Preoperative Preparation and Anesthetic Management of Patients With Myasthenia Gravis

doi:10.1016/S1043-0679(99)70019-5

Seminars in Thoracic and Cardiovascular Surgery

Volume 11, Issue 1, January 1999, Pages 47-53

https://doi.org/10.1016/S1043-0679(99)70019-5 Get rights and content

Patients with myasthenia gravis have specific clinical problems that must be addressed by the anesthesiologist when surgery is contemplated. Optimal perioperative management of myasthenia gravis patients undergoing thymectomy requires careful preoperative assessment and preparation. This assessment and preparation includes evaluation for concomitant autoimmune, respiratory, and cardiac disorders as well as optimization of medical management for myasthenia. There are important intraoperative concerns to be addressed including appropriate monitoring, premedication, and other agents used during surgery including muscle relaxants and anesthetic agents. Postoperatively, attention must be directed specifically to pain relief, ventilatory management, and the appropriate titration of reversal agents and anticholinesterase inhibitors. Optimal management of all these factors maximizes the chance for successful and uncomplicated hospitalization.

References (53)

WJ Book et al.
Anesthesia and neuromuscular diseases
Anesth Clin North Am
(1996)
TC Gibson
The heart in myasthenia gravis
Am Heart J
(1975)
KA Johannessen et al.
Left ventricular function in myasthenia gravis
Am j Cardiol
(1992)
DG Mulder et al.
Thymectomy for myasthenia gravis
Am j Surg
(1983)
DR Gracey et al.
Plasmapheresis in the treatment of ventilator-dependent myasthenia gravis patients: Report of four cases
Chest
(1984)
G d'Empaire et al.
Effect of prethymectomy plasma exchange on postoperative respiratory function in myasthenia gravis
J Thor Cardiovasc Surg
(1985)
D O'Flaherty et al.
Total intravenous anesthesia with propofol for transsternal thymectomy in myasthenia gravis
J Clin Anesth
(1992)
A Baraka
Onset of neuromuscular block in myasthenic patients
Br j Anaesth
(1992)
DR Gracey et al.
Postoperative respiratory care after transsternal thymectomy in myasthenia gravis: A 3-year experience in 53 patients
Chest
(1984)
C Colp et al.
Vocal cord paralysis in myasthenia gravis following anesthesia
Chest
(1980)

A Baraka

Anaesthesia and myasthenia gravis

Can J Anaesth

(1992)

ME Seybold

Myasthenia gravis: A clinical and basic science review

JAMA

(1983)

PB Christensen et al.

Associated autoimmune diseases in myasthenia gravis: A population-based study

Acta Neurol Scand

(1995)

Zulueta jj et al.

Respiratory dysfunction in myasthenia gravis

Clin Chest Med

(1994)

I Ringqvist et al.

Respiratory mechanics in untreated myasthenia gravis with special reference to the respiratory forces

Acta Med Scand

(1971)

CO Borel et al.

Ventilatory drive and carbon dioxide response in ventilatory failure due to myathenia gravis and Guillain-Barre syndrome

Crit Care Med

(1993)

H Hofstad et al.

Heart disease in myasthenia gravis

Acta Neurol Scand

(1984)

MP Mehta et al.

Anesthesia and neuromuscular diseases

Middle East j Anesthesiol

(1985)

DB Drachman

Myasthenia gravis

N Engl J Med

(1994)

P Goti et al.

Comparative effects of plasma exchange and pyridostigmine on respiratory muscle strength and breathing pattern in patients with myasthenia gravis

Thorax

(1995)

PA Spence et al.

Role of plasmapheresis in preparing myasthenic patients for thymectomy: Initial results

Can j Surg

(1984)

DS Girnar et al.

Anesthesia for transcervical thymectomy in myasthenia gravis

Anesth Analg

(1976)

J Takeda et al.

Suppression of neuromuscular transmission by sevoflurane in patients with myasthenia gravis

Anesthesiology

(1993)

E Nilsson et al.

Neuromuscular effects of isoflurane in patients with myasthenia gravis

Acta Anaesthesiol Scand

(1990)

RM Khan et al.

Total intravenous anesthesia for diagnostic endoscopy in myasthenia gravis child

Middle East J Anesthesio113

(1996)

B de Jose Maria et al.

Myasthenia gravis and regional anaesthesia

Can j Anaesth

(1995)

Cited by (31)

