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تحميل الدليل التدريبي

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 books & Resources

 

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A CORE LIST OF ANESTHESIA BOOKS AND JOURNALS

 

 

Textbook of Anaesthesia - Aitkenhead A R Smith G - 14 Dec 2006Bottom of Form

 

The Anaesthesia Science Viva Book
... Short Answer Questions in Anaesthesia, 2nd Edition, this new book is the ... perfect companion volume to The Clinical Anaesthesia Viva Book by Mills et al.

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The Clinical Anaesthesia Viva Book
... anaesthetist wishing to practice anaesthesia as a consultant in the UK. Several books deal with the written and basic science viva component of the FRCA ...

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JOURNALS

*Bready LL, et al. Decision Making in Anesthesiology: An Algorithmic Approach. Mosby, 2007

 

*Chestnut DH, ed. Year Book of Anesthesiology and Pain Management 2007. Elsevier, 2007

 

*Dershwitz M, et al. Anesthesiology Examination and Board Review. 6th ed. McGraw-Hill, 2006

 

*Fischer HBJ, et al. Fundamentals of Regional Anaesthesia. Cambridge University Press, 2004

 

*Gravlee GP, et al. Cardiopulmonary Bypass: Principles and Practice. 3rd ed. Lippincott Williams and Wilkins, 2007

 

*Hensley FA Jr., et al, eds. A Practical Approach to Cardiac Anesthesia. 4th ed. Lippincott Williams and Wilkins, 2007

 

*Hung OR, et al, eds. Management of the Difficult and Failed Airway. McGraw-Hill, 2007 [with DVD]

 

*Marshall A, et al. Striving for the Comfort Zone: A Perspective on Julius Jeffreys. Windy Knoll, 2004 [also 2007 2nd ed. on CD]

 

*Marucci C, et al, eds. Avoiding Common Anesthesia Errors. Lippincott Williams and Wilkins, 2007

 

*McWilliams TS. New Lights in the Valley: The Emergence of UAB. University of Alabama Press, 2007

 

*Middleton C, ed. Epidural Analgeisa in Acute Pain Management. Wiley, 2007

 

*Parsons PE, et al. Critical Care Secrets. 4th ed. Mosby, 2007

 

*Yao F-SF, ed. Yao and Artusio's Anesthesiology: Problem-Oriented Patient Management. 6th ed. Lippincott Williams and Wilkins, 2007

 

*Aldrete JA. The Human Factor in Anesthesia and Patient Care. Editorial Alfil, 2005

 

*Burch TM, et al. Conquer the PTE Exam. Saunders, 2007

 

*Gaiser R. Pocket Anesthesiology. [Blueprints Series] Lippincott Williams and Wilkins, 2007

 

*Gallagher C, et al. Anesthesia Unplugged: A Step-by-Step Guide to Techniques and Procedures. McGraw-Hill, 2007

 

*Shapiro FE. Manual of Office-Based Anesthesia Procedures. Kluwer, 2007

 

*Sieber FE. Geriatric Anesthesia. McGraw-Hill, 2007

 

*Sykes K, et al. Anaesthesia and the Practice of Medicine: Historical Perspectives. Royal Society of Medicine Press, 2007

 

*Wong CA. Spinal and Epidural Anesthesia. McGraw-Hill, 2007

 

 1. *AMBULATORY SURGERY

*McGoldrick KE, ed. Ambulatory Anesthesiology: A Problem-Oriented Approach. Williams & Wilkins, 1994.

*Shapiro FE. Manual of Office-Based Anesthesia Procedures. Kluwer, 2007

*Society for Ambulatory Anesthesia. Educational Guidelines for Subspecialty Anesthesia Training in Ambulatory Anesthesia. Rev. ed. SAMBA, 1997

*Springman SR. Ambulatory Anesthesia. Mosby, 2006

*Steele SM, et al. Ambulatory Anesthesia and Perioperative Analgesia. McGraw-Hill, 2005

*Twersky RS, ed. Ambulatory Anesthesia Handbook. Mosby-Year Book, 1994.

