A case report on anaesthetic management of off-pump cornonary artery bypass grafting and thymectomy in a patient with myasthenia gravis

Background: Myasthenia gravis (MG) is an autoimmune neuromuscular disorder resulting in weakness and fatigability of skeletal muscles; usually due to autoantibodies directed against acetylcholine receptors (AChRs) at neuromuscular junctions (NMJs). (1) Therefore, careful perioperative management is required because of the unpredictable susceptibility to muscle relaxants. There are not many reports describing the management of myasthenic patients undergoing cardiac surgery with prophylactic thymectomy. Case presentation: In this report, we describe the successful anaesthetic management of a patient with MG undergoing off-pump coronary artery bypass grafting (OPCABG) using titrated dose of cistracurium for muscle relaxation. We chose cisatracurium due to non-enzymatic hoffmans elimination into non-active metabolite, short duration of action, less histamine release and minimal laudanosine production. Other studies, have used rocuronium in MG patients with suggamadex availability as a backup, (1) whereas cisatracurium (2) and atracurium (4) has been used in low resource centres. Conclusions: We concluded cisatracurium is safe during general anaesthesia in MG patients undergoing OPCABG when combined with intraoperative continuous Bispectral index (BIS) and intermittent train-of-four (TOF) monitoring.