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BMC Anesthesiology
Published in: BMC Anesthesiology 1/2023

Open Access 01-12-2023 | Myasthenia Gravis | Research

Propofol TCI or sevoflurane anesthesia without muscle relaxant for thoracoscopic thymectomy in myasthenia gravis patients: a prospective, observational study

Authors: Vo Van Hien, Nguyen Huu Tu, Nguyen Dang Thu

Published in: BMC Anesthesiology | Issue 1/2023

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Abstract

Background

Myasthenia gravis (MG) patients interact unpredictably with anesthetic agents, including neuromuscular blocking agents. Here, we investigate the effectiveness of general anesthesia without muscle relaxants using either propofol via target-controlled infusion systems (TCI) or sevoflurane in MG patients undergoing thoracoscopic thymectomy.

Methods

This prospective, open-label, observational study was conducted in a university hospital. We included 90 myasthenic patients undergoing thoracoscopic thymectomy with general anesthesia. Patients received induction and maintenance anesthesia with propofol TCI (group P, n = 45) or induction with propofol 2–3 mg.kg−1 and maintenance anesthesia with sevoflurane (group S, n = 45). In both groups, the procedure was performed under the guidance of entropy with sufentanil but not a muscle relaxant. Intubation conditions, hemodynamic changes, respiratory function, neuromuscular transmission, arterial blood gas, and complications were evaluated.

Results

All patients achieved good intubation conditions. Hemodynamic instability was more frequent in group S than in group P, mostly in the induction stage, and was controllable. The reduction in the intraoperative train-of-four ratio from baseline at 30 min, 60 min, and 90 min in group S was 10.3%, 14.2%, and 14.3%, respectively, significantly higher than that in group P (6.8%, 7.2%, and 8.4%, respectively), which completely recovered at the end of the surgery. All patients were extubated in the operating room without complications. No other significant differences between the groups were observed.

