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SEVOFLURANE ANESTHESIA 
WITHOUT MUSCLE RELAXANTS 
FOR THORACOSCOPIC 
THYMECTOMY 
IN MYASTHENIA GRAVIS 
Vo Van Hien 
Nguyen Huu Tu 
Mai Van Vien
Introduction 
 Myasthenia gravis (MG) is a chronic autoimmune disorder 
related to the thymus gland. 
 Thymectomy is one of the effective methods to treat MG. 
 Patients with myasthenia gravis did sentitivity to the drugs 
were used in anesthesia → Choice drugs and anesthesia 
technique plays an important role in the success of 
operation.
introduction 
 Respiratory complications depend on anesthetic technique: 
 Mulder et al (1972): 50% of pts need ventilatory support. 
 Suwanchi (1995): Comparision general anesthesia vs 
epidural anesthesia and iv. propofol: early extubation in 
operating room 29%- 78%. 
 Catherine Chevalley et al (2001)(*): 
+ Time need ventilation support : 2-48h 
+ Propofol was used (1994): No need to ventilate 
postoperative.
Vo van hien
introduction 
 In Vietnam, Đo Tat Cuong (1996) reported postoperative 
ventilation depend on method of anesthesia : 
 Anesthesia: 15.65% 
 Acupunture: 3.5% 
 Nguyen Van Thanh (1998) studied on 47 pts: 
 Required ventilation support: 15/47pts 
 Mortality: 3 patients due to respiratory infections.
introduction 
Side effects of long-term ventilatory support on MG pts: 
• Infections: respiratory, pneumonia, sepsis → death. 
• Prolonged hospitalization days 
• Increased treatment costs 
Anesthesiologists’ recommendations: 
“Avoid muscle relaxants in MG patients”
introduction 
CChhooiiccee ddrruugg ?? 
DDoossee?? 
IInnttuubbaattiioonn ?? 
AAiirrwwaayyss iinnjjuurriieess?? 
HHeemmooddyynnaammiicc cchhaannggee?? 
EEaassyy ffoorr ssuurrggeeoonn?? 
NNOO MMUUSSCCLLEE 
RREELLAAXXAANNTTSS 
!!!!!! 
EEaarrllyy eexxttuubbaattiioonn?? 
RReessppiirraattoorryy ccoommpplliiccaattiioonn??
objectives 
To evaluate the use of sevoflurane and 
without muscle relaxants 
for thoracoscopic thymectomy in MG patients 
and post-operative respiratory status
methods 
 Subjects: Intervention study on 28 MG patients scheduled to 
undergo thoracoscopic thymectomy 
 Monitor: Datex Omeda: ECG (DII), SpO2, EtCO2, invasive 
aterial blood pressure (ABP), module Entropy (RE, SE), TOF. 
 Induction: 
- Atropin: 0.5mg; Sufentanil: 0.5mcg/kg; 
- Propofol 2.5-3 mg/kg 
- Local anesthesia with 10 cc of lidocaine hydrochloride 2% 
was sprayed on the vocal cords and into the trachea
methods 
 Intubation Univent tube 
- Loss eyelid reflex 
- RE, SE<50 
- Check tube and blocker’s position by endoscopy equipment 
(Olympus) 
 Ventilate A/C mode : Vt = 10ml/kg; f=14l/ph; FiO2= 60%→ 
PetCO2= 28-32 mmHg. 
 OLV: Vt=5ml/kg, f=16-20; FiO2= 100% → Ppeak < 30 cm 
H2O, PetCO2=30-35mmHg. 
 Sufentanil: 0.2mcg/kg/h
methods 
 Adjust concentration of sevoflurane 
Criterial ABP > 130% 
baseline 
70% < ABP 
<130% 
ABP < 70% 
baseline 
RE, SE>60 ↑ Sevorane ↑ Sevorane 
Increase infusion 
and ephedrine iv 
before ↑ Sevorane 
40<RE,SE<60 Nicardipine iv 
Adequate 
depth of 
anesthesia 
Increase infusion 
and ephedrine iv 
RE, SE <40 Nicardipine iv ↓ Sevorane ↓ Sevorane
methods 
 Stop sufentanil 15 minutes before the end of surgery 
 Stop sevoflurane at the end of surgery. 