*Wetchler BV, ed. Anesthesia for Ambulatory Surgery. 2nd ed. Philadelphia: Lippincott, 1990.

*White PF, ed. Ambulatory Anesthesia and Surgery. Saunders, 1997

*White PF, ed. Outpatient Anesthesia. Churchill Livingston, 1990.

*Whitman JG, ed. Day-Case Anaesthesia and Sedation. Blackwell, 1994.

 

2. *AWARENESS

*Bonke B, et al, eds. Memory and Awareness in Anaesthesia III. Van Gorcum, 1996

*Bonke B, et al, eds. Memory and Awareness in Anaesthesia. Swets & Zeitlinger, 1990.

Ghoneim MM, ed. Awareness During Anesthesia. Butterworth Heinemann, 2001

*Jordan C, et al, eds. Memory and Awareness in Anaesthesia IV. Imperial College Press, 2000

*Rosen M, et al, eds. Consciousness, Awareness and Pain in General Anesthesia. Butterworths, 1987.

*Sebel PS, et al, eds. Memory and Awareness in Anesthesia. Prentice Hall, 1993.

 

3. *BASIC SCIENCES

*Antognini JF, et al, eds. Neural Mechanisms of Anesthesia. Humana Press, 2002

*Black SM, et al. Essential Anatomy for Anesthesia. Churchill Livingstone, 1998

*Collins VJ, ed. Physiologic and Pharmacologic Bases of Anesthesia. Williams and Wilkins, 1996.

*Davis PD, et al. Basic Physics and Measurements in Anaesthesia. 5th ed. Butterworth-Heinemann, 2003

*Ellis H, et al, eds. Anatomy for Anaesthetists. 8th ed. Blackwell, 2004

*Goudsouzian N, et al. Physiology for the Anesthesiologist. 2nd ed. Appleton-Century-Crofts, 1984.

*Hemmings HC Jr, et al, eds. Foundations of Anesthesia: Basic Sciences for Clinical Practice. 2nd ed. Mosby, 2005  

*Lumb AB. Nunn's Applied Respiratory Physiology. 6th ed. Elsevier, 2005   

*Moody E, et al, eds. Molecular Bases of Anesthesia. CRC Press, 2001

*Mushin WW, et al. Physics for the Anesthetist. 4th ed. Blackwell, 1987.

*Scurr C et al, eds. Scientific Foundations of Anaesthesia. 4th ed. Heinemann Medical Books, 1990.

*Snell RS, et al. Clinical Anatomy for Anesthesiologists. Appleton and Lange, 1988.

*Stoelting RK, et al, eds. Pharmacology and Physiology in Anesthetic Practice. 4th ed. Lippincott Williams and Wilkins, 2005

*West JB. Respiratory Physiology - The Essentials. 4rd ed. Williams and Wilkins, 1990.

*West JB. Ventilation/Blood Flow and Gas Exchange. 5th ed. Blackwell, 1990.

*Yaksh TL, ed al, eds. Anesthesia: Biologic Foundations. Lippincott-Raven, 1997

 

4. *BOARD REVIEWS

*ABA/ASA. In-Training Examinations. 1978-1985.

*Bowman-Howard M. Anesthesia Review. 2nd ed. Lippincott Williams and Wilkins, 2006

*Bready LL, et al, eds. Decision Making in Anesthesiology: An Algorithmic Approach. 3rd ed. Mosby, 1999

*Burch TM, et al. Conquer the PTE Exam. Saunders, 2007

*Chambers WA, et al. Clinical Scenarios in Anaesthesia. Churchill Livingstone, 1995.

*Chee WK. Rapid-Sequence Review of Anesthesiology with Time-Limited Pressure. Butterworth- Heinemann, 1997

* Chu L. Clinical Anesthesiology Board Review: A Test Simulation and Self-Assessment Tool. McGraw-Hill, 2005

*Connelly NR, et al, eds. Review of Clinical Anesthesia. 4th ed. Lippincott Williams and Wilkins, 2006

*Craft TM, et al. Key Topics in Anesthesia. Mosby, 1995.