Myasthenia Gravis and Thymoma Surgery: A Clinical Update for the Cardiothoracic Anesthesiologist
2019, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Hypothyroidism from autoimmune thyroiditis can worsen symptoms of MG, therefore thyroid function should be investigated in patients who do not respond to conventional therapies.17 Patients with MG can present with concomitant systemic lupus erythematous and rheumatoid arthritis that should be evaluated thoroughly to detect cervical spine instability.17 Other comorbidities associated with MG include obstructive sleep apnea, polymyositis, neuromyotonia, hypogammaglobulinemia, and blood cytopenias.34-36
Myasthenia gravis (MG) is a rare neuromuscular disorder characterized by skeletal muscle weakness. Patients with MG who have thymoma and thymic hyperplasia have indications for thymectomy. The perioperative care of patients with MG scheduled for thymus resection should be focused on optimizing their neuromuscular function, identifying factors related to postoperative mechanical ventilation, and avoiding of triggers associated with myasthenic or cholinergic crisis. Minimally invasive surgical techniques, use of regional analgesia, and avoidance or judicious administration of neuromuscular blocking drugs (NMBs) is recommended during the perioperative period. If NMBs are used, sugammadex appears to be the drug of choice to restore adequately the neuromuscular transmission. In patients with postoperative myasthenic crisis, plasma exchange or intravenous immune globulin and mechanical support is recommended.
Guillain-barré syndrome and myasthenia gravis
2008, Essentials of Neuroanesthesia and Neurointensive Care: A Volume in Essentials of Anesthesia and Critical Care
Guillain-Barré Syndrome and Myasthenia Gravis
2008, Essentials of Neuroanesthesia and Neurointensive Care
Perioperative management of patients with neurologic disease
2004, Neurologic Clinics
Therapy of Myasthenia Gravis and Myasthenic Syndromes
2003, Neurological Disorders: Course and Treatment: Second Edition
This chapter discusses myasthenia gravis and myasthenic syndromes, and its related therapies. Myasthenia gravis (MG) and the myasthenic syndromes are diseases that affect the neuromuscular junction. In autoimmune MG, autoantibodies reduce the number of available acetylcholine receptors (AChRs), and thereby impair neuromuscular transmission. Initially, the most important clues to the diagnosis of MG were obtained from history and clinical examinations. The cardinal features of MG are weakness and fatigability of skeletal muscles, usually in a characteristic distribution. The weakness increases with activity and improves with rest. Typically, the signs and symptoms are more pronounced at the end of the day. The presenting symptoms vary from patient to patient, but in more than half of the cases, the initial complaints include diplopia and ptosis, often followed by difficulties in speech, chewing and swallowing, or by weakness of the upper and lower extremities. The distribution of muscle weakness is usually bilateral and is often proximal but may be asymmetrical and may involve different muscle groups over the course of the disease.
Undiagnosed myasthenia gravis unmasked by neuromuscular blockade
2001, British Journal of Anaesthesia
Citation Excerpt :
Rheumatoid arthritis and systemic lupus erythematosis present their own problems respectively. Myasthenia gravis results from production of autoantibodies against the nicotinic AchR at the neuromuscular junction which reduces the number of functioning receptors either by competitive block, increased degradation of receptors or by complement mediated lysis of receptors.6 In general, myasthenics have one-third as many normally functioning AchRs as those who are disease free.
Myasthenia gravis is an uncommon autoimmune disease resulting in destruction of the post-synaptic nicotinic receptors at the neuromuscular junction. We describe a 43-yr-old, 95 kg patient who presented for elective laparoscopic cholecystectomy. She was given vecuronium 10 mg to facilitate tracheal intubation. At the end of the procedure the patient could not maintain adequate spontaneous ventilation despite administration of two doses of neostigmine 2.5 mg. Subsequent investigation led to a diagnosis of myasthenia gravis. We discuss the investigation, diagnosis, and subsequent management of such a patient and emphasize that tactile estimation of the train-of-four ratio is not a reliable indicator of adequate recovery of neuromuscular function.

View all citing articles on Scopus

View full text

Preoperative Preparation and Anesthetic Management of Patients With Myasthenia Gravis

Anesth Clin North Am

Am Heart J

Am j Cardiol

Am j Surg

Chest

J Thor Cardiovasc Surg

J Clin Anesth

Br j Anaesth

Chest

Chest

Anaesthesia and myasthenia gravis

Can J Anaesth

Myasthenia gravis: A clinical and basic science review

JAMA

Associated autoimmune diseases in myasthenia gravis: A population-based study

Acta Neurol Scand

Respiratory dysfunction in myasthenia gravis

Clin Chest Med

Respiratory mechanics in untreated myasthenia gravis with special reference to the respiratory forces

Acta Med Scand

Ventilatory drive and carbon dioxide response in ventilatory failure due to myathenia gravis and Guillain-Barre syndrome

Crit Care Med

Heart disease in myasthenia gravis

Acta Neurol Scand

Anesthesia and neuromuscular diseases

Middle East j Anesthesiol

Myasthenia gravis

N Engl J Med

Comparative effects of plasma exchange and pyridostigmine on respiratory muscle strength and breathing pattern in patients with myasthenia gravis

Thorax

Role of plasmapheresis in preparing myasthenic patients for thymectomy: Initial results

Can j Surg

Anesthesia for transcervical thymectomy in myasthenia gravis

Anesth Analg

Suppression of neuromuscular transmission by sevoflurane in patients with myasthenia gravis

Anesthesiology

Neuromuscular effects of isoflurane in patients with myasthenia gravis

Acta Anaesthesiol Scand

Total intravenous anesthesia for diagnostic endoscopy in myasthenia gravis child

Middle East J Anesthesio113

Myasthenia gravis and regional anaesthesia

Can j Anaesth