 Extubation when: 
- Awake 
- Head lift > 5 seconds 
- RR < 30/min 
- Inspiratory force > 25cmH2O 
 Assess respiratory status: breathing frequency; SpO2, blood 
gas. 
 Evaluate airway injuries at 24h postoperative.
II-- SSTTAATT ppoorrttaabbllee 
cclliinniiccaall aannaallyysseerr 
Medical e UUnniivveenntt ttuubbqueei’’msse nts used in study 
ppoossiittiioonn 
iinn ttrraacchheeaa 
--ppHH 
-PPaaOO22 
-PPaaCCOO22 
-HHCCOO33-- 
-BBEE 
-BBBB
Vo van hien
recorded Data 
 General characteristics 
 Intubation conditions (Viby Mogensen Score), number of 
attemps to intubate. 
 Hemodynamic changes at induction, before and after 
intubation and intraoperative. 
 Neuromuscular effect of sevoflurane on MG: TOF 
 Surgeons’ satisfaction: VAS score 
 Time to extubation and respiratory status: f, SpO2 , PaO2, 
PaCO2, pH,… 
 Clinical symtom due to airway injuries: sorethroat, 
hoarseness and observe by laryngostroboscopy.
results 
General characteristics 
Characteristics Results 
Gender 
Male 8 (28.6%) 
Female 20 (71.4%) 
Age (X±SD) (years) 39.5 ± 9.7 
Classification 
(folow 
Osserman) 
I 5 (17.9%) 
IIa 16 (57.1%) 
IIb 7 (25.0%) 
Duration of disease (months) 95.6 ± 8.73 
3-121
Time in anesthesia 
Time 
Results 
Loss eyelid reflex (seconds) 
112.6± 28.5 
57- 140 
Achive RE, SE <50 (seconds) 
149.5 ± 17.6 
103 – 186 
Intubation time (minutes) 
6.0± 1.5 
3.5 – 12.8 
results
Agent dose for induction and maintaining 
Purpose Results 
Propofol for induction (mg) 189,75±40,3 
110- 230 
Total dose of sevoflurane for maintaining (ml) 125,35±59,6 
Inspiratory concentration of sevorane for 
maintaining (%) 
3,05± 2,4 
results
results 
Intubation condition 
82.1 
17.9 
0 
100 
80 
60 
40 
20 
0 
Rate (%) 
Excelent Good Poor 
Intubation condition
results 
Side effects intraoperative 
Side Effects Results 
Induction- 
Intubation 
Coughing 2 (10,5%) 
Involuntary 
3 (15,8%) 
movements 
Laryngospasm 0 
Maintaining 
Involuntary 
movements 
4 (21,1%) 
Awake 0
150 
results 
mmHg) 
130 
110 
(IABP 90 
Mean 70 
50 
T0 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T13 T14 Induction 
Intubation Surgery The 
end 
Mean IABP changes
results 
Heart rate changes 
150 
130 
110 
90 
70 
50 
T0 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T13 T14 
Heart rate (f/min)
results 
Neuromuscular transmission intraoperative 
92.1 
79.3* 75.3* 76.5* 
91.7 
100 
80 
60 
40 
20 
0 
TOF (%) 
Baseline 30 min 60 min 90 min The end 
Time
Dù kiÕn kÕt luËn
results 
Relative between myasthenia class and TOF 
at the 60th minute intraoperative 
y = -10.6x + 97 
R2 = 0.767; r= - 0.87579 
100 
90 
(%) 
80 
TOF 70 
60 
50 
Độ nhược cơ 
(1:I; 2: IIa; 3:IIb) 1 2 3
results 
Surgeons’ satisfaction 
Level Results 
Total satisfied 25 (89.3%) 
Quite satisfied 3 (10.7%) 
Medium 0 
Poor 0 
No satisfaction 0
