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ANESTHESIA FOR SURGERY OF THYMECTOMY TO TREAT 
MYASTHENIA GRAVIS 
AT CHORAY HOSPITAL FROM 2004 – 2012. 
PhD.MD. Dong Pham Van 
Dr. Thao Trang Nguyen Thi 
THE ANESTHETIC 
DEPARTEMENT
OVERVIEW
OVERVIEW 
 AAnn aauuttooiimmmmuunnee ddiisseeaassee.. 
 AAggeess,, bbootthh sseexxeess,, ffeemmaallee >> mmaallee.. 
 HHiissttoorryy ooff mmuussccllee wweeaakknneessss,, mmoovvee iiss 
ffaattiigguuee,, rreesstt iiss ggrraadduuaallllyy iimmpprroovveedd.. 
 1100 -- 1155%% ffoorr tthhyymmoommaass,, 7755%% ffoorr tthhyymmiicc 
aabbnnoorrmmaalliittiieess.. 
 TThhyymmeeccttoommyy:: oonnee ooff eeffffiiccaacciioouuss tthheerraappiieess..
OVERVIEW 
 General anesthesia with double-lumen 
endotracheal tube, with or without NMBDs. 
 Some drugs cause weak muscle. 
 Vietnam hasn’t a lot of study topics like 
this yet. 
Purposes: 
To investigate the correlation between 2 groups 
patients with and without using NMBDs vs post-op 
respiratory failure ratio and recoverable time after 
anesthesia.
PHYSIOLOGY OF NEUROMUSCULAR 
TRANSMISSIONS
MOTOR UNIT
PHYSIOLOGY OF NEUROMUSCULAR 
TRANSMISSION 
Stimulated neuron ® 
openning Calci channel 
® Ach from synaptic 
vesicles in presynapse 
terminal go out. 
Ach – AchR ® 
openning channel 
® Na, Ca flows enter ® 
depolarizing motor end 
plate. 
® Action potential 
across on cell 
membrane surface.
MECHANISM OF NMBDs 
 Depolarizing NMBDs: linking AChR ® 
Depolarize the end plate® phase I block 
® prolonged connection of succinylcholin 
® Deforming AchR structure ® phase II 
block. 
 Non-depolarizing NMBDs: linking with 1 a 
unit ® abnormalities of Ach-AChR ® no 
depolarize the end plate.
SSIITTEESS OOFF NNEEUURROOMMUUSSCCUULLAARR 
TTRRAANNSSMMIISSSSIIBBLLEE DDYYSSFFUUNNCCTTIIOONN
EFFECTS OF NMBDs IN 
NEUROMUSCULAR DYSFUNCTIONS 
 DDeeccrreeaassiinngg tthhee nnuummbbeerr ooff AACChhRRss 
bbeeccaauussee ooff:: 
• CChhaannggiinngg tthhee ffuunnccttiioonn ooff AACChhRRss .. 
• IInnccrreeaassiinngg tthhee ddeeggrraaddaattiioonn ooff AACChhRRss.. 
• DDeessttrrooyyiinngg tthhee ssuurrffaaccee ooff ppoossttssyynnaappssee.. 
 RReessiissttaannccee wwiitthh ddeeppoollaarriizziinngg NNMMBBDDss.. 
 SSeennssiittiivviittyy wwiitthh nnoonn--ddeeppoollaarriizziinngg NNMMBBDDss..
SUBJECTS AND RESEARCH 
METHODS
SUBJECTS AND RESEARCH 
METHODS 
Research design: retrospection, description with 
analysis. 
Time, place: at Cho Ray hospital from 03/2004 to 
06/2012. 
Surgical methods:Thymectomy by endoscopic 
surgery.
SUBJECTS AND RESEARCH 
METHODS 
RReesseeaarrcchh mmeetthhooddss:: 
IInncclluussiioonn ccrriitteerriiaa:: IIIIAA,, IIIIBB ((OOsssseerrmmaann)),, 22 
ggrroouuppss,, 11sstt ggrroouupp:: uussee NNMMBBDDss;; 22nndd ggrroouupp:: nnoo uussee 
NNMMBBDDss.. 
EExxcclluussiioonn ccrriitteerriiaa:: ppaattiieennttss wwiitthh rreessppiirraattoorryy 
ffaaiilluurree,, MMGG ccrriissiiss,, pprree--oopp ppyyrriiddoossttiiggmmiinnee 
bbrroommiiddee >> 775500 mmgg//dd;; II,, IIIIII,, IIVV ggrraaddee;; IIIIAA,, IIIIBB wwiitthh 
ccaarrddiiaacc,, cchhrroonniicc ppuullmmoonnaarryy ddiisseeaassee,, sseeqquueellaa ooff 
ssttrrookkee..
