Miyastenia Gravis Tanılı, Distal Radius Kırık Operasyonu Geçirecek Olguda İnfraklavikular Blok ile Anestezi Yönetimi
Özet
Miyastenia gravis (MG), nöromüsküler kavşakta postsinaptik membranda nikotinik asetilkolin reseptörlerinin (AChR) etkilenmesi ile kas yorgunluğu ve güçsüzlük ile seyreden bir hastalıktır. Hastaların klinik seyirleri dışında postoperatif solunum yetmezliği riskinin yüksek olması anestezi hekimleri açısından özellikle önem arz etmektedir (1). MG postsinaptik membranda AChR karşı oluşan otoantikorlar nedeniyle presinaptik nörondan salınan asetilkolin (ACh) yeterli yanıt bulamaz ve deporalizasyon başlamaz, bu sebeple kas kasılamaz. Antijenitedeki farklılık nedeniyle düz kasları etkilemeyen hastalık özellikle çizgili kaslarda yorgunluk, güçsüzlük semptomları ile ortaya çıkar. Hastalığın heterojenitesi semptomlar yönünden oldukça yüksektir (2).
Miyastenia Gravis, hipotiroidi tanıları olan 52 yaşında, boyu 162 santimetre (cm), vücut ağırlığı 66 kilogram (kg) kadın hasta, düşme sonrası sol dirsekte ağrı şikayeti ile acil servise başvurmuş, çekilen üst ekstremite direk grafisinde sol distal radiusta olekranon kırığı, sol pubik hatta kırık tespit edilmesi üzerine ortopedi ve travmatoloji servisi tarafından servis yatışı yapılmıştı.
Hastanın özgeçmişinde bilinen hipotiroidi öyküsü nedeniyle Levotiroksin 100 µg (1x1) kullanımı, MG nedeniyle 32 yıl boyunca Piridostigmin 60 mg (1x1) kullanımı mevcuttu. Hastaya ortopedi ve travmatoloji servisi tarafından sol distal radius olekranon kırığı nedeniyle plak vida ile osteosentez planlanması üzerine preoperatif hazırlık için anestezi bölümüne danışılmıştır. Hastaya ultrasonografi (USG) eşliğinde infraklaviküler blok planlandı, hazırlık yapıldı. 8 mm 22 Gauge (G) sonografi ile görülebilir yalıtımlı blok iğnesi in-plane teknikle aksiler arter çevresine ilerletildi. 20 ml %0,5 bupivakain aksiler arter çevresinde U şeklinde yayılacak şekilde infüze edildi. Lokal anesteziğin yayılımı izlendi. Blok etkisi muayene edildikten sonra operasyon başladı. Operasyon sonrası hastanın yakın takibi devam etti. Ek analjezik ihtiyacı olmadı.
Miyastenia Gravis hastalığın heterojenitesi açısından ve komplikasyonların yönetimi açısından rejyonel tekniklerin kullanımını önemli kılmaktadır. Tanı almamış bireylerin sık olması nedeniyle hastayı ameliyat öncesi değerlendirirken anestezist özellikle uyanık olmalıdır. İntraoperatif hazırlıkların dikkatle yapılması ve postoperatif takibin iyi yapılması gerekmektedir.
Myasthenia gravis (MG) is a disease characterized by muscle fatigue and weakness due to the impairment of nicotinic acetylcholine receptors (AChR) at the postsynaptic membrane in the neuromuscular junction. For anesthesiologists, the high risk of postoperative respiratory failure in these patients is of particular concern beyond their clinical course. In MG, autoantibodies against AChR at the postsynaptic membrane prevent acetylcholine (ACh) released from the presynaptic neuron from eliciting an adequate response, thus inhibiting depolarization and subsequent muscle contraction. Due to antigenic differences, the disease does not affect smooth muscles but manifests with symptoms of fatigue and weakness in striated muscles. The heterogeneity of the disease is considerable in terms of symptoms.
