Use Of Intravenous Immunoglobulin And Management Of Anesthesia For Preparation To Thymectomy In A Case With Myasthenia Gravis That Was Intractable To Classical Treatment Modalities

Abstract

Myasthenia gravis (MG) is a rare, autoimmune disease. In our study we aimed to present multidisciplinary approaches of neurology, cardiovascular surgery and anesthesia departments and the successful anesthesia technique in our patient who received intravenous immunoglobulin (IVIG) therapy due to chronic MG and then underwent thymectomy. Thymectomy is beneficial in ~40-90% of MG patients. Besides thymectomy, anticholinesterases, corticosteroids, immunosuppressives and plasma exchange (PE) often improve the prognosis of patients with life threatening symptoms. IVIG might be an alternative to PE in the prethymectomy preparation of MG patients with generalized involvement but not more severe than type II B and thymectomy should be performed within 10 days after IVIG treatment as the effect of IVIG is temporary.A 48 years old female patient having the diagnosis of MG for 10 years and evaluated as class II B according to Osserman classification received prydostigmine, prednisolon and azatiyoprin therapy previously. Despite the treatment, through last 3 months complaints of patient were increased. For this reason the patient was scheduled for thymectomy and 400 mg/kg IVIG therapy for 5 days was started preoperatively. Four days later, the patient was taken into thymectomy. In anesthesia induction 3 mg/kg propofol and 100 μg fentanyl was used, but no sedative and neuromuscular blocking agent (NMB) was used. Case was ventilated with %50 O2 % 50 N2O combination and 2% Sevoflurane for 5 minutes. There wasn’t any unfavorable response to intubation. While considering previous steroid treatment, patient was applied 250 mg prednisolone. During the operation there was no need for NMB. After the operation, successful tracheal extubation was achieved in the operating room and the patient transferred to the cardiovascular surgery intensive care unit (CSICU). Case was given O2 supply for a time. She was discharged to the ward 2 days later and then she was discharged home 5 days later.Multidisciplinary approach and the successful anesthesia technique were effective in discharge of our MG case after thymectomy following IVIG treatment without any problem. PE can be applied in longer time and due to some associated complications, hospitalization time prolongs (10 days) and cost increases. On the other hand, IVIG treatment can be applied in a shorter time (5 days) but it is more expensive. For this reason we think that comparative studies in large series are needed and case selection must be done appropriately. Selected MG cases can be operated successfully with preoperative IVIG use especially with multidisciplinary approach and successful anesthesia management. By this way, also hospitalization times, cost and complication can be decreased.