Time in anesthesia 
Duration Results 
Duration of surgery (min) 
125.6 ± 20.3 
85 - 145 
Duration of anessthesia (min) 
143.7 ± 18.9 
90 -180 
Δ awake (min) 
11.2± 2.9 
8.0 – 15.0 
extubation (min) 
12.7 ± 3.7 
8.0 -17.0 
Self-awareness (min) 
13.9 ± 1.9 
8 -18 
results 
Δ awake (min) 11.2± 2.9 
8.0- 15.0 
Δ extubation(min) 12.7 ± 3.7 
8.0- 17.0
spo2 and respiratory rate Changes after extubation 
100 
99 
98 
97 
96 
95 
Before 
15 min 30 min 2h 6h 12h 24h 48h 72h 
extubation 
24 
RR (r/ph) 
22 
20 
18 
16 
14 
12 
10 
Before 
15 min 30 min 2h 6h 12h 24h 48h 72h 
extubation 
SpO2 (%)
PaO2 changes 
350 
300 
250 
200 
150 
100 
50 
Pre-ope DLV OLV 2h after 
extubation 
1st day 
post ope 
2nd day 
post-ope 
3 rd day 
post -ope 
Arterial blood gas changes
PaCO2 changes 
45 
43 
41 
39 
37 
35 
Pre-ope DLV OLV 2h after 
extubation 
1st day 
post ope 
2nd day 
post ope 
3rd post 
ope 
Arterial blood gas changes
pH changes 
7.44 
7.42 
7.4 
7.38 
7.36 
7.34 
7.32 
7.3 
Pre-ope DLV OLV 2h after 
extubation 
1st day 
post ope 
2nd day 
post ope 
3rd post 
ope 
Arterial blood gas changes
Airway injuries 
Clinical symtoms 
Symtoms Results 
Sore-throat 5 (17.8%) 
Hoarseness 1(3.6%) 
Both sore-throat and hoarseness 1(3.6%) 
Total 7 (28.0%) 
- ZHong and et al. 13%- 20%- 30% 
- Heike K. 44% - 17%
Injuries were observed by laryngostroboscopy 
No injury 
78.5% 
laryngeal injuries 
14.3% 
Both tracheal and 
larygeal injuries 
3.6% 
Tracheal injuries 
3.6% 
Airway injuries
conclusions 
Sevoflurane anesthesia without muscular relaxants for 
thoracoscopic thymectomy in MG 
Good intubating conditions 
 Stable hemodynamic 
Faster recovery 
100% of the patients successfully to extubate at 
operating room. 
No patients required reintubation due to respiratory 
failure. 
Airway injuries due to intubation: 28%
Thank fo r your attention!

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Vo van hien

  • 1. SEVOFLURANE ANESTHESIA WITHOUT MUSCLE RELAXANTS FOR THORACOSCOPIC THYMECTOMY IN MYASTHENIA GRAVIS Vo Van Hien Nguyen Huu Tu Mai Van Vien
  • 2. Introduction  Myasthenia gravis (MG) is a chronic autoimmune disorder related to the thymus gland.  Thymectomy is one of the effective methods to treat MG.  Patients with myasthenia gravis did sentitivity to the drugs were used in anesthesia → Choice drugs and anesthesia technique plays an important role in the success of operation.
  • 3. introduction  Respiratory complications depend on anesthetic technique:  Mulder et al (1972): 50% of pts need ventilatory support.  Suwanchi (1995): Comparision general anesthesia vs epidural anesthesia and iv. propofol: early extubation in operating room 29%- 78%.  Catherine Chevalley et al (2001)(*): + Time need ventilation support : 2-48h + Propofol was used (1994): No need to ventilate postoperative.