SUBJECTS AND RESEARCH 
METHODS 
RReesseeaarrcchh pprroocceessss:: 
PPrreeaanneesstthheettiicc eexxaammiinnaattiioonn 
PPrreeaanneesstthheettiicc ddrruuggss:: nnoo 
IInndduuccttiioonn:: PPrrooppooffooll oorr sseevvoofflluurraannee,, SSuuffeennttaanniill,, 
oorr ffeennttaannyyll ((IIVV)).. UUssee oorr nnoo uussee:: 
ssuuxxaammeetthhoonniiuummee,, aattrraaccuurriiuumm,, rrooccuurroonniiuumm.. 
IInnttuubbaattiinngg ddoouubbllee--lluummeenn ttuubbee.... 
MMaaiinntteennaannccee:: SSeevvoofflluurraannee,, iissoofflluurraannee,, TTIIVVAA 
oorr TTCCII,, ssuuffeennttaanniill oorr ffeennttaannyyll ((IIVV)).. IInn eenndd ooff 
ssuurrggeerryy,, ssttoopp ddrruuggss && cchhaannggee eennddoottrraacchheeaall 
ttuubbee.. 
PPoosstt--oopp:: mmoonniittoorriinngg vviittaall ssiiggnnss,, AABBGG,, SSPPOO22,, 
MMGG ccrriissiiss……aannaallggeessiiaa:: ttrraammaaddooll,, ppeerrffaallggaann,, oorr 
nniissiiddooll..
SUBJECTS AND RESEARCH 
METHODS 
CCoolllleecctteedd vvaarriiaabblleess:: 
-- AAggee,, sseexx,, MMGG ddeeggrreeee,, ppuullssee,, BBPP,, SSppOO22.. 
-- SSuurrggiiccaall ttiimmee,, ttiimmee ooff ssppoonnttaanneeoouuss 
vveennttiillaattiioonn vviiaa eennddoottrraacchheeaall ttuubbee,, rreeccoovveerryy 
rroooomm,, iinn hhoossppiittaall.. RRaattiioo ooff rreessppiirraattoorryy ffaaiilluurree,, 
ppoosstt--oopp mmeecchhaanniissmm vveennttiillaattiioonn.. 
-- PPeerriiooppeerraattiivvee ddrruuggss:: ffeennttaannyyll,, ssuuffeennttaanniill;; 
pprrooppooffooll,, iissoofflluurraannee,, sseevvoofflluurraannee;; 
ssuuxxaammeetthhoonniiuumm,, aattrraaccuurriiuumm,, rrooccuurroonniiuumm.. 
-- PPoosstt--oopp ddrruuggss:: ttrraammaaddooll..
RESULTS & DISCUSSIONS
RESULTS & DISCUSSIONS 
124 patients 
Table 1: Ratio of patients using 
of relaxant drugs and no. 
Table 2. Ratio of relaxant drugs.
DISTRIBUTION OF AGES, SEXES IN 
02 GROUPS 
Characteri 
zations 
1st Group 
n = 43 (%) 
2nd Group 
n = 81 (%) 
Total 
n= 124(%) 
P 
Age X ± SD 
Min 
Max 
30.33 ± 11.07 
13 
55 
34.30 ± 11.65 
14 
62 
32.16 ± 11.23 
13 
62 
0.069 
Sex Male 
Female 
10 (23.3%) 
33 (76.7%) 
27 (33.3%) 
54 (66.7%) 
37 (29.8%) 
87 (70.2%) 
< 0.001 
Comments: 70.2% female, 29,8% male, this difference was statistically 
significant, with p < 0.001. Average age was 32.16 ± 11.23, this difference wasn’t 
statistically significant between 2 groups. p > 0.05.
SURGICAL TIME. 
Time (minute) 1st group 
(n = 43) 
2nd group 
(n = 81) 
p 
X ± SD 
Min 
Max 
104 ± 52.11 
45 
190 
96 ± 52.52 
30 
200 
0.672 
Comments: The surgical time wasn’t statictically significant difference 
between 2 groups, with p > 0.05.
TIME OF SPONTANEOUS VENTILATION 
VIA ENDOTRACHEAL TUBE IN 
RECOVERY ROOM 
1st Group 2nd Group 
Comments: 1st group 21.61 ± 11.40 was longer 2nd group 5.69 ± 5.13, the 
difference was statictically significant, with p < 0.001.
