A 56 y/o male with MG affecting extraocular and bulbar musculature presents for transcervical thymectomy.

Myasthenia Gravis
Reflux esophagitis

pyridostigmine 660 mg OD (divided doses)
prednisone 20 mg OD (divided doses)
metoclopramide 10 mg 4 times a day

Spirometry is done and shows
VC 50% predicted
FEV1/FVC ratio 80%
Max breathing capacity = 45% predicted

pt RSi'd with 4 mg/kg thiopental & suxx 1mg/kg
After 60 sec. twitch height is decreased by 60% & pt is tubed with some difficulty

Anesthesia is maintained with Nitrous Oxide, O2 & Sevo
At return of twitch vecc 0.05 mg/kg is given

Surgery is 1.5 hours long.

Emergence is managed by turning off gas, TOF X 4
Neostigmine 0.06 mg/kg is given
glyco 0.01 mg/kg is given

When pt responds to command the pt is extubated and the pt becomes immediately dyspneic.

HERE are the first group of questions:

1) What the hell happened?
2) Why?
3) What is the lesion of myasthenia gravis?