Happy Monday everyone. I hope you all had a great weekend. I had a case last week with a patient who has myasthenia gravis. Patient has to be paralyzed due to the type of the surgery she had to undergo. I figure it would be a good topic to discuss. As we all know, MG patients are hypersensitive to neuromuscular blockade due to the reduced number of acetylcholine receptors.
Sugammadex has become readily available in most of the hospitals these days. Remember my older post that sugammadex acts like a pacman. It binds to rocuronium/vecuronium and encapsulates the molecule. The 1:1 binding forms cyclodextrin which educes the amount of free NMB agent in plasma. Subsequently the concentration gradient favors movement of NMB agent away from the neuromuscular junction. Hence, patient who has myaesthenia gravis can quickly return to his/her base line level after full reversal dose of sugammadex is given. This is supported by the case report by Shad et al. that they were successful in using sugammadex to reverse rocuronium induced neuromuscular blockade in an elderly octagenarian with Myaesthenia Gravis undergoing emergency laporotomy. We also found that administration of sugammadex fully restored the base line of neuromuscular function in less than 5 minutes. Our patient was on cellcept to control her MG. After administering sugammadex, patient was able to take 450ml tidal volume on her own. Patient was successfully extubated after surgery.
Here you go. Now you know that we don’t have to worry about residual muscular blockade with the NMB anymore for patients who have MG. Go ahead and give NMB for intubation because we can reverse the patient.
Shah D1, Dharmarajah A2. Use of Sugammadex in an octagenerian with Myaesthenia Gravis undergoing emergency laporotomy. J Clin Anesth. 2017 Feb;37:109-110. doi: 10.1016/j.jclinane.2016.11.008. Epub 2017 Jan 8.