  • 5. introduction  In Vietnam, Đo Tat Cuong (1996) reported postoperative ventilation depend on method of anesthesia :  Anesthesia: 15.65%  Acupunture: 3.5%  Nguyen Van Thanh (1998) studied on 47 pts:  Required ventilation support: 15/47pts  Mortality: 3 patients due to respiratory infections.
  • 6. introduction Side effects of long-term ventilatory support on MG pts: • Infections: respiratory, pneumonia, sepsis → death. • Prolonged hospitalization days • Increased treatment costs Anesthesiologists’ recommendations: “Avoid muscle relaxants in MG patients”
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  • 8. objectives To evaluate the use of sevoflurane and without muscle relaxants for thoracoscopic thymectomy in MG patients and post-operative respiratory status
  • 9. methods  Subjects: Intervention study on 28 MG patients scheduled to undergo thoracoscopic thymectomy  Monitor: Datex Omeda: ECG (DII), SpO2, EtCO2, invasive aterial blood pressure (ABP), module Entropy (RE, SE), TOF.  Induction: - Atropin: 0.5mg; Sufentanil: 0.5mcg/kg; - Propofol 2.5-3 mg/kg - Local anesthesia with 10 cc of lidocaine hydrochloride 2% was sprayed on the vocal cords and into the trachea
  • 10. methods  Intubation Univent tube - Loss eyelid reflex - RE, SE<50 - Check tube and blocker’s position by endoscopy equipment (Olympus)  Ventilate A/C mode : Vt = 10ml/kg; f=14l/ph; FiO2= 60%→ PetCO2= 28-32 mmHg.  OLV: Vt=5ml/kg, f=16-20; FiO2= 100% → Ppeak < 30 cm H2O, PetCO2=30-35mmHg.  Sufentanil: 0.2mcg/kg/h
  • 11. methods  Adjust concentration of sevoflurane Criterial ABP > 130% baseline 70% < ABP <130% ABP < 70% baseline RE, SE>60 ↑ Sevorane ↑ Sevorane Increase infusion and ephedrine iv before ↑ Sevorane 40<RE,SE<60 Nicardipine iv Adequate depth of anesthesia Increase infusion and ephedrine iv RE, SE <40 Nicardipine iv ↓ Sevorane ↓ Sevorane
  • 12. methods  Stop sufentanil 15 minutes before the end of surgery  Stop sevoflurane at the end of surgery.  Extubation when: - Awake - Head lift > 5 seconds - RR < 30/min - Inspiratory force > 25cmH2O  Assess respiratory status: breathing frequency; SpO2, blood gas.  Evaluate airway injuries at 24h postoperative.
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  • 15. recorded Data  General characteristics  Intubation conditions (Viby Mogensen Score), number of attemps to intubate.  Hemodynamic changes at induction, before and after intubation and intraoperative.  Neuromuscular effect of sevoflurane on MG: TOF  Surgeons’ satisfaction: VAS score  Time to extubation and respiratory status: f, SpO2 , PaO2, PaCO2, pH,…  Clinical symtom due to airway injuries: sorethroat, hoarseness and observe by laryngostroboscopy.