*Curry SE. Anesthesiology: Pre-Test, Self-Assessment and Review. 2nd ed. McGraw Hill, 1997.

*DeKornfeld TJ, et al., eds. Anesthesiology: Specialty Board Review. 9th ed. Appleton & Lange, 1995.

*Dershwitz M. MGH Board Review of Anesthesiology. 5th ed. Appleton and Lange, 1998

*Faust RJ, ed. Anesthesiology Review. 3rd ed. Churchill Livingstone, 2001

*Gallagher CJ. Board Stiff TEE. Elsevier, 2004

*Gallagher CJ, et al. Board Stiff Too: Preparing for the Anesthesia Orals. 2nd ed. Butterworth Heinemann, 2000

*Gardner AM. Anesthesiology: Specialty Board Review. 8th ed. Medical Examination, 1991.

*Gwartz BL. Anesthesiology Oral Exam Review. 2 vols. Gwartz Examination Service, 1993.

*Hall BA, et al. Anesthesia: A Comprehensive Review. 3rd ed. Mosby, 2003

*Kahn CH, et al. Pain management: PreTest Self-Assessment and Review. McGraw-Hill, 1996.

*Katz J, ed. Anesthesiology: A Comprehensive Study Guide. McGraw-Hill, 1996.

*Morgan GE, et al. Clinical Anesthesiology. 3rd ed. Lange, 2001

*Muravchick S. The Anesthetic Plan: Physiologic Principles to Clinical Strategies. Mosby-Year Book, 1990.

*Poterack K. The Underground Guide to the Anesthesia Oral Boards. Privately printed, 1992.

*Reed AP, et al, eds. Clinical Cases in Anesthesia. 3rd ed. Elsevier, 2005

*Robertson KM, et al. Anesthesiology: Pearls of Wisdom. Boston Medical Publishing, 2001

*Robertson KM, et al. Anesthesiology Board Review. 2nd ed. McGraw-Hill, 2006

*Roizen MF, et al, eds. Essence of Anesthesia Practice. 2nd ed. Saunders, 2001

*Smith GA, ed. Anesthesia Practice Questions. Medtext, 1998

*Smith GA, ed. Mastering the Written Boards. Medtext, 1998

*Starr M. Anesthesiology Boards: A Survival Guide. Churchill Livingstone, 1999

*Weinberg GL, ed. Basic Science Review of Anesthesiology. McGraw Hill, 1996.

*Yao FSF, ed. Yao and Artusio's Anesthesiology: Problem-Oriented Patient Managment. 5th ed. Lippincott Williams & Wilkins, 2003

 

5. *CARDIOVASCULAR

*Andropoulos DB, ed. Anesthesia for Congenital Heart Disease. Blackwell, 2005

*Atlee JL. Perioperative Cardiac Dysrhythmias: Mechanisms, recognition, management. 2nd ed. Year Book Publisher, 1990.

*Atlee JL. Arrhythmias and Pacemakers: Practical Management for Anesthesia and Critical Care Medicine. Saunders, 1995.

*Arrowsmith JE, et al. Problems in Anesthesia: Cardiothoracic Surgery. Martin-Dunitz, 2003

*Bosnjak ZJ, et al, eds. Anesthesia and Cardiovascular Disease. Academic Press, 1995.

*Caldicott L, et al. Vascular Anaesthesia: A Practical Approach. Butterworth-Heinemann, 1999

*Chaney MA, ed. Regional Anesthesia for Cardiothoracic Surgery. Lippincott Williams and Wilkins, 2002

*Cheng DCH, et al, eds. Perioperative Care in Cardiac Anesthesia and Surgery. Lippincott Williams and Wilkins, 2006

*DiNardo JA, ed. Anesthesia for Cardiac Surgery. 2nd ed. Appleton and Lange, 1997

*Ellison N, et al, eds. Effective Hemostasis in Cardiac Surgery. W.B. Saunders, 1988.