RATIO OF MECHANISM 
VENTILATION IN RECOVERY ROOM 
Mechanism 
Ventilation 
1st group 
(n = 43) 
2nd group 
(n = 81) 
p 
Yes 
No 
9 (20.9) 
34 (79.1) 
6 (7.4) 
75 (92.6) 
0.028 
Comments: : 1st group 20.9% was higher than 2nd group 7.4%, the 
difference was statictically significant, with p < 0.05.
TTIIMMEE OOFF PPOOSSTT--OOPP MMEECCHHAANNIISSMM 
VVEENNTTIILLAATTIIOONN BBEETTWWEEEENN 0022 
GGRROOUUPPSS 
56.06 ± 57.98 
1st Group 2nd Group 
Comments : 1st group 56.06 ± 57.98 was longer than 2nd group 3.50 ± 
1.33, the difference was statictically significant, with p < 0.05.
POST-OP RESPIRATORY FAILURE 
RATIO BETWEEN 02 GROUPS. 
100 
90 
80 
70 
60 
50 
40 
30 
20 
10 
0 
60.5 
7.4 
25.8 
39.5 
92.6 
74.2 Suy hô hấp Không SHH 
Nhóm 1 Nhóm 2 Tổng 
1st Group 2nd Group Total 
Comments: : 1st group 60.5% was higher than 2nd group 7.4%, the 
difference was statictically significant, with p < 0.001.
TIME IN RECOVERY ROOM OF 02 
GROUPS. 
1st Group 2nd Group 
Comments: : 1st group 30.94 ± 34.81 was longer than 2nd group 9.77 ± 
9.38, the difference was statictically significant, with p < 0.001.
CCOONNCCLLUUSSIIOONN 
MG patients have the same status, general 
anesthesia, surgical time, using the same 
anesthetic and analgesic drugs during and 
post-op ® the patients, who use NMBDs 
were the time of post-op spontaneous 
ventilation via endotrachea, of mechanism 
ventilation, of staying recovery room longer 
and ratio of post-op mechanism ventilation, 
respiratory faillure higher than the ones no 
use NMBDs.
Nguyen thi thao trang ta

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Nguyen thi thao trang ta

  • 1. ANESTHESIA FOR SURGERY OF THYMECTOMY TO TREAT MYASTHENIA GRAVIS AT CHORAY HOSPITAL FROM 2004 – 2012. PhD.MD. Dong Pham Van Dr. Thao Trang Nguyen Thi THE ANESTHETIC DEPARTEMENT
  • 3. OVERVIEW  AAnn aauuttooiimmmmuunnee ddiisseeaassee..  AAggeess,, bbootthh sseexxeess,, ffeemmaallee >> mmaallee..  HHiissttoorryy ooff mmuussccllee wweeaakknneessss,, mmoovvee iiss ffaattiigguuee,, rreesstt iiss ggrraadduuaallllyy iimmpprroovveedd..  1100 -- 1155%% ffoorr tthhyymmoommaass,, 7755%% ffoorr tthhyymmiicc aabbnnoorrmmaalliittiieess..  TThhyymmeeccttoommyy:: oonnee ooff eeffffiiccaacciioouuss tthheerraappiieess..
  • 4. OVERVIEW  General anesthesia with double-lumen endotracheal tube, with or without NMBDs.  Some drugs cause weak muscle.  Vietnam hasn’t a lot of study topics like this yet. Purposes: To investigate the correlation between 2 groups patients with and without using NMBDs vs post-op respiratory failure ratio and recoverable time after anesthesia.
  • 7. PHYSIOLOGY OF NEUROMUSCULAR TRANSMISSION Stimulated neuron ® openning Calci channel ® Ach from synaptic vesicles in presynapse terminal go out. Ach – AchR ® openning channel ® Na, Ca flows enter ® depolarizing motor end plate. ® Action potential across on cell membrane surface.
  • 8. MECHANISM OF NMBDs  Depolarizing NMBDs: linking AChR ® Depolarize the end plate® phase I block ® prolonged connection of succinylcholin ® Deforming AchR structure ® phase II block.  Non-depolarizing NMBDs: linking with 1 a unit ® abnormalities of Ach-AChR ® no depolarize the end plate.
