SummaryMyasthenia gravis, affecting neuromuscular transmission, leads to a large variability in sensitivity to depolarising and non-depolarising neuromuscular blocking drugs. We report the successful use of the modified l-cyclodextrin sugammadex in a myasthenic patient to reverse a rocuronium-induced deep level of neuromuscular block. After spontaneous neuromuscular recovery of T2 (second twitch of the train-of-four series), we administered 2 mg.kg )1 of sugammadex intravenously, reversing neuromuscular blockade to a train-of-four ratio (T4 ⁄ T1) > 90% within 210 s. Sugammadex, in combination with objective neuromuscular monitoring, can be used to reverse rocuronium-induced neuromuscular blockade in patients with myasthenia gravis, thereby avoiding the need for reversal with acetylcholinesterase inhibitors. Myasthenia gravis is an autoimmune disease affecting neuromuscular transmission. Auto-antibodies against the acetylcholine receptor reduce the total amount of acetylcholine receptors resulting in an unpredictable response to administered neuromuscular blocking drugs [1,2]. Clinically, patients show increasing muscle weakness and fatigue with repetitive use, followed by partial recovery with rest [3,4]. The anaesthetic management of myasthenia is challenging. Regional and local anaesthesia should be employed when possible, but many surgical interventions require neuromuscular blockade. Because of the large variability in sensitivity to nondepolarising neuromuscular blocking drugs, the dose of the latter must be carefully titrated. Neuromuscular transmission must be monitored continuously by objective devices to ensure complete reversal of neuromuscular block before emergence from anaesthesia. Sugammadex, a newly introduced modified l-cyclodextrin, encapsulates steroidal neuromuscular blocking drugs, and could therefore facilitate return to pre-operative muscle function.
Case reportA 72-year-old male patient (weight 88 kg, height 172 cm) was scheduled for elective radical prostatectomy.Written consent for the procedure, anaesthesia, collection of data and publication was obtained. The patient had been diagnosed with myasthenia gravis in 1988 and undergone a thymectomy in 1989. He had developed only slight ocular symptoms (ptosis). The pre-operative serum level of acetylcholine receptor antibodies was 4.2 nmol.l )1. Pre-operative blood chemistry, ECG and respiratory function (spirometry) were all within normal limits and he was noted to have hyperlipidaemia. His daily medication comprised of simvastatin and 10 mg pyridostigmine in the morning. Slight ocular weakness (ptosis) persisted despite the medication. Preoperatively the patient had a Leventhal score of 0 points: a score of < 10 points means there is a low risk of requiring postoperative mechanical ventilation [5].The patient was not premedicated, but did receive his usual dose of pyridostigmine. Following pre-oxygenation, anaesthesia was induced in the supine position with intravenous administration of 20 lg sufentanil and 200 mg propofol. Anaesthesia was...
The muscle weakness in critically ill patients can be replicated in our novel rat model. Inflammation and immobilization independently lead to muscle weakness.
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