Thoracic epidural anesthesia for severe myasthenia gravis patient undergoing laparoscopic cholesistectomy

Abstract

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease characterized by different degrees of weakness and fatigue of skeletal muscles after physical exercise. It has an incidence of 2-10/100000 per year. The optimal anesthetic management of these patients is still controversial. A 69 yearold male patient with MG was scheduled for laparoscopic cholesistectomy due to gallbladder stone. Epidural puncture was performed by a 18G Tuohy needle inserted between 7th and 8th thoracic vertebrae. After the placement of epidural catheter, a combination of 40 mg bupivacaine, 100 mg prilocaine and 100 µg fentanil were applied slowly. Pneumoperitonium was applied with approximetly 12 mmHg CO2 for laparoscopic view. At the 10th minute of the surgery, a sudden deep bradicardia was observed. Following administration of one mg of atropine, heart rate of the patient turned to normal ranges within 30 seconds. In the postoperative period no respiratory or cardiac complications were detected and the patient was discharged from hospital after three days. Anesthetic management of MG patients should be individualized due to increased risk of intraoperative and postoperative complications. Their increased sensitivity to nondepolarizing muscle relaxants can lead to prolonged postoperative mechanical ventilation need. In adult patients, regional anaesthesia alone can be a good and safe method for myasthenic patients by eleminating the need for muscle relaxants and opioids in abdominal surgeries. In this case we prefer to insert a thoracic epidural catheter to control the level of blockage intraoperatively. Continuous epidural infusion allowed us to maintain postoperative analgesia without intravenous opioid agents