  • 9. SSIITTEESS OOFF NNEEUURROOMMUUSSCCUULLAARR TTRRAANNSSMMIISSSSIIBBLLEE DDYYSSFFUUNNCCTTIIOONN
  • 10. EFFECTS OF NMBDs IN NEUROMUSCULAR DYSFUNCTIONS  DDeeccrreeaassiinngg tthhee nnuummbbeerr ooff AACChhRRss bbeeccaauussee ooff:: • CChhaannggiinngg tthhee ffuunnccttiioonn ooff AACChhRRss .. • IInnccrreeaassiinngg tthhee ddeeggrraaddaattiioonn ooff AACChhRRss.. • DDeessttrrooyyiinngg tthhee ssuurrffaaccee ooff ppoossttssyynnaappssee..  RReessiissttaannccee wwiitthh ddeeppoollaarriizziinngg NNMMBBDDss..  SSeennssiittiivviittyy wwiitthh nnoonn--ddeeppoollaarriizziinngg NNMMBBDDss..
  • 12. SUBJECTS AND RESEARCH METHODS Research design: retrospection, description with analysis. Time, place: at Cho Ray hospital from 03/2004 to 06/2012. Surgical methods:Thymectomy by endoscopic surgery.
  • 13. SUBJECTS AND RESEARCH METHODS RReesseeaarrcchh mmeetthhooddss:: IInncclluussiioonn ccrriitteerriiaa:: IIIIAA,, IIIIBB ((OOsssseerrmmaann)),, 22 ggrroouuppss,, 11sstt ggrroouupp:: uussee NNMMBBDDss;; 22nndd ggrroouupp:: nnoo uussee NNMMBBDDss.. EExxcclluussiioonn ccrriitteerriiaa:: ppaattiieennttss wwiitthh rreessppiirraattoorryy ffaaiilluurree,, MMGG ccrriissiiss,, pprree--oopp ppyyrriiddoossttiiggmmiinnee bbrroommiiddee >> 775500 mmgg//dd;; II,, IIIIII,, IIVV ggrraaddee;; IIIIAA,, IIIIBB wwiitthh ccaarrddiiaacc,, cchhrroonniicc ppuullmmoonnaarryy ddiisseeaassee,, sseeqquueellaa ooff ssttrrookkee..
  • 14. SUBJECTS AND RESEARCH METHODS RReesseeaarrcchh pprroocceessss:: PPrreeaanneesstthheettiicc eexxaammiinnaattiioonn PPrreeaanneesstthheettiicc ddrruuggss:: nnoo IInndduuccttiioonn:: PPrrooppooffooll oorr sseevvoofflluurraannee,, SSuuffeennttaanniill,, oorr ffeennttaannyyll ((IIVV)).. UUssee oorr nnoo uussee:: ssuuxxaammeetthhoonniiuummee,, aattrraaccuurriiuumm,, rrooccuurroonniiuumm.. IInnttuubbaattiinngg ddoouubbllee--lluummeenn ttuubbee.... MMaaiinntteennaannccee:: SSeevvoofflluurraannee,, iissoofflluurraannee,, TTIIVVAA oorr TTCCII,, ssuuffeennttaanniill oorr ffeennttaannyyll ((IIVV)).. IInn eenndd ooff ssuurrggeerryy,, ssttoopp ddrruuggss && cchhaannggee eennddoottrraacchheeaall ttuubbee.. PPoosstt--oopp:: mmoonniittoorriinngg vviittaall ssiiggnnss,, AABBGG,, SSPPOO22,, MMGG ccrriissiiss……aannaallggeessiiaa:: ttrraammaaddooll,, ppeerrffaallggaann,, oorr nniissiiddooll..
  • 15. SUBJECTS AND RESEARCH METHODS CCoolllleecctteedd vvaarriiaabblleess:: -- AAggee,, sseexx,, MMGG ddeeggrreeee,, ppuullssee,, BBPP,, SSppOO22.. -- SSuurrggiiccaall ttiimmee,, ttiimmee ooff ssppoonnttaanneeoouuss vveennttiillaattiioonn vviiaa eennddoottrraacchheeaall ttuubbee,, rreeccoovveerryy rroooomm,, iinn hhoossppiittaall.. RRaattiioo ooff rreessppiirraattoorryy ffaaiilluurree,, ppoosstt--oopp mmeecchhaanniissmm vveennttiillaattiioonn.. -- PPeerriiooppeerraattiivvee ddrruuggss:: ffeennttaannyyll,, ssuuffeennttaanniill;; pprrooppooffooll,, iissoofflluurraannee,, sseevvoofflluurraannee;; ssuuxxaammeetthhoonniiuumm,, aattrraaccuurriiuumm,, rrooccuurroonniiuumm.. -- PPoosstt--oopp ddrruuggss:: ttrraammaaddooll..