*Estafanous FG, et al, eds. Cardiac Anesthesia. 2nd ed. Lippincott Williams and Wilkins, 2001

*Gravlee GP, ed. Cardiopulmonary Bypass: Principles and Practice. 2nd ed. Lippincott Williams & Wilkins, 2000

*Hensley FA Jr, et al. A Practical Approach of Cardiac Anesthesia. 3rd ed. Lippincott Williams & Wilkins, 2003

*Kambam J, ed. Cardiac Anesthesia for Infants and Children. Mosby-Year Book, 1994.

*Kaplan JA, et al, eds. Kaplan’s Cardiac Anesthesia. 5th ed. Elsevier Saunders, 2006

*Kaplan JA, ed. Vascular Anesthesia. Churchill Livingstone, 1991.

* Lake CL , et al, eds. Pediatric Cardiac Anesthesia. 4th ed. Lippincott Williams and Wilkins, 2005

*Leung JM. Cardiac and Vascular Anesthesia. Mosby, 2004

*Levitzky MG, et al. Cardiopulmonary Physiology in Anesthesiology. McGraw-Hill, 1996

*Mangano DT, ed. Preoperative Cardiac Assessment. Lippincott, 1990.

*Mark JB. Atlas of Cardiovascular Monitoring. Churchill-Livingstone, 1997.

*Mora CT, ed. Cardiopulmonary Bypass: Principles and Techniques of Extracorporeal Circulation. Springer-Verlag, 1995.

*Reves JG. Cardiothoracic Anesthesia. Churchill Livingstone, 1998 [Atlas of Anesthesia, vol. 8]

*Reves JG, et al, eds. Common Problems in Cardiac Anesthesia. Year Book, 1987.

*Simpson JI, ed. Anesthesia and the Patient with Co-Existing Heart Disease. Little, Brown, 1993.

*Simpson JI, ed. Anesthesia for Aortic Surgery. Butterworth-Heinemann, 1997

*Stanley TH, et al, eds. Anesthesiology and the Cardiovascular Patient. Kluwer, 1996.

*Tarhan S, ed. Cardiovascular Anesthesia and Postoperative Care. 2nd ed. Year Book, 1989.

*Thomas SJ, ed. Manual of Cardiac Anesthesia. 2nd ed. Churchill Livingstone, 1993.

Thys DM, et al, eds. Textbook of Cardiothoracic Anesthesiology. McGraw-Hill, 2001

*Troianos CA, ed. Anesthesia for the Cardiac Patient. Mosby, 2002

Tuman KJ, ed. Outcome Measurements in Cardiovascular Medicine. Lippincott Williams and Wilkins, 1999

*Warltier DC, ed. Ventricular Function. Williams & Wilkins, 1995.

*Wasnick JD. Handbook of Cardiac Anesthesia and Perioperative Care: A Demythologized Approach. Butterworth-Heinemann, 1998

*Yeager MP, et al, eds. Anesthesiology and Vascular Surgery. Appleton & Lange, 1990.

*Youngberg JA, et al, eds. Cardiac, Vascular and Thoracic Anesthesia. Churchill Livingstone, 1999

 

6. *CLOSED CIRCUIT ANESTHESIA

*Baum JA. Low Flow Anaesthesia. 2nd ed. Butterworth Heinemann, 2001

*Droh R, et al, eds. Closed-Circuit System and Other Innovations in Anaesthesia. Springer-Verlag, 1986.

*Lowe HJ, Ernst EA. The Quantitative Practice of Anesthesia: Use of Closed Circuit. Williams and Wilkins, 1981.

 

7. *CRITICAL CARE

*Abrams KJ, et al, eds. Trauma Anesthesia and Critical Care of Neurological Injury. Futura, 1997

*American Society of Critical Care Anesthesiologists. Anesthesiology Residents' Guide to Learning in the Intensive Care Unit. ASCCA, 1995.

*Apostolakos MJ, et al. Intensive Care Manual. McGraw-Hill, 2001

*Atlee JL, et al, eds. Critical Care Cardiology in the Perioperative Period. Springer, 2001

*Bigatello LM, ed. Critical Care Handbook of the Massachusetts General Hospital . 4th ed. Lippincott Williams and Wilkins, 2006

*Brenner M, et al. Critical Care Medicine 2002-2003. Current Clinical Strategies, 2001

*Brown DL, ed. Cardiac Intensive Care. Saunders, 1998.