Conclusions

Anesthesia with propofol TCI or sevoflurane without muscle relaxants in MG patients offered safe and effective conditions for thoracoscopic thymectomy. Sevoflurane achieved higher levels of intraoperative muscular relaxation than propofol TCI. Postoperative neuromuscular function was not affected by these anesthetics.
Literature
1.
2.
Sussman J, Farrugia ME, Maddison P, Hill M, Leite MI, Hilton-Jones D. The Association of British Neurologists’ myasthenia gravis guidelines. Ann N Y Acad Sci. 2018;1412(1):166–9.CrossRefPubMed
3.
Narayanaswami P, Sanders DB, Wolfe G, Benatar M, Cea G, Evoli A, Gilhus NE, Illa I, Kuntz NL, Massey J, et al. International consensus guidance for management of myasthenia gravis: 2020 update. Neurology. 2021;96(3):114–22.CrossRefPubMedPubMedCentral
4.
5.
Dillon FX. Anesthesia issues in the perioperative management of myasthenia gravis. Semin Neurol. 2004;24(1):83–94.CrossRefPubMed
6.
Gurunathan U, Kunju SM, Stanton LML. Use of sugammadex in patients with neuromuscular disorders: a systematic review of case reports. BMC Anesthesiol. 2019;19(1):213.CrossRefPubMedPubMedCentral
7.
8.
Hristovska AM, Duch P, Allingstrup M, Afshari A. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev. 2017;8(8):Cd012763.PubMed
9.
Raval AD, Uyei J, Karabis A, Bash LD, Brull SJ. Incidence of residual neuromuscular blockade and use of neuromuscular blocking agents with or without antagonists: a systematic review and meta-analysis of randomized controlled trials. J Clin Anesth. 2020;64:109818.CrossRefPubMed
10.
Fuchs-Buder T, Romero CS, Lewald H, Lamperti M, Afshari A, Hristovska AM, Schmartz D, Hinkelbein J, Longrois D, Popp M, et al. Peri-operative management of neuromuscular blockade: a guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol. 2023;40(2):82–94.CrossRefPubMed
11.
Fernandes HDS, Ximenes JLS, Nunes DI, Ashmawi HA, Vieira JE. Failure of reversion of neuromuscular block with sugammadex in patient with myasthenia gravis: case report and brief review of literature. BMC Anesthesiol. 2019;19(1):160.CrossRefPubMedPubMedCentral
12.
Sugi Y, Nitahara K, Shiroshita T, Higa K. Restoration of train-of-four ratio with neostigmine after insufficient recovery with sugammadex in a patient with myasthenia gravis. A A Case Rep. 2013;1(3):43–5.CrossRefPubMed
13.
Riki Kveraga JP: UpToDate. Anesthesia for the patient with myasthenia gravis. 2022.
14.
Benhamou D, Constant I, Longrois D, Molliex S, Nouette-Gaulain K, Bull A. Use of volatile anaesthetic agents in anaesthesia: a survey of practice in France in 2012. Anaesth Crit Care Pain Med. 2015;34(4):205–9.CrossRefPubMed
15.
Leslie K, Clavisi O, Hargrove J. Target-controlled infusion versus manually-controlled infusion of propofol for general anaesthesia or sedation in adults. Cochrane Database Syst Rev. 2008;3:Cd006059.
16.
Myasthenia Gravis Foundation of America. Myasthenia gravis clinical classification.
17.
Fuchs-Buder T, Brull SJ, Fagerlund MJ, Renew JR, Cammu G, Murphy GS, Warlé M, Vested M, Fülesdi B, Nemes R et al: Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents III: The 2023 Geneva revision. Acta Anaesthesiol Scand. 2023.
18.
O’Sullivan KE, Kreaden US, Hebert AE, Eaton D, Redmond KC. A systematic review of robotic versus open and video assisted thoracoscopic surgery (VATS) approaches for thymectomy. Ann Cardiothorac Surg. 2019;8(2):174–93.CrossRefPubMedPubMedCentral
19.
Elsayed HH, Moharram AA. Tailored anaesthesia for thoracoscopic surgery promoting enhanced recovery: rhe state of the art. Anaesth Crit Care Pain Med. 2021;40(2):100846.CrossRefPubMed
20.
Narimatsu E, Munemura Y, Kawamata M, Imaizumi H, Namiki A, Iwasaki H. Tracheal intubation without neuromuscular relaxants for thymectomy in myasthenic patients. J Med. 2003;34(1–6):47–58.PubMed
21.
Della Rocca G, Coccia C, Diana L, Pompei L, Costa MG, Tomaselli E, Di Marco P, Vilardi V, Pietropaoli P. Propofol or sevoflurane anesthesia without muscle relaxants allow the early extubation of myasthenic patients. Can J Anaesth. 2003;50(6):547–52.CrossRefPubMed
