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

Hx:
Myasthenia Gravis
Reflux esophagitis

Tx:
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?