identified in the pre-protocol group patients. CONCLUSIONS: Although the application of our protocol results in a substantial reduction in the recovery of patients in the ICU and in hospital costs, there was no substantial difference in mortality and morbidity between patients admitted to the surgical ward or to ICU.
http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2011.02564.x/pdf
Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org
Anesthesia and myasthenia gravis.
Blichfeldt-Lauridsen L, Hansen BD.
Department of Anesthesiology, Sydvestjysk Sygehus Esbjerg, Denmark.louise@blichfeldtnet.dk
Acta Anaesthesiol Scand. 2012 Jan;56(1):17-22. doi: 10.1111/j.1399-6576.2011.02558.x. Epub 2011 Oct 19.
Abstract
Myasthenia gravis (MG) is a disease affecting the nicotinic acetylcholine receptor of the post-synaptic membrane of the neuromuscular junction, causing muscle fatigue and weakness. The myasthenic patient can be a challenge to anesthesiologists, and the post-surgical risk of respiratory failure has always been a matter of concern. The incidence and prevalence of MG have been increasing for decades and the disease is underdiagnosed. This makes it important for the anesthesiologist to be aware of possible signs of the disease and to be properly updated on the optimal perioperative anesthesiological management of the myasthenic patient. The review is based on electronic searches on PubMed and a review of the references of the articles. The following keywords were used: myasthenia gravis AND neuromuscular blocking agents, myasthenia gravis AND sevoflurane, myasthenia gravis AND epidural, myasthenia gravis AND neuromuscular blockade reversal and myasthenia gravis AND pyridostigmine. The articles included were from reviews and clinical trials written in English. MG patients can easily be anesthetized without need for post-surgery mechanical ventilation whether it is general anesthesia or peripheral nerve block. Volatile anesthesia or the use of an epidural for the patient makes it possible to avoid the use of neuromuscular blocking agents, and when used, it should be in smaller doses and the patient should be carefully monitored. This review shows that with thorough pre-operative evaluation, continuing the daily pyridostigmine and careful monitoring the MG patient can be managed safely.
http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2011.02558.x/pdf
Protocolo estandarizado para el manejo perioperatorio de los pacientes con miastenia gravis
A standardized protocol for the perioperative management of myasthenia gravis patients. Experience with 110 patients.
Gritti P, Sgarzi M, Carrara B, Lanterna LA, Novellino L, Spinelli L, Khotcholava M, Poli G, Lorini FL, Sonzogni V.
Department of Anesthesia and Intensive Care, Ospedali Riuniti di Bergamo, Italy. grittip@libero.it
Acta Anaesthesiol Scand. 2012 Jan;56(1):66-75. doi: 10.1111/j.1399-6576.2011.02564.x. Epub 2011 Oct 19.
Abstract
BACKGROUND: Video-assisted thoracoscopic extended thymectomy (VATET) is well established in the treatment of myasthenia gravis; however, patient selection remains controversial. Perioperative management protocol is lacking, and concerns regarding post-operative myasthenic crisis still remain. We performed a retrospective observational study evaluating the impact of the introduction of a protocol in the perioperative management of patients with myasthenia gravis who underwent VATET. METHODS: The perioperative management protocol was developed by a team of neurologists and anesthesiologists who reviewed the literature and their previous experience on myasthenia gravis patients. Respiratory, clinical, and neurological patient features were included in the protocol evaluation. A retrospective review of patients who underwent VATET before and after introduction to the protocol was finally performed. RESULTS: The medical records of 66 patients (pre-protocol group) and 44 patients (protocol group) were available for the study. In the pre-protocol group, 17 patients (26%) were admitted to intensive care unit (ICU) during the post-operative period, while three patients (6.8%) of the protocol group met the criteria for ICU post-operative admission. This resulted in a reduction of 73.5% of patients admitted to ICU (P = 0.023) and in an 80% (P = 0.002) reduction of the use neuromuscular blocking agents. Two post-operative myasthenic crises preceded by bulbar symptoms (1.8%) were identified in the pre-protocol group patients. CONCLUSIONS: Although the application of our protocol results in a substantial reduction in the recovery of patients in the ICU and in hospital costs, there was no substantial difference in mortality and morbidity between patients admitted to the surgical ward or to ICU.
http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2011.02564.x/pdf
Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org
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