Perioperative Anesthetic Management of Myasthenia Gravis Patients

Abstract

Routine pre-medication with sedatives or opioids should be avoided because of the depressive effect on respiration. When possible, local or regional anesthesia should be used. If local anesthetics are used, amide local anesthetics should be chosen over esters. Neuromuscular blocking agents should be avoided in patients with MG unless absolutely necessary. Myasthenic patients are resistant to depolarizing neuromuscular blockade while they are extremely sensitive to nondepolarizing NMBAs, so dosing should be guided by monitoring with a quantitative train-of-four peripheral nerve stimulator. Sugammadex can be used to reverse the blockade of the steroidal NMBAs. The need for postoperative monitoring for patients with MG should be individualized based on the clinical features, the risk factors for myasthenic crisis, the surgical procedure, the type of anesthetic and the need for postoperative care, including pain relief. Myasthenic crisis can be precipitated by surgery, administration of NMBAs, or any of a number of medications and conditions. Myasthenic crisis requires endotracheal intubation and ventilation either invasive or non-invasive techniques, intensive care and often rapid immunomodulating therapy. Key words: Negativeinspiratory force- Noninvasive positive pressure ventilation- Neuromuscular blocking agents- Positive end-expiratory pressure- Pulmonary function testing- Ryanodine receptor