Thymectomy

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How long on pyridostigmine? Functional status after initiation of pyridostigmine? Airway exam? How difficult was the intubation? What was the response to muscle relaxants during the case?
 
Whether or not I'll extubate at the end is rarely something I decide upfront. Gotta see how the case goes. But in general, if I think they can fly (an theres no surgical reason for PPV) I'll usually try to pull it. In most patients it's better to be off the ventilator-- of course that's just not realistic in some pt/sxs. Easy enough airway and decent functional status, took his pyrido... Barring any intraop issues I give pulling it a try.... Pretty easy to tell if someone isn't pulling good volumes they might be better off "resting"
 
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No suggamadex in usa :-( I don't paralyze these people either, routinely. Once I had one for a gastric bypass that surgeon complained was "tight". I pushed propofol but he wasn't going for it... So I think I gave 5-10 of roc.... It was early on in the case and it went ok. Of course it couldn't be the patient has a 50 pound abdominal wall, it was my lack of relaxant
 
What's the dose of pyridostigmine? Symptoms of MG? Bulbar involvement? If he's getting a thymectomy, he may have been symptomatic enough to warrant the big procedure. What about airway exam? Are there prior airway notes?
 
nasal semi awake FOI, he keeps the tube with a sternotomy and bmi 62
 
Depends on size of thymoma (any chance of bronchomalacia?) and how bad preop sx are, I think. There are some numbers I memorized for boards about risk for failing extubation or prolonged intubation (current pyridostigmine dose, vital capacity volume, NIF...something like that) that might guide your prediction/preop discussion.

I'd use Remi if you needed paralysis.

dc
 
I would question the diagnosis of MG: if you have enough strength to stuff your face to get to a BMI of 62...
Probably just tired because he's fat
Anyhow buff and turf i'm not going down for some fatso: leave the tube in and let the ICU deal with him
 
My quick response would be to avoid relaxant and keep intubated. The stress of surgery alone could send him into crisis despite removing the bulk of the offending organ, remember he will still have circulating antibodies. You could extubate him only to have him fail in the ICU over the next few hours. You don't want to be called emergently to intubate a blue patient with a BMI of 64. I would also likely opt for an awake fiber optic if there was any question his airway would be a problem.
 
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