A 52-year-old female patient, 162 cm in height and weighing 66 kg, diagnosed with hypothyroidism and myasthenia gravis, presented to the emergency department with left elbow pain following a fall. Direct radiography of the upper extremity revealed an olecranon fracture in the left distal radius and a fracture in the left pubic area, leading to her admission to the orthopedics and traumatology service. The patient had a history of hypothyroidism managed with Levothyroxine 100 µg (1x1) and had been using Pyridostigmine 60 mg (1x1) for 32 years for MG. The orthopedics and traumatology service planned osteosynthesis with a plate and screws for the left distal radius olecranon fracture and consulted the anesthesia department for preoperative preparation. An infraclavicular block was planned and performed under ultrasound guidance. An 8 mm, 22-gauge insulated block needle, visible via sonography, was advanced around the axillary artery using the in-plane technique. Subsequently, 20 ml of 0.5% bupivacaine was infused around the axillary artery in a U-shaped distribution. The spread of the local anesthetic was observed, and the block effect was confirmed before surgery commenced. Postoperative follow-up of the patient continued with no need for additional analgesics.
The heterogeneity of myasthenia gravis and the management of its complications underscore the importance of regional techniques. Anesthesiologists must be particularly vigilant when evaluating patients preoperatively, especially given the prevalence of undiagnosed cases. Careful intraoperative preparation and diligent postoperative monitoring are essential.
Referanslar
BLICHFELDT‐LAURIDSEN L, HANSEN BD. Anesthesia and myasthenia gravis. Acta Anaesthesiol Scand [Internet]. 2012 Jan 19;56(1):17–22. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2011.02558.x
Racca F, Vianello A, Mongini T, Ruggeri P, Versaci A, Vita GL, et al. Practical approach to respiratory emergencies in neurological diseases. Neurol Sci [Internet]. 2020 Mar 2;41(3):497–508. Available from: http://link.springer.com/10.1007/s10072-019-04163-0
Morren JA, Li Y. Myasthenia gravis: Frequently asked questions. Cleve Clin J Med [Internet]. 2023 Feb 1;90(2):103–13. Available from: https://www.ccjm.org//lookup/doi/10.3949/ccjm.90a.22017
Farrugia M. Myasthenic syndromes. J R Coll Physicians Edinb [Internet]. 2011 Mar 1;41(1):43–8. Available from: http://www.rcpe.ac.uk/journal/issue/journal_41_1/farrugia.pdf
Nilsson E, Meretoja OA. Vecuronium Dose—Response and Maintenance Requirements in Patients with Myasthenia Gravis. Anesthesiology [Internet]. 1990 Jul 1;73(1):28–32. Available from: https://pubs.asahq.org/anesthesiology/article/73/1/28/31639/Vecuronium-Dose-Response-and-Maintenance
Sanfilippo M, Fierro G, Cavalletti M V, Biancari F, Vilardi V. Rocuronium in two myasthenic patients undergoing thymectomy. Acta Anaesthesiol Scand [Internet]. 1997 Nov;41(10):1365–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9422307
Sungur Ulke Z, Senturk M. Mivacurium in patients with myasthenia gravis undergoing video-assisted thoracoscopic thymectomy. Br J Anaesth [Internet]. 2009 Aug;103(2):310–1. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19596766
Baraka A, Siddik S, Kawkabani N. Cisatracurium in a myasthenic patient undergoing thymectomy. Can J Anaesth [Internet]. 1999 Aug;46(8):779–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10451139
de Boer HD, Shields MO, Booij LHDJ. Reversal of neuromuscular blockade with sugammadex in patients with myasthenia gravis: a case series of 21 patients and review of the literature. Eur J Anaesthesiol [Internet]. 2014 Dec;31(12):715–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25192270
Daum P, Smelt J, Ibrahim IR. Perioperative management of myasthenia gravis. BJA Educ [Internet]. 2021 Nov;21(11):414–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2058534921000822
Spiegel P. [Block of the brachial plexus. Infraclavicular transpectoral perivascular technic]. Rev Bras Anestesiol [Internet]. 1967;17(1):48–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/5595548
