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Propofol and remifentanil without muscle relaxants in a patient with myasthenia gravis for emergency surgery

Vincenzo Fodale, MD^*, Caterina Pratico’, MD^*, Francesco Piana, MD, Alfina Caruso, MD, Tullio Lucanto, MD^*, Salvatore Coniglio, MD and Letterio B. Santamaria, MD^*

^* Messina, Italy
Taormina, Italy

To the Editor:

Laparoscopic surgery is considered a minimally invasive technique but requires excellent muscle relaxation, whereas the use of neuromuscular blocking drugs (NMBD) is related to an increased incidence of postoperative mechanical ventilation and pulmonary complications in patients with myasthenia gravis.¹ Therefore, the use of techniques avoiding NMBD has been recommended. Anesthesia with propofol and remifentanil has been reported in elective surgery and well prepared myasthenic patients.²

An 80-yr-old male myasthenic patient (stage IIb Ossermann), with a previous history of prolonged neuromuscular blockade after anesthesia, was scheduled for emergency surgery for gangrenous perforated cholecystitis with peritonitis. Considering the patient’s critical condition, the surgeons suggested a laparoscopic technique. Following preoperative fluid resuscitation, the patient was premedicated with atropine 0.5 mg iv and remifentanil 0.25 µg•kg^-1•min^-1. Anesthesia was induced with propofol 1.7 mg•kg^-1. Intubation was performed without difficulty at the first attempt using an endotracheal tube 7.5 mm and conditions evaluated as "acceptable"³ (jaw relaxation complete, laryngoscopy easy, vocal cords open, no coughing, no movement). Anesthesia was maintained with propofol 4 to 6 mg•kg^-1•hr^-1 and remifentanil 0.25 to 0.35 µg•kg^-1•min^-1 in air/oxygen. Controlled ventilation was adjusted to maintain normocapnia. Peak airway pressure ranged from 16 to 21 cm H₂O and from 20 to 23 cm H₂O during pneumoperitoneum (intra-abdominal pressure 10–12 cm H₂O). Surgery lasted 75 min. During emergence from anesthesia, spontaneous breathing resumed, the patient became fully conscious within 15 min and the tracheal tube was removed based on the adequacy of respiration (tidal volume 480 mL, 13 breaths•min^-1) and blood gas analysis. The postoperative course was uneventful and respiratory support was not required.

An anesthetic technique avoiding the use of NMBD was adopted after evaluating the possible risks and advantages, above all after considering the conflicting risks of prolonged neuromuscular blockade and the potential risk of aspiration. Because of his previous history of prolonged neuromuscular blockade, the administration of NMBD was associated with a high probability of postoperative mechanical ventilation and pulmonary infections,¹ especially in a critically ill patient with peritonitis. Regarding the risk of aspiration, initiating a narcotic infusion before controlling the airway may be criticized. However, the low remifentanil infusion rate (about half that of a healthy patient) should be considered as a premedication to reduce airway and hemodynamic responses to intubation,⁴ rather difficult to control with a low dose of propofol only. Insertion of a laryngoscope and tracheal intubation in an inadequately anesthetized patient with peritonitis may increase the risk of aspiration, laryngospasm, bronchospasm and excessive cardiovascular responses.

References

1 Hubler M, Litz RJ, Albrecht DM. Combination of balanced and regional anaesthesia for minimally invasive surgery in a patient with myasthenia gravis. Eur J Anaesthesiol 2000; 17: 325–8.[Medline]

2 Lorimer M, Hall R. Remifentanil and propofol total intravenous anaesthesia for thymectomy in myasthenia gravis. Anaesth Intensive Care 1998; 26: 210–2.[Medline]

3 Troy AM, Huthinson RC, Easy WR, Kenney GN. Tracheal intubating conditions using propofol and remifentanil target-controlled infusions. Anaesthesia 2002; 57: 1204–7.[Medline]

4 Erhan E, Ugur G, Gunusen I, Alper I, Ozyar B. Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of neuromuscular blockade. Can J Anesth 2003; 50: 108–15.[Abstract/Free Full Text]

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