*Chernow B, ed. Pharmacologic Approach to the Critically Ill Patient, 3rd ed. William & Wilkins, 1994.

*Civetta JM, et al, eds. Critical Care. 3rd ed. Lippincott-Raven, 1996.

*Dellinger RP, ed. Self-Assessment in Multidisciplinary Critical Care: A Comprehensive Review. 5th ed. Society of Critical Care Medicine, 2003

*Fink MP, et al, eds. Textbook of Critical Care. 5th ed. Elsevier, 2005  

*Gallagher TJ, ed. Postoperative Care of the Critically Ill Patient. Williams and Wilkins, 1995.

*Hall JB, et al, eds. Principles of Critical Care. 3rd ed. McGraw-Hill, 2005  

*Irwin RS, et al, eds. Procedures and Techniques in Intensive Care Medicine. 3rd ed. LWW, 2003

*Kirby RR, et al. Handbook of Critical Care, Lippincott, 1994.

*Kruse JA, et al. Saunders Manual of Critical Care. Saunders, 2002

*Marini JJ, et al. Critical Care Medicine: The Essentials. 3rd ed. Lippincott Williams and Wilkins, 2006

*Marino PL. The ICU Book. 3rd ed. Lippincott Williams and Wilkins, 2006

*Miller RD, ed. Atlas of Anesthesia. Volume 1: Critical Care. Churchill Livingstone, 1997

*Morton NS, et al. Paediatric Anaesthesia and Critical Care in the District Hospital. Butterworth-Heinemann, 2003

*Murray MJ, et al, eds. Critical Care Management: Perioperative Management. 2nd ed. Lippincott Williams and Wilkins, 2002

*Papadakos PJ, et al. Critical Care: The Requisites in Anesthesiology. Elsevier, 2005  

*Parrillo JE, et al, eds. Critical Care Medicine: Principles of Diagnosis and Management in the Adult. 2nd ed. Mosby, 2001

*Parillo JE, ed. Current Therapy in Critical Care Medicine. 3rd ed. Mosby, 1997

*Parsons PE, et al. Critical Care Secrets. 3rd ed. Hanley and Belfus, 2003

*Rello J, et al, eds. Critical Care Infectious Diseases Textbook. Kluwer, 2001

*Shabot MM, et al, eds. Decision Support Systems in Critical Care. Springer-Verlag, 1994.

*Shoemaker WC, et al, eds. Procedures and Monitoring for the Critically Ill. Saunders, 2001.

*Susla GM, et al. Handbook of Critical Care Drug Therapy. Churchill Livingstone, 1994.

*Tinker J, et al. Care of the Critically Ill Patient. 2nd ed. Springer-Verlag, 1992.

*Tobin MJ, ed. Principles and Practice of Intensive Care Monitoring. McGraw-Hill, 1998

*Varon J, et al. Handbook of Practical Critical Care Medicine. Springer, 2001

*Varon J, et al. Near Misses in Pulmonary and Cardiothoracic Critical Care. Butterworth-Heinemann, 1999

*Varon J, ed. Practical Guide to the Care of the Critically Ill Patient. Mosby-Year Book, 1994.

*Venkatesh B, et al. Data Interpretation in Critical Care Medicine. Butterworth-Heinemann, 2003

*Webb AR, et al, eds. Oxford Textbook of Critical Care. Oxford Medical, 1999

*Zimmerman JL, ed. Multidisciplinary Critical Care Review Course. Society of Critical Care Medicine, 2003

 

 

 

 

