Case study

1. Il paziente miastenico
in anestesia generale
Vincenzo Pennestrì
Anestesia e Rianimazione
P.O. Misericordia

3. Presentazione del paziente
❖ MP 60 aa donna, ricovero per intervento in elezione di
pielolitotomia in calcolosi renale in VLS
❖ APR: diagnosi di MG nel 2009; esami strumentali negativi per
timoma; periodi di remissione dopo trattamento medico,
alternati a brevi fasi di riacutizzazione; pregresso intervento per
colecistectomia (estubata in Rianimazione dopo qualche ora
nel postoperatorio).
❖ APP: in terapia medica; lieve ptosi palpebrale; buona
funzionalità respiratoria alla spirometria (ai limiti della norma);
non allergie

7. Condotta Anestesiologica…
❖ Premedicazione: midazolam 2 mg ev
❖ Induzione AG:
❖ propofol 2 mg/Kg ev
❖ rocuronium 0,2 mg/Kg ev
❖ remifentanyl 0,5/mcg/kg/min
❖ Mantenimento
❖ sevoflurano 0.9 MAC/O2 40%/Aria 60%
❖ rocuronio 0,5 mg/kg boli su TOF >0
❖ remifentanyl 0,25-1 mcg/kg/min

9. …Condotta Anestesiologica
❖ Fine intervento > TOF 2
❖ Risveglio
❖ stop sevoflurano
❖ stop remifentanyl
❖ sugammadex 200 mg ev
❖ dopo 140 sec TOF 94%
ost-operatorio in T. subintensiva (24 ore di monitoraggio parametri vital

12. Warnings/Precautions
Concerns related to adverse effects:
• Cardiovascular effects: Bradycardia, hypotension, and dysrhythmias may
occur, particularly with IV use; risk may be increased in patients with certain
cardiovascular conditions (eg, coronary artery disease, cardiac arrhythmias,
recent acute coronary syndrome). Risk may also be increased in patients
with myasthenia gravis. When IV neostigmine is administered for the
reversal of nondepolarizing neuromuscular-blocking agents, atropine or
glycopyrrolate should be administered concurrently or prior to neostigmine
to lessen the risk of bradycardia.
• Cholinergic crisis: Overdosage may result in cholinergic crisis, characterized
by extreme muscle weakness and potentially fatal respiratory paralysis.
Cholinergic crisis should be distinguished from myasthenic crisis, which is also
characterized by extreme muscle weakness, but would require radically
different treatment.
• Hypersensitivity reactions: Symptoms of hypersensitivity have included
urticaria, angioedema, erythema multiforme, generalized rash, facial
swelling, peripheral edema, pyrexia, flushing, hypotension, bronchospasm,
bradycardia, and anaphylaxis. Have atropine and epinephrine ready to treat
hypersensitivity reactions.
• Neuromuscular effects: Large doses of IV neostigmine administered for the
reversal of nondepolarizing neuromuscular-blocking agents when
neuromuscular blockade is minimal can result in neuromuscular dysfunction.
Reduce the dose of neostigmine if recovery from neuromuscular blockade is
nearly complete.

14. ind of hard to ask a dead guy what it did w
Grazie per la cortese attenzione!