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Parasternal, Serratus Plane and Adductor Canal Nerve Blocks for Pain Control post CABG of Patient with Myasthenia Gravis
Fri, April 7, 4:15-5:45 pm
Salon 6

Please note, medically challenging cases are removed three months after the meeting and scientific abstracts after three years.


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•Myasthenia Gravis (MG) is a neurological autoimmune disorder of the neuromuscular junction (NMJ), characterized by the fatigable weakness of musculature with repetitive action. This is caused by the destruction, or presence, of abnormal acetylcholine (ACh) receptors in the NMJ, which leads to an inability to generate effective endplate potentials for coordinated muscular contraction. 
•The disease has been classically defined using the Osserman Classification. Severity is based on the extent to which generalized muscle weakness or respiratory dysfunction is present. 
Anesthetic Implications of Myasthenia Gravis
•Oro-pharyngeal or respiratory muscle weakness leads to increased likelihood of prolonged post-operative ventilation. 
•Autoimmune attack of cardiac muscle leads to increased likelihood of heart failure, cardiovascular defects, and conduction abnormalities
•Drugs to avoid or use with caution or include inhalational and intravenous anesthetics, beta-blockers, muscle relaxants, antibiotics and opioid analgesics.
Case Presentation
•69-year-old man with MG on daily pyridostigmine therapy, thyroid cancer status post thyroidectomy, hypertension, obstructive sleep apnea on home CPAP, paroxysmal atrial fibrillation (A-Fib), and congestive heart failure (EF 40-45%) presented with a 1-week history of angina.
•Heart catheterization multi-vessel disease involving the left main and right coronary arteries
•PFT without mild obstruction due to air trapping, however no major obstructive or restrictive disease
•Procedure: 3-vessel CABG with endovascular vein harvesting, left atrial appendage ligation, and partial thymectomy via midline sternotomy.

Postoperative Course

•POD #0: Patient met all extubation criteria and was extubated in the operating room immediately
•POD #3: Patient requested repeat parasternal plane nerve blocks for further analgesia.
•POD #3-5: Patient developed paroxysmal A-Fib requiring escalation of anti-arrhythmic therapy
•POD #10: Patient was discharged. 
Discussion and Conclusion
•Inadequate post-operative pain control in the ICU population has multiple sequelae:
•Hindrance of depth of respiration and difficulty weaning from mechanical ventilation
•Increased circulating catacholamines from stress response can induce tissue hypoxia and catabolism.
•Psychological stressors and delirium
•Parasternal Intercostal Fascia Block and Serratus Plane Block can be useful in management of rib-cage pain and can decrease the need for post-operative opioids and the likelihood of medication-induced respiratory compromise
•Multidisciplinary team-based strategy is paramount for positive outcomes in MG patient population.
•Surgeons – urgency of planned procedure
•Neurology – pre-operative medical optimization, including plasmapheresis treatments as indicated
•Anesthesiology – Avoidance of potential triggers and use of regional techniques where indicated
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