An unusual case of multiple failed extubations in a neurosurgical patient

Abstract

A 41 year old woman, ASA PS1, an operated case of Chiari type 1 malformation, syringomyelia and syringobulbia, was posted for right syringopleural shunt. After a routine on-table extubation, immediately postoperatively, she lost consciousness, became progressively hypoxaemic requiring emergent reintubation. Blood gases revealed severe respiratory acidosis. The patient was systematically evaluated for likely causes of respiratory failure considering the sites of surgery and her preoperative surgical condition, i.e., brainstem, chest and larynx. She failed three trials of extubation, at different stages of her evaluation. Suspecting an undiagnosed neurological condition, the neurologist’s evaluation discovered a three-month history of easy fatiguability, dysphagia and ptosis. Nerve conduction studies also pointed to the diagnosis of myasthaenia gravis. After initiating steroids and neostigmine, the patient made a steady recovery and was successfully weaned off the ventilator.