Myasthenia Gravis.

[KLPM]

Just a student doing an ICU rotation here and wanting some pointers from the guys here about what to think about for this case. Supervisor wants this to be "my case" (what that means but ****) so I think I need a lot of help .

64yo, male with recently diagnosed ocular myasthenia gravis scheduled to have a thymectomy next week. Only complaint related to MG is diplopia and I don't think he is on any meds for it. Thymoma looks pretty big on chest CT. The plan at the moment is to keep him ventilated in ICU post-op.

- Heavy smoker with COPD requiring PRN Ventolin + Tiotropium B.I.D.
- BMI = 35
- BP = 160/130, untreated, hardly ever goes to his doctor but says apparently it's like that every time he goes
- Gets angina-like chest pains from time to time with exertion
- No recent BSL results

What kind of questions should I be asking myself?

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[nap$ter]

Just a student doing an ICU rotation here and wanting some pointers from the guys here about what to think about for this case. Supervisor wants this to be "my case" (what that means but ****) so I think I need a lot of help .

64yo, male with recently diagnosed ocular myasthenia gravis scheduled to have a thymectomy next week. Only complaint related to MG is diplopia and I don't think he is on any meds for it. Thymoma looks pretty big on chest CT. The plan at the moment is to keep him ventilated in ICU post-op.

- Heavy smoker with COPD requiring PRN Ventolin + Tiotropium B.I.D.
- BMI = 35
- BP = 160/130, untreated, hardly ever goes to his doctor but says apparently it's like that every time he goes
- Gets angina-like chest pains from time to time with exertion
- No recent BSL results

What kind of questions should I be asking myself?

what do you think? meaning - what work have you done on your own so far? google "anesthetic concerns" for "anterior mediastinal mass" and "myasthenia gravis" to start...

"supervisor" meaning your resident? attending?

 

[Idiopathic]

try to compartmentalize things. preop (access, monitors, meds)->induction (meds, method of intubation, specific concerns)->maintenance (type of anesthesia, major intraop pitfalls)->postop (ICU vs PACU, post op ventilation, etc)

each of his comorbid conditions will create specific needs, sometimes its easier to think in organ systems as you are going through the preparation and discussion

 

[Hernandez]

Just a student doing an ICU rotation here and wanting some pointers from the guys here about what to think about for this case. Supervisor wants this to be "my case" (what that means but ****) so I think I need a lot of help .

64yo, male with recently diagnosed ocular myasthenia gravis scheduled to have a thymectomy next week. Only complaint related to MG is diplopia and I don't think he is on any meds for it. Thymoma looks pretty big on chest CT. The plan at the moment is to keep him ventilated in ICU post-op.

- Heavy smoker with COPD requiring PRN Ventolin + Tiotropium B.I.D.
- BMI = 35
- BP = 160/130, untreated, hardly ever goes to his doctor but says apparently it's like that every time he goes
- Gets angina-like chest pains from time to time with exertion
- No recent BSL results

What kind of questions should I be asking myself?

Well first ask why he's getting off label dosing of spiriva....ok sorry.

Divide into your plan into 3-4 categories
1) acute issues,

A)post op care
B)post op vent management, and specifically how MIGHT mg affect the vent interactions...perhaps know some medical treatments for mg, and also know a measurement which you could obtain on someone on a vent which could predict if the muscular effects of MG would limit respiratory muscle strength and therefore extubation.​

2) chronic issues
3) ICU prophylaxis (lines/tubes/nutrition/dvt/GI prophylaxis/skin care/etc)

Then make sure you read everything on MG, and know why they're doing the surgery, etc etc etc.

 

[KLPM]

To be honest I have always been interested in perioperative medicine but never any good at it. So fully expecting to make a fool of myself ..... [but that's kind of the point]

In terms of cardiovascular fitness I had be worried about this man being obese + probably undiagnosed hypertenion + angina + still smoking is likely to have coronary disease. I had be concerned about problems like perioperative MI and death. I would do an exam to check of evidence of CHF, peripheral vascular disease, murmurs etc. and order labs to check for DM. Although I think he has enough risk factors to warrant doing some investigations like ECG (resting, stress) and maybe ECHO or coronary angiography depending on what I found.

In terms of pulmonary risks, the patient has had years of poorly controlled COPD and still a smoker. According to the letter his general practitioner wrote us this man is short of breath just talking! They are all risks for postoperative pulmonary complications and being obese as well he might be at risk of PEs and OSA. This is where I am not sure if ordering lung function tests, chest x ray or ABG will actually change anything since we already know his lungs are bad.

I will get back once I have done more reading and collected my thoughts more. But thanks everyone for suggesting how to frame my planning!

 

[Hernandez]

To be honest I have always been interested in perioperative medicine but never any good at it. So fully expecting to make a fool of myself ..... [but that's kind of the point]

In terms of cardiovascular fitness I had be worried about this man being obese + probably undiagnosed hypertenion + angina + still smoking is likely to have coronary disease. I had be concerned about problems like perioperative MI and death. I would do an exam to check of evidence of CHF, peripheral vascular disease, murmurs etc. and order labs to check for DM. Although I think he has enough risk factors to warrant doing some investigations like ECG (resting, stress) and maybe ECHO or coronary angiography depending on what I found.

In terms of pulmonary risks, the patient has had years of poorly controlled COPD and still a smoker. According to the letter his general practitioner wrote us this man is short of breath just talking! They are all risks for postoperative pulmonary complications and being obese as well he might be at risk of PEs and OSA. This is where I am not sure if ordering lung function tests, chest x ray or ABG will actually change anything since we already know his lungs are bad.

I will get back once I have done more reading and collected my thoughts more. But thanks everyone for suggesting how to frame my planning!

Pre-op pulm clearance is easy.... "He's at moderate risk of post -op pulm complications but benefits out weigh risk and we will follow along closely with you post op, please be diligent with IS, early ambulatory and DVT prophylaxis. He has also been instructed to stop smoking, greater than 10 minutes was spent talking about risks, methods and support groups with the pt"

About the OSA, what would be the post op risks of OSA?

 

[KLPM]

About the OSA, what would be the post op risks of OSA?

OSA present a number of issues. Pre-operatively, OSA often goes undiagnosed and therefore untreated. It contributes to perioperative cardiovascular and pulmonary complications (e.g. MI, arrhythmias, respiratory arrest). OSA-related comorbidities include hypertension (systemic, pulmonary), lower saturation, vascular disease and heart failure. In this particular patient, I had be worried about undiagnosed OSA. While a sleep study is usually ordered to confirm the diagnosis, I have also seen some treat with CPAP empirically based on history and risks.

OSA has been associated with difficult intubation as the pathophysiology behind the condition is collapsed pharynx and loss of protective airway reflexes. This may be exacerbated with medications such as benzodiazepines and opiates as pre-medication or intra-operatively.

Post-operatively, is where a lot of problems can occur. Normally when a patient becomes obstructed, the arterial level of CO2 builds up and centrally stimulates respiration. However, a patient coming out of surgery having received narcotics, sedatives, anaesthetic agents etc. may have blunted CNS control of respiration and this may lead to severe hypoxaemia. So general measures such as pulse ox monitoring, sitting up/semirecumbent position, supplemental oxygen or CPAP therapy may be needed.

I can see how the problems I pointed out above can be complicated by his co-morbid COPD and smoking.