Orbit Decompression & Myasthenia
Managing neuromuscular junction pathology in the setting of acute ophthalmic trauma and full stomach risks.
"A 25 y.o. woman with Myasthenia Gravis is scheduled for decompression of the orbit to relieve a compressive optic neuropathy sustained in a car crash 4 hours ago. Meds: Pyridostigmine 30 mg qid; Prednisone. PHYS: BP 128/86; HR 98; RR 20; O2 Sat 97% (room air)."
Sensitivity to neuromuscular blockers, intraocular pressure control, and managing the 'full stomach' risk in Myasthenia.
Defend your anesthetic management plan for a patient at risk of both respiratory failure and optic nerve injury. Neuro-muscular disorders are common secondary clinical challenges.
How a Board-Certified Consultant answers this scenario.
Managing Myasthenia Gravis (MG) requires careful titration of neuromuscular blockers (NMBs). I will warn the patient about the potential for post-operative mechanical ventilation.
My induction will be a Rapid Sequence Induction due to the 'full stomach' risk from the recent trauma, but I will significantly reduce or avoid my dose of non-depolarizing NMBs, as these patients are extremely sensitive to them. Conversely, they may be resistant to succinylcholine, so if I use it, I will use a slightly higher dose (1.5-2.0 mg/kg) for rapid securing of the airway.
Intraoperatively, I will use a volatile-heavy technique to provide some muscle relaxation without the need for additional blockers. I will also be mindful of her steroids and provide stress-dose hydrocortisone. My goal is a smooth emergence without residual paralysis to prevent a myasthenic crisis; I will use quantitative twitch monitoring and only extubate once she meets strict criteria for airway protection and ventilation.