Anesthesia for thymectomy in myasthenia gravis: A report of 115 cases

A. El-Dawlatly. A. Turkistani . K.Alkattan*,W.Hajjar*. M.B Delvi, A. Alshaer,   Fdammas , W.Alotaibi

Abdelazeem El-Dawlatly M.D

Professor of Anesthesia

College of Medicine

King Saud University

Ahmed Turkistani FCCM

Associate Professor

Chairman. Department of Anesthesia

King Saud University

Khalid Alkattan FRCS*

Professor of Thoracic Surgery

King Saud University

Waseem Hajjar FRCS*

Assistant Professor of Thoracic Surgery

King Saud University

Mohamed Bilal Delvi M.D

Assistant Professor of Anesthesia

College of Medicine

King Saud University

Ahmed Alshaer M.D

Consultant Anesthetist

King Fahad Cardiac Center

Wadha Alotaibi KSUF

Assistant Professor of Anesthesia

King Saud University      

Fatma Damas KSUF

Assistant Professor of Anesthesia

Consultant Anesthetist

King Khalid University Hospital

Address for correspondence Abdelazeem Au El-Dawlatly Riyadh H461 P.O.Box 2925 Saudia Arabia dawlatlv ksu. edu. sa http://faculty.ksu.edu.sa/dawlatly

  INTRODUCTION

Myasthenia Gravis (MG) is an autoimmune disease associated with acetyicholine receptor deficiency at the motor endplate. This deficiency is thought to be due to circulating acetyicholine antibodies that result in the deposition of immune complexes (IgG and complement) on the post synaptic membrane of the neuromuscular junction (1). Osserman and Genkins. both physicians at Mount Sinai Hospital. published a clinical classification of MG that is still widely used (2). The diagnosis of MG can be confirmed with several tests. Edrophonium (Tension) test is confirmative. Usually administered i.v in small (2-8mg) doses. Electromyography (EMG) is also could be used for the diagnosis of MG. Repetitive stimulation of a peripheral motor nerve leads to decreasing responses by innervated muscle in a patient with MG. The presence of anti-acetylcholine antibodies in the sewn detected by radioimmunoassay is diagnostic for MG (3). The treatment of MG could be either medical or surgical. Anticholinesterse drug like pyridostigniine is commonly used as oral preparation. Immune suppression with corticosteroids is another medical modality to prevent or attenuate the destruction of acetylcholine receptors at the motor end plate. Besides plasniapheresis which is indicated in severe bulbar symptoms patients.Thymectom is practiced to treat MG. Different approaches are used. Maximal thymectomy is commonly practiced in our setup through cervical and sternotomy approaches (4). Recently. thoracoscopic thymectomy has been practiced with encouraging results. Anesthesia for thymectomy in MG is challenging. We have adopted a non-muscle relaxant anesthetic technique which is widely used nowadays (5).

In this report we reviewed our experience with anesthesia for thymectomy in MG with respect to anesthetic technique. incidence of postoperative ventilation in relation to preoperative condition and se’ erity of the disease.

 

 PATIENTS AND METHODS

The computerized data base and medical records of 115 patients \\ho underwent thymectomy between July 1 988 and January 2007 were reviexed. The following variables were obtained: demographic data, the duration of the disease. Osserman scale. technique of anesthesia and drugs used. Also preoperative preparation of patients including the drugs used to control mvasthenic crisis and number of plasmapheresis sessions were obtained. The diagnosis of myasthenia gravis was based upon clinical picture and response to edrophonium chloride (Tensilon). decremented response on electrophysiological study and high antibody serum titer against aceti choline receptors. All patients underv ent transcervical-transsternal maximaF thvmectomy except five who underwent thoracoscopic thymectomv. Anesthesia was managed according to preference of attending anesthetist. The other variables obtained were: type of anesthetic. use of neuromuscular blocking drugs. duration of anesthesia. and duration of postoperative mechanical ventilation. Depending on postoperative outcome. patients were divided into two groups: group I who were extubated at end of surgery in OR and group 2 who remained ventilated postoperatively. Data were analyzed using a statistical software package (Graph pad. version 3 for \indows, San Diego. California. USA). Data were presented as mean+sd. percentage or ratio as appropriate. Data were compared using parametric or non parametric paired student T-test. P value <0.05 vas considered significant. C orrel ati on performed using spearman non parametric method.