  • 17. RESULTS & DISCUSSIONS 124 patients Table 1: Ratio of patients using of relaxant drugs and no. Table 2. Ratio of relaxant drugs.
  • 18. DISTRIBUTION OF AGES, SEXES IN 02 GROUPS Characteri zations 1st Group n = 43 (%) 2nd Group n = 81 (%) Total n= 124(%) P Age X ± SD Min Max 30.33 ± 11.07 13 55 34.30 ± 11.65 14 62 32.16 ± 11.23 13 62 0.069 Sex Male Female 10 (23.3%) 33 (76.7%) 27 (33.3%) 54 (66.7%) 37 (29.8%) 87 (70.2%) < 0.001 Comments: 70.2% female, 29,8% male, this difference was statistically significant, with p < 0.001. Average age was 32.16 ± 11.23, this difference wasn’t statistically significant between 2 groups. p > 0.05.
  • 19. SURGICAL TIME. Time (minute) 1st group (n = 43) 2nd group (n = 81) p X ± SD Min Max 104 ± 52.11 45 190 96 ± 52.52 30 200 0.672 Comments: The surgical time wasn’t statictically significant difference between 2 groups, with p > 0.05.
  • 20. TIME OF SPONTANEOUS VENTILATION VIA ENDOTRACHEAL TUBE IN RECOVERY ROOM 1st Group 2nd Group Comments: 1st group 21.61 ± 11.40 was longer 2nd group 5.69 ± 5.13, the difference was statictically significant, with p < 0.001.
  • 21. RATIO OF MECHANISM VENTILATION IN RECOVERY ROOM Mechanism Ventilation 1st group (n = 43) 2nd group (n = 81) p Yes No 9 (20.9) 34 (79.1) 6 (7.4) 75 (92.6) 0.028 Comments: : 1st group 20.9% was higher than 2nd group 7.4%, the difference was statictically significant, with p < 0.05.
  • 22. TTIIMMEE OOFF PPOOSSTT--OOPP MMEECCHHAANNIISSMM VVEENNTTIILLAATTIIOONN BBEETTWWEEEENN 0022 GGRROOUUPPSS 56.06 ± 57.98 1st Group 2nd Group Comments : 1st group 56.06 ± 57.98 was longer than 2nd group 3.50 ± 1.33, the difference was statictically significant, with p < 0.05.
  • 23. POST-OP RESPIRATORY FAILURE RATIO BETWEEN 02 GROUPS. 100 90 80 70 60 50 40 30 20 10 0 60.5 7.4 25.8 39.5 92.6 74.2 Suy hô hấp Không SHH Nhóm 1 Nhóm 2 Tổng 1st Group 2nd Group Total Comments: : 1st group 60.5% was higher than 2nd group 7.4%, the difference was statictically significant, with p < 0.001.
  • 24. TIME IN RECOVERY ROOM OF 02 GROUPS. 1st Group 2nd Group Comments: : 1st group 30.94 ± 34.81 was longer than 2nd group 9.77 ± 9.38, the difference was statictically significant, with p < 0.001.
  • 25. CCOONNCCLLUUSSIIOONN MG patients have the same status, general anesthesia, surgical time, using the same anesthetic and analgesic drugs during and post-op ® the patients, who use NMBDs were the time of post-op spontaneous ventilation via endotrachea, of mechanism ventilation, of staying recovery room longer and ratio of post-op mechanism ventilation, respiratory faillure higher than the ones no use NMBDs.

Editor's Notes

  1. Định nghĩa Berlin về ARDS 6/2012: không còn ALI; loại áp lực ĐM phổi bít (PAWP). Thời gian: trong vòng 1 tuần XQ Oxy hóa: (1) Nhẹ 200 &amp;lt; P/F ≤ 300; (2) TB 100 &amp;lt; P/F ≤ 200; (3) nặng P/F ≤ 100; tất cả PEEP ≥ 5
  2. - Ngay cả thể tích khí lưu thông 6 ml/kg tốt hơn hoặc xấu hơn thể tích khí lưu thông 8 ml/kg vẫn còn là vấn đề đang bàn cãi. Tuy nhiên, cho đến khi có những bằng chứng chứng minh ngược lại, Vt 6 ml/kg nên được xem như tiêu chuẩn cho điều trị. Cần nhấn mạnh là các thử nghiệm của ARDS network, tính Vt dựa trên cân nặng lý tưởng, không phải cân nặng thực tế, và nếu tính trên cân nặng thực tế thì trung bình Vt là 5 ml/kg.