Raj PP, Montgomery SJ, Nettles D, Jenkins MT. Infraclavicular brachial plexus block--a new approach. Anesth Analg [Internet]. 1973;52(6):897–904. Available from: http://www.ncbi.nlm.nih.gov/pubmed/4796563
Kaye AD, Allampalli V, Fisher P, Kaye AJ, Tran A, Cornett EM, et al. Supraclavicular vs. Infraclavicular Brachial Plexus Nerve Blocks: Clinical, Pharmacological, and Anatomical Considerations. Anesthesiol Pain Med [Internet]. 2021 Oct 31;11(5). Available from: https://brieflands.com/articles/aapm-120658.html
Sheikh S, Alvi U, Soliven B, Rezania K. Drugs That Induce or Cause Deterioration of Myasthenia Gravis: An Update. J Clin Med [Internet]. 2021 Apr 6;10(7):1537. Available from: https://www.mdpi.com/2077-0383/10/7/1537
Referanslar
BLICHFELDT‐LAURIDSEN L, HANSEN BD. Anesthesia and myasthenia gravis. Acta Anaesthesiol Scand [Internet]. 2012 Jan 19;56(1):17–22. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2011.02558.x
Racca F, Vianello A, Mongini T, Ruggeri P, Versaci A, Vita GL, et al. Practical approach to respiratory emergencies in neurological diseases. Neurol Sci [Internet]. 2020 Mar 2;41(3):497–508. Available from: http://link.springer.com/10.1007/s10072-019-04163-0
Morren JA, Li Y. Myasthenia gravis: Frequently asked questions. Cleve Clin J Med [Internet]. 2023 Feb 1;90(2):103–13. Available from: https://www.ccjm.org//lookup/doi/10.3949/ccjm.90a.22017
Farrugia M. Myasthenic syndromes. J R Coll Physicians Edinb [Internet]. 2011 Mar 1;41(1):43–8. Available from: http://www.rcpe.ac.uk/journal/issue/journal_41_1/farrugia.pdf
Nilsson E, Meretoja OA. Vecuronium Dose—Response and Maintenance Requirements in Patients with Myasthenia Gravis. Anesthesiology [Internet]. 1990 Jul 1;73(1):28–32. Available from: https://pubs.asahq.org/anesthesiology/article/73/1/28/31639/Vecuronium-Dose-Response-and-Maintenance
Sanfilippo M, Fierro G, Cavalletti M V, Biancari F, Vilardi V. Rocuronium in two myasthenic patients undergoing thymectomy. Acta Anaesthesiol Scand [Internet]. 1997 Nov;41(10):1365–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9422307
Sungur Ulke Z, Senturk M. Mivacurium in patients with myasthenia gravis undergoing video-assisted thoracoscopic thymectomy. Br J Anaesth [Internet]. 2009 Aug;103(2):310–1. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19596766
Baraka A, Siddik S, Kawkabani N. Cisatracurium in a myasthenic patient undergoing thymectomy. Can J Anaesth [Internet]. 1999 Aug;46(8):779–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10451139
de Boer HD, Shields MO, Booij LHDJ. Reversal of neuromuscular blockade with sugammadex in patients with myasthenia gravis: a case series of 21 patients and review of the literature. Eur J Anaesthesiol [Internet]. 2014 Dec;31(12):715–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25192270
Daum P, Smelt J, Ibrahim IR. Perioperative management of myasthenia gravis. BJA Educ [Internet]. 2021 Nov;21(11):414–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2058534921000822
Spiegel P. [Block of the brachial plexus. Infraclavicular transpectoral perivascular technic]. Rev Bras Anestesiol [Internet]. 1967;17(1):48–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/5595548
Raj PP, Montgomery SJ, Nettles D, Jenkins MT. Infraclavicular brachial plexus block--a new approach. Anesth Analg [Internet]. 1973;52(6):897–904. Available from: http://www.ncbi.nlm.nih.gov/pubmed/4796563
Kaye AD, Allampalli V, Fisher P, Kaye AJ, Tran A, Cornett EM, et al. Supraclavicular vs. Infraclavicular Brachial Plexus Nerve Blocks: Clinical, Pharmacological, and Anatomical Considerations. Anesthesiol Pain Med [Internet]. 2021 Oct 31;11(5). Available from: https://brieflands.com/articles/aapm-120658.html
Sheikh S, Alvi U, Soliven B, Rezania K. Drugs That Induce or Cause Deterioration of Myasthenia Gravis: An Update. J Clin Med [Internet]. 2021 Apr 6;10(7):1537. Available from: https://www.mdpi.com/2077-0383/10/7/1537
