RevBrasAnestesiol.2017;67(2):221---222
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Successful
use
of
sugammadex
for
caesarean
section
in
a
patient
with
myasthenia
gravis
Lokman
Soyoral,
Ugur
Goktas
∗,
Muhammed
Bilal
Cegin,
Volkan
Baydi
YuzuncuYilUniversity,FacultyofMedicine,DepartmentofAnaesthesiologyandReanimation,Van,Turkey
Received14July2014;accepted7August2014 Availableonline22November2014
KEYWORDS
Myastheniagravis; Sugammadex; Pregnancy
Abstract Myastheniagravisisanautoimmunedisorderthatischaracterizedbymuscle weak-nessthatfluctuates,worseningwithexertion,andimprovingwithrest.Diagnosisofmyasthenia gravisismadefollowingclinicalandphysicalexaminationandisconfirmedbyserum immunoas-says to measure autoantibody levels. Myasthenia gravis especially when associated with pregnancy isahigh-risk disease, andits course isunpredictable. We described thesecond reportaboutuseofsugammadexafterrocuroniumforacaesareandeliverywithmyasthenia gravis,but,unlikeourcasethatformerlywasdiagnosedwithmyastheniagravis,thepatientwas extubatedonpostoperativesuccessfullyandwedidnotencounteranyrespiratoryproblems. ©2014SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALAVRAS-CHAVE
Miasteniagrave; Sugammadex; Gravidez
Ousobem-sucedidodesugamadexparacesarianaempacientecommiasteniagrave
Resumo Miasteniagrave(MG)éumadoenc¸aautoimunecaracterizadaporfraquezamuscular queflutua,piorandocomoesforc¸ofísicoemelhorandocomorepouso.OdiagnósticodeMGé feitoapósexameclínicoefísicoeconfirmadoporimunoensaiosséricosparamedirosníveisde autoanticorpos.MG,especialmentequandoassociadaàgravidez,éumadoenc¸adealtoriscoe decursoimprevisível.Descrevemososegundorelatosobreousodesugamadexapósrocurônio paraumpartocesáriocommiasteniagrave,mas,aocontráriodenossocasoquefoipreviamente diagnosticadocommiasteniagrave,apacientefoiextubadacomsucessonopós-operatóriosem qualquerproblemarespiratório.
©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mail:mdugoktas@yahoo.com(U.Goktas).
http://dx.doi.org/10.1016/j.bjane.2014.08.008
222 L.Soyoraletal.
Introduction
Myastheniagravis(MG)isanautoimmunedisorderaffecting
nearly1millionindividualsworldwide.1Itistwiceas
com-monamongwomenasitisamongmen.2 Thisautoimmune
diseaseischaracterizedbymuscleweaknessthatfluctuates,
worseningwithexertion,andimprovingwithrest.
Diagno-sisofMGismadefollowingclinicalandphysicalexamination
andisconfirmedbyserumimmunoassaystomeasure
autoan-tibodylevels.3,4Qietal.concludedthatpregnantpatients
sufferedfromMG,withtheincidenceof0.023%ina17year
retrospectiveanalysisthatpatientsadmittedtothehospital
duetopregnancy.5
We described the second report about use of
sugam-madexafterrocuroniumforacaesareandeliverywithMG,
but,unlikeourcasethatformerlywasdiagnosedwithMG,
thepatientwasextubatedonpostoperativesuccessfullyand
wedidnotencounteranyrespiratoryproblems.
Case
A 28-year-old 76kg woman was admitted at 39 weeks
of gestation (G1P1). The Patient had been diagnosed 16
years ago as MG. She used pyridostigmine (60mg/day)
during 14 years. Physicalexamination wasnormal except
proximalupper/lowerextremityweakness(3/5).
Anaesthe-sia was induced with propofol (2mg/kg) and rocuronium
(0.5mg/kg). The endotracheal intubation was easily
achieved 150s after the administration of rocuronium.
Anaesthesiawasmaintainedwithsevoflurane(2---2.5%)and
oxygen/air(40---60%).Alivelyfemaleinfantwasborn.
Phys-icalfeatures werenormal (weight: 3300g,length: 55cm,
headcircumference:34cm,APGARscore:6/8/10)anddid
not see any signs of muscular hypotonisity. MG was not
observed in the newborn. The newborn was admitted to
neonatalintensivecareunitforsurveillance.Durationofthe
operationwas20min.Sugammadexwasused(2mg/kg) at
theendofthesurgery.Patientwasextubatedwithout
prob-lemin2minaftersugammadex.Thepatientwastransferred
tonormalwardafterpostoperative1hfromrecoveryunit.
Onthethirdpostpartalday,thepatientcouldbedismissed
ingoodclinicalcondition.
Discussion
Garciaetal.6describedthefirstuseofsugammadexafter
rapidsequenceinductionusingrocuroniumforacaesarean
deliveryinapatientrecentlydiagnosedwithMG.
Unfortu-natelytheir patient had persistent muscle weakness that
preventedextubation.Theyconcludedthatmyastheniamay
have exacerbated by both surgery and the initiation of
treatment. But, in ourcase itwasextubated successfully
within2minafteradministrationofsugammadex.
Nowadays authors recommendation on using
sugam-madexasthenewstrategyofmusclerelaxantreversalseems
to be a safe and reliable option in patients with
muscu-larandneuromusculardiseases.7Becausethemainproblem
liesintitrationofneuromuscularblockingagentsaswellas
theriskofanti-cholinesteraseoverdoseafterreversalwhich
may itselfcause excessivemuscleweakness andneed for
postoperativeventilation.8
Berlitetal.9concludedthatMGespeciallywhen
associ-ated withpregnancy isa high-risk disease, andits course
is unpredictable. Severe up to life-threatening conditions
mightoccurespeciallyduetogeneralizedweakness,in
par-ticularrespiratoryinsufficiencyendangeringtheparturient
aswellasthenewborn.
Weconcludedthat agood resultcanbe obtainedwith
sugammadex toreach the preoperative respiratory effort
inthepregnantpatientswithnon-newlydiagnosedMGwho
have preoperative good clinical condition for respiratory
functionsduetoregularlyreceivedtreatment.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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