136 https://oamjms.eu/index.php/mjms/index Scientifc Foundation SPIROSKI, Skopje, Republic of Macedonia Open Access Macedonian Journal of Medical Sciences. 2021 Aug 24; 9(C):136-139. https://doi.org/10.3889/oamjms.2021.7002 eISSN: 1857-9655 Category: C - Case Reports Section: Case Report in Surgery Perioperative Approach in a Patient with Myasthenia Gravis Saimir Kuci 1 * , Alfred Ibrahimi 1 , Shaban Memeti 2 , Marsela Goga 1 , Selman Dumani 3 , Ali Refatllari 3 1 Department of Cardiac Anesthesia, Mother Teresa University Hospital Center, Tirana, Albania; 2 University Clinic of Paediatric Surgery, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia; 3 Department of Cardiac Surgery, Mother Teresa University Hospital Center, Tirana, Albania Abstract BACKGROUND: Myasthenia gravis is an autoimmune neuromuscular disorder that causes the destruction and overall decrease in functional acetylcholine receptors at the neuromuscular junction. The resultant respiratory and cardiovascular implications are a primary cause of mortality; therefore, a complete and comprehensive understanding of this disorder is vital for the anesthesia provider. Anesthesia management in myasthenia gravis is a great challenge for all anesthesiologists. In this disease, even small doses of muscle relaxants could lead to delayed recovery for respiratory muscles. CASE REPORT: We present the case of a 38 years old woman (weight 87 kg) diagnosed with Myasthenia Gravis, which symptoms have worsened recently. The case demonstrates the anesthetic challenges involved, with a focus on the overall approach, pharmacologic considerations, physiological changes, and an emphasis on preoperative operative and post-operative optimization. CONCLUSION: Thymectomy is a common procedure performed in cases of myasthenia gravis (MG) with a thymoma or general MG that does not improve with medical therapy. During anesthesia, the use of propofol or sevofurane with opioids without the use of any neuromuscular blocking agents has been used with success. Edited by: Igor Spiroski Citation: Kuci S, Ibrahimi A, Memeti S, Goga M, Dumani S, Refatllari A. Perioperative Approach in a Patient with Myasthenia Gravis. Open Access Maced J Med Sci. 2021 Aug 24; 9(C):136-139. https://doi.org/10.3889/ oamjms.2021.7002 Keywords: Thymecomy; Myasthenia gravis; Neuromuscular disorder *Correspondence: Saimir Kuci, Department of Cardiac Anesthesia, Mother Teresa University Hospital Center, Rr. Dibres 372, Tirane, Albania. E-mail: saimirkuci@gmail.com Received: 05-Aug-2021 Revised: 12-Aug-2021 Accepted: 14-Aug-2021 Copyright: © 2021 Saimir Kuci, Alfred Ibrahimi, Shaban Memeti, Marsela Goga, Selman Dumani, Ali Refatllari Funding: This research did not receive any fnancial support Competing Interests: The authors have declared that no competing interests exist. Open Access: This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 International License (CC BY-NC 4.0) Introduction The incidence of myasthenia gravis (MG) is cited as 50–142 cases per 1 million or 0.25 to 2.0 per 100,000 population [1], [2]. Gender discrepancy is present, and women 20–30 years of age are most often afected, followed by men who are often older than 60 years of age when their disease presents [1]. The disease is a chronic autoimmune disorder characterized by a decrease in acetylcholine receptors at the neuromuscular junction secondary to their destruction or inactivation by circulating antibodies [1]. Muscular weakness, fatigability, and rapid exhaustion especially after repetitive voluntary muscle use, as with exercise, are the hallmark signs of the disorder. Four Stages of the disease have been classifed based on the severity of muscular involvement and range from self-limiting extraocular muscle involvement Stage I to severe whole-body generalized muscular weakness Stage IV [3]. Patients are at an increased risk of pulmonary aspiration because of pharyngeal and laryngeal muscle weakness, and they may present with dysphagia, dysarthria, and an overall difculty of handling secretions. Cardiovascular involvement usually occurs and manifests in atrial fbrillation, heart block, and cardiomyopathy, with the presented case having hypertension as the only known cardiovascular manifestation. Myasthenia gravis has historically been a challenging disease for the anesthetist to manage because of its involvement in the pulmonary, muscular, and cardiovascular systems as well as with drug interactions. Case Report An 87-kg, 168-cm, 38-year-old woman presented with the main complaint of weakness of the entire limbs nausea, and vomiting then blurred vision for 7–8 months, symptoms that have worsened recently. On physical examination, there was right ptosis. Muscle strength based on the MRC scale was 3. After Neurologist consultation and tests that were made including rapid nerve stimulation examination, which showed a decremental decrease of >10% in the abductor muscles of the minimi digit, trapezius, and right ocular orbicularis the patient was diagnosed with Myasthenia Gravis. Chest CT scan was performed showing a visible heterogeneous mass with contrast enhancement