22.
Chen L, Xie W, Zheng D, Wang S, Wang G, Sun J, Tai Q, Chen Z. Early extubation after thymectomy is good for the patients with myasthenia gravis. Neurol Sci. 2019;40(10):2125–32.CrossRefPubMedPubMedCentral
23.
Vakkuri A, Yli-Hankala A, Sandin R, Mustola S, Høymork S, Nyblom S, Talja P, Sampson T, van Gils M, Viertiö-Oja H. Spectral entropy monitoring is associated with reduced propofol use and faster emergence in propofol-nitrous oxide-alfentanil anesthesia. Anesthesiology. 2005;103(2):274–9.CrossRefPubMed
24.
El Hor T, Van Der Linden P, De Hert S, Mélot C, Bidgoli J. Impact of entropy monitoring on volatile anesthetic uptake. Anesthesiology. 2013;118(4):868–73.CrossRefPubMed
25.
Viertiö-Oja H, Maja V, Särkelä M, Talja P, Tenkanen N, Tolvanen-Laakso H, Paloheimo M, Vakkuri A, Yli-Hankala A, Meriläinen P. Description of the entropy algorithm as applied in the datex-ohmeda s/5 entropy module. Acta Anaesthesiol Scand. 2004;48(2):154–61.CrossRefPubMed
26.
Nitahara K, Sugi Y, Higa K, Shono S, Hamada T. Neuromuscular effects of sevoflurane in myasthenia gravis patients. Br J Anaesth. 2007;98(3):337–41.CrossRefPubMed
27.
Nilsson E, Muller K. Neuromuscular effects of isoflurane in patients with myasthenia gravis. Acta Anaesthesiol Scand. 1990;34(2):126–31.CrossRefPubMed
28.
Gritti P, Carrara B, Khotcholava M, Bortolotti G, Giardini D, Lanterna LA, Benigni A, Sonzogni V. The use of desflurane or propofol in combination with remifentanil in myasthenic patients undergoing a video-assisted thoracoscopic-extended thymectomy. Acta Anaesthesiol Scand. 2009;53(3):380–9.CrossRefPubMed
29.
Caldwell JE, Laster MJ, Magorian T, Heier T, Yasuda N, Lynam DP, Eger EI 2nd, Weiskopf RB. The neuromuscular effects of desflurane, alone and combined with pancuronium or succinylcholine in humans. Anesthesiology. 1991;74(3):412–8.CrossRefPubMed
30.
Dilger JP, Vidal AM, Mody HI, Liu Y. Evidence for direct actions of general anesthetics on an ion channel protein. A new look at a unified mechanism of action. Anesthesiology. 1994;81(2):431–42.CrossRefPubMed
31.
Bowman WC. Prejunctional and postjunctional cholinoceptors at the neuromuscular junction. Anesth Analg. 1980;59(12):935–43.CrossRefPubMed
32.
Leuzzi G, Meacci E, Cusumano G, Cesario A, Chiappetta M, Dall’armi V, Evoli A, Costa R, Lococo F, Primieri P, et al. Thymectomy in myasthenia gravis: proposal for a predictive score of postoperative myasthenic crisis. Eur J Cardiothorac Surg. 2014;45(4):e76-88. discussion e88.CrossRefPubMed
33.
Chevalley C, Spiliopoulos A, de Perrot M, Tschopp JM, Licker M. Perioperative medical management and outcome following thymectomy for myasthenia gravis. Canad J Anaesth. 2001;48(5):446–51.CrossRef
34.
Sun Y, Li S, Wang S, Li C, Li G, Xu J, Wang H, Liu F, Yao G, Chang Z, et al. Predictors of 1-year mortality in patients on prolonged mechanical ventilation after surgery in intensive care unit: a multicenter, retrospective cohort study. BMC Anesthesiol. 2020;20(1):44.CrossRefPubMedPubMedCentral
35.
Leventhal SR, Orkin FK, Hirsh RA. Prediction of the need for postoperative mechanical ventilation in myasthenia gravis. Anesthesiology. 1980;53(1):26–30.CrossRefPubMed
36.
Menghesha H, Schroeter M, Nelke C, Ruck T, Schlachtenberger G, Welskop C, Camo A, Heldwein M, Bennink G, Wahlers T, et al. The impact of thymectomy in subgroups of Myasthenia gravis patients: a single center longitudinal observation. Neurol Res Pract. 2023;5(1):24.CrossRefPubMedPubMedCentral
Metadata
Title
Propofol TCI or sevoflurane anesthesia without muscle relaxant for thoracoscopic thymectomy in myasthenia gravis patients: a prospective, observational study
Authors
Vo Van Hien
Nguyen Huu Tu
Nguyen Dang Thu
Publication date
01-12-2023
Publisher
BioMed Central
Published in
BMC Anesthesiology / Issue 1/2023
Electronic ISSN: 1471-2253
DOI
https://doi.org/10.1186/s12871-023-02296-6

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