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Pediatric Myasthenia Gravis
Started by lfesiam
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What kind of case?
Elective old school open appy (not lap)
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Did a lung ressection on a adult bulbar myasthenic, used low dose muscle relaxant - was able to reverse in the end - pt did well. That bieng said, wouoldnt give relaxant routinely - and unlike a thoracic surgeon the peds surgeon is unlikely to be able to manage a complex pt like this if you cant get em off the vent at the end - I'd try hard to only use gas and a little narcotic.
Hey lfesiam, see your a med student. You can give some more info when presenting a pt. Its always a good idea to start practicing the presentation of your patients. Your attending will be much more impressed to get additional info than simply wow, next case has MG!
Here is my crack at it.
MG patients are at risk for perioperative respiratory dysfunction, bulbar symptoms with aspiration risk, altered response to neuromuscular blockade (sensitive NDMR, resistant/variable to Sux), they may be on medications with anesthetic impact (steroids, immuno-suppressants, anticholinesterase inhibitors) and they are at risk post-operativly of myasthenic or cholinergic crisis.
To start I would want to know the age and weight of the patient and a past medical history. In particular I would like to know the history around his MG, onset, duration of illness, severity (exercise tolerance, bulbar symptoms, previous pneumonias/aspirations), prior hospitalizations/ICU admissions/surgery's, and treatments undertaken (steroids, immuno-suppressants, anticholinesterase inhibitors, IVIG, plasmapharesis). This is in addition to a standard AMPLE history.
I would obtain a full set of vitals and examine the patient (airway, resp, cvs) with particular focus on a neuro examination strength.
For an appy you don't really have time to optomize the neuro-status much (eg. no plasmapharesis if really weak). Usually I would have the patient take his usual mestinon dose in the am but acute abdomen means this will not happen.
For the OR, standard monitors + nerve stimulator. Despite knowing this forum would still do cricoid pressure and RSI with Propofol, Fent, Sux (2 mg/kg). If not that worried about resp status could alternately do modified RSI with low pressure positive pressure ventilation and starting with 1/10th your usual dose of Roc and titrate to nerve twitch or simply bag them for a while with volatile to weaken then and intubate then. If on significant steroids could consider a stress dose. Run the case just with narcotic/volatile, no NMDR as surgeon really should be happy with volatile induced muscular relaxation and it's only an appy anyways.
If pt was significantly weak pre-op can start IV neostigmine at 1/30-1/60th of usual daily mestinon dose. If not concerned about pt's pre-op strength would extubate awake in OR and txfr to PACU with neuro consult for following on floor. If kid was quite weak pre-op and looked floppy post would keep intubated and sedated and txfr to ICU to wait for rest of volatiles to blow off.
Any ways, there you go.
CanGas
3 days till the written exam and counting thus I am reading SDN and procrastinating because I am sick of studying
Here is my crack at it.
MG patients are at risk for perioperative respiratory dysfunction, bulbar symptoms with aspiration risk, altered response to neuromuscular blockade (sensitive NDMR, resistant/variable to Sux), they may be on medications with anesthetic impact (steroids, immuno-suppressants, anticholinesterase inhibitors) and they are at risk post-operativly of myasthenic or cholinergic crisis.
To start I would want to know the age and weight of the patient and a past medical history. In particular I would like to know the history around his MG, onset, duration of illness, severity (exercise tolerance, bulbar symptoms, previous pneumonias/aspirations), prior hospitalizations/ICU admissions/surgery's, and treatments undertaken (steroids, immuno-suppressants, anticholinesterase inhibitors, IVIG, plasmapharesis). This is in addition to a standard AMPLE history.
I would obtain a full set of vitals and examine the patient (airway, resp, cvs) with particular focus on a neuro examination strength.
For an appy you don't really have time to optomize the neuro-status much (eg. no plasmapharesis if really weak). Usually I would have the patient take his usual mestinon dose in the am but acute abdomen means this will not happen.
For the OR, standard monitors + nerve stimulator. Despite knowing this forum would still do cricoid pressure and RSI with Propofol, Fent, Sux (2 mg/kg). If not that worried about resp status could alternately do modified RSI with low pressure positive pressure ventilation and starting with 1/10th your usual dose of Roc and titrate to nerve twitch or simply bag them for a while with volatile to weaken then and intubate then. If on significant steroids could consider a stress dose. Run the case just with narcotic/volatile, no NMDR as surgeon really should be happy with volatile induced muscular relaxation and it's only an appy anyways.
If pt was significantly weak pre-op can start IV neostigmine at 1/30-1/60th of usual daily mestinon dose. If not concerned about pt's pre-op strength would extubate awake in OR and txfr to PACU with neuro consult for following on floor. If kid was quite weak pre-op and looked floppy post would keep intubated and sedated and txfr to ICU to wait for rest of volatiles to blow off.
Any ways, there you go.
CanGas
3 days till the written exam and counting thus I am reading SDN and procrastinating because I am sick of studying
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Local + Ketamine