 

 RESULTS

There were 110 adult patients (age>l2vr) and 5. pediatrics with age <12 yr. The mean age was 27±12 yr with range between 4 and 61 yr. There were 73 female patients and 42 male patients. The percentage of patients in relation to the duration of the disease in months is given in table 1. The percentage of patients in relation to the Osserman classes is given in table 2. There were 55 patients who had positive antibody titer against acetyicholine receptors versus 60 patients who showed negative test. Three sessions of plasmapheresis were performed in 72 patients (63%). Premedication was achieved either with diazepam or lorazepam to 67 (58%) patients 2hr preoperatively. Pyridostigmine alone was given to 42 (3 6%) patients and combined with steroids to 73 (63° o’) patients and continued till day of surgery. Anesthesia was induced using fentanyl-thiopentone in 45 patients and with sufentanilpropofol in 70 patients. Combined general anesthesia and thoracic epidural analgesia was used in 75 patients. In 89 patients (77°o) tracheal intubation was performed using topical analgesia using laryngo-tracheal analgesia kit (Abbott. USA) without neuromuscular blocking drugs. In 26 patients (23%) different neuromuscular blockers were used. Anesthesia was maintained with N20/02 and isoflurane in 28 patients and with sevoflurane in 87 patients. Intraoperative monitoring included. routing ECG. arterial and central venous pressure monitoring, pulse oximeter. endtidal carbon dioxide and temperature monitoring. For those patients who received neuromuscular blocking drugs. peripheral nerve stimulator was used. After completion of surgery respiratory status was assessed and tracheal extubation was performed using the following criteria: recovery of neuromuscular junction using rrve stimulator in patients who received muscle relaxants. adequate tidal volume (>5mlkg). triggering of ventilator with inspiratory force> -20 cm H20. In 100patients (87%) the trachea was extubated in the immediate postoperative period. In this group the trachea was extubated in the OR in 83 patients while in the rest the trachea was extubated 1-6 hr later in the surgical intensive care unit. Fifteen patients in group 2 (13%) required postoperative ventilation for a period ranged from 6 to 48 hr. Surgical duration was ranging from four to five hours. All patients were admitted to SICU postoperatively.

There were no operative or postoperative mortality reported in our series. In our series there was positive correlation between patient age. Osserman class, and postoperative ventilation (P<O.05). patients (87%) the trachea was extubated in the immediate postoperative period. In this group the trachea was extubated in the OR in 83 patients while in the rest the trachea was extubated 1-6 hr later in the surgical intensive care unit. Fifteen patients in group 2 (13%) required postoperative ventilation for a period ranged from 6 to 48 hr. Surgical duration was ranging from four to five hours. All patients were admitted to SICU postoperatively.

There were no operative or postoperative mortality reported in our series. In our series there was positive correlation between patient age. Osserman class, and postoperative ventilation (P<O.05).

 