  • 16. results General characteristics Characteristics Results Gender Male 8 (28.6%) Female 20 (71.4%) Age (X±SD) (years) 39.5 ± 9.7 Classification (folow Osserman) I 5 (17.9%) IIa 16 (57.1%) IIb 7 (25.0%) Duration of disease (months) 95.6 ± 8.73 3-121
  • 17. Time in anesthesia Time Results Loss eyelid reflex (seconds) 112.6± 28.5 57- 140 Achive RE, SE <50 (seconds) 149.5 ± 17.6 103 – 186 Intubation time (minutes) 6.0± 1.5 3.5 – 12.8 results
  • 18. Agent dose for induction and maintaining Purpose Results Propofol for induction (mg) 189,75±40,3 110- 230 Total dose of sevoflurane for maintaining (ml) 125,35±59,6 Inspiratory concentration of sevorane for maintaining (%) 3,05± 2,4 results
  • 19. results Intubation condition 82.1 17.9 0 100 80 60 40 20 0 Rate (%) Excelent Good Poor Intubation condition
  • 20. results Side effects intraoperative Side Effects Results Induction- Intubation Coughing 2 (10,5%) Involuntary 3 (15,8%) movements Laryngospasm 0 Maintaining Involuntary movements 4 (21,1%) Awake 0
  • 21. 150 results mmHg) 130 110 (IABP 90 Mean 70 50 T0 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T13 T14 Induction Intubation Surgery The end Mean IABP changes
  • 22. results Heart rate changes 150 130 110 90 70 50 T0 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T13 T14 Heart rate (f/min)
  • 23. results Neuromuscular transmission intraoperative 92.1 79.3* 75.3* 76.5* 91.7 100 80 60 40 20 0 TOF (%) Baseline 30 min 60 min 90 min The end Time
  • 24. Dù kiÕn kÕt luËn
  • 25. results Relative between myasthenia class and TOF at the 60th minute intraoperative y = -10.6x + 97 R2 = 0.767; r= - 0.87579 100 90 (%) 80 TOF 70 60 50 Độ nhược cơ (1:I; 2: IIa; 3:IIb) 1 2 3
  • 26. results Surgeons’ satisfaction Level Results Total satisfied 25 (89.3%) Quite satisfied 3 (10.7%) Medium 0 Poor 0 No satisfaction 0
  • 27. Time in anesthesia Duration Results Duration of surgery (min) 125.6 ± 20.3 85 - 145 Duration of anessthesia (min) 143.7 ± 18.9 90 -180 Δ awake (min) 11.2± 2.9 8.0 – 15.0 extubation (min) 12.7 ± 3.7 8.0 -17.0 Self-awareness (min) 13.9 ± 1.9 8 -18 results Δ awake (min) 11.2± 2.9 8.0- 15.0 Δ extubation(min) 12.7 ± 3.7 8.0- 17.0
  • 28. spo2 and respiratory rate Changes after extubation 100 99 98 97 96 95 Before 15 min 30 min 2h 6h 12h 24h 48h 72h extubation 24 RR (r/ph) 22 20 18 16 14 12 10 Before 15 min 30 min 2h 6h 12h 24h 48h 72h extubation SpO2 (%)
  • 29. PaO2 changes 350 300 250 200 150 100 50 Pre-ope DLV OLV 2h after extubation 1st day post ope 2nd day post-ope 3 rd day post -ope Arterial blood gas changes
  • 30. PaCO2 changes 45 43 41 39 37 35 Pre-ope DLV OLV 2h after extubation 1st day post ope 2nd day post ope 3rd post ope Arterial blood gas changes
  • 31. pH changes 7.44 7.42 7.4 7.38 7.36 7.34 7.32 7.3 Pre-ope DLV OLV 2h after extubation 1st day post ope 2nd day post ope 3rd post ope Arterial blood gas changes
  • 32. Airway injuries Clinical symtoms Symtoms Results Sore-throat 5 (17.8%) Hoarseness 1(3.6%) Both sore-throat and hoarseness 1(3.6%) Total 7 (28.0%) - ZHong and et al. 13%- 20%- 30% - Heike K. 44% - 17%
  • 33. Injuries were observed by laryngostroboscopy No injury 78.5% laryngeal injuries 14.3% Both tracheal and larygeal injuries 3.6% Tracheal injuries 3.6% Airway injuries
  • 34. conclusions Sevoflurane anesthesia without muscular relaxants for thoracoscopic thymectomy in MG Good intubating conditions  Stable hemodynamic Faster recovery 100% of the patients successfully to extubate at operating room. No patients required reintubation due to respiratory failure. Airway injuries due to intubation: 28%
  • 35. Thank fo r your attention!