 DISCUSSION

Anesthesia for thymectomy in myasthenia gravis is challenging. We can classify the different anesthetic techniques for thyrnectomv into: muscle relaxant and non-muscle relaxant techniques. It is well known that myasthenic patient is sensitive to non- depolarizing neuromuscular blockers (NMBs) and resistant to depolarizing NMBs. Intermediate and short acting non-depolarizing NMBs can be used in myasthenic patients monitored with mechanomyogram. Inhalation anesthetics rna produce muscle relaxation in myasthenic patients. Isoflurane and sevoflurane were reported to produce muscle relaxant effect in rnvasthenic patient. Desfiurane in myasthenic patients was not reported: however, in normal patients it reduces the requirements of NMBs (6. Currently we are using non-muscle relaxant technique NMRT) which we adopted in 1994. for maximal thymectom. The technique includes the insertion of thoracic epidural analgesia (TEA) in an awake patient prior to induction of general anesthesia (GA). After placement of routine monitoring and insertion of arterial cannula. anesthesia induced with sufentanil 0. lmcg/kg b.w followed with propofol 3mg’kg b.w \hile the patient breathing via face mask 60% nitrous oxide in oxygen through Magill circuit. Direct laryngoscopy then attempted and the larynx is sprayed with 4% lignocaine 2-4m1 using laryngotracheal analgesia cannula (ETA. 24 laser pores. Abbott, USA>. Two minutes later the trachea is intubated. Anesthesia is maintained using 60°o N20/02. propofol infusion 6-12 mg/kg b.w and epidural bupivacaine 0.125° o infusion 4-6m1’hr. This technique eliminates the need of NMBs and epidural offers better intra and postoperative pain control in addition to on table extubation of the trachea. Nasogastric tube (NGT) is also inserted and kept during the postoperative period. Recently the same technique. without use of TEA. has been verified and supported by Sanjax et al. in their study on the use of propofol or Sevoflurane without muscle relaxants in thyrnectorny for MG with encouraging results (7). Furthermore. the same technique. without use of TEA. was also supported by Rocca et al. in their published report on the use of propofol or sevoflurane without muscle relaxants vhicb allowed early extubation of mvasthenic patients (8). In our series \\C have nearly an established protocol for preoperative preparation of our patients scheduled to undergo thymectomy. It includes clinical diagnosis which is supported by laboratory confirmative tests vhich involves the use of electrophysiological studies besides serum level of antibodies against acetyl choline enzyme. Also medical treatment for all patients is part of our standard protocol in the form of anticholinesterase drugs and corticosteroids depending on the severity of the disease. Our preoperative protocol also includes three sessions of plasmapheresis. One of the important preoperative tests is pulmonary function test. In one study we have demonstrated that preoperative forced vital capacity (FVC) and forced mid-expiratory flow rate between 25 and 75° o of FVC (FEF25-75%) were noted to have large discrimination coefficient value to predict the need for postoperative ventilation (9).

 In the current series 89 patients received no muscle relaxant for endotracheal intubation and in all of them the trachea was extubated in the immediate postoperative period. Among patients who received muscle relaxant. in 11 patients the trachea was extubated in the immediate postoperative period and in 15 patients they required short term postoperative ventilation. In our series v e have also reported 5 cases ho underwent video-assisted thoracoscopic thymectomy (VATT). Currently, there is increasing interest in VATT in MG. Thoracoscopic thymectomy offers several advantages compared to open technique. namely, less postoperative morbidity. minimal discomfort, rapid functional recovery, shorter postoperative hospital stays and reduction of hospitalization cost. Also it offers excellent cosmetichealing compared to sternotomy 1O). In the literature there are many publications on the anesthetic management of trans-sternal thymectom). However, very few on ‘ATT. During earlier phases of VAfl. we have used the same non-muscle relaxant technique combined with TEA. on the assumption that it could be converted to open surgical technique at any time during the procedure. Hoever, later we have modified our technique to be non-muscle relaxant without TEA (1 fl. Our current anesthetic technique for VAfl includes, non-muscle relaxant approach. intubating the trachea with double lumen tube (DLT) after topical spray to vocal cords, and continuous infusion of propofol and sufentanil. In that case one lung ventilation (OLV) should be established.

In conclusion, anesthesia for thymectomy is challenging. We believe that the use of NMRT provides excellent intubating conditions. Also the use of NMRT has encountered for earl) tracheal extubation of patients in the operation room. The use of propofol infusion and TEA in trans-sternal thymectomy provides good operative and postoperative conditions. We believe that the use of modified non-muscle relaxant technique in VAfl surgery provides excellent intubating, operative and postoperative conditions. We also believe that for such procedure an established protocol ‘.shich involves perioperative mAnagement is essential for better outcome.

 

 REFERENCES

1) Phillips LH. The epidemiology of myasthenia gravis. Neurol Clin 1994:12:263-

271.

2) Osserman KF. Genkins G. Studies in myasthenia gravis: Review of a twenty-year experience in over 1200 patients. Mt Sinai J Med 1971:38:497-537.

3) Abel M and Eisenkraft JB. Anesthetic implications of myasthenia gravis. Mt Sinai J Med 2002:69:31-37.

4) Baraka A. Taha S. Yazbeck V. et al. Vecuronium block in the myasthenic patient. Influence of anticholinesterase therapy, Anaesthesia 1993:48:588-590.

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