ANESTHESIA FOR

MYASTHENIA GRAVIS

By : Rima Hajjar
MEDIII
PATHOPHYSIOLOGY

Antibodies against
AchR

Destruction of post-
synaptic membrane

Inconsistent generation
of Action Potential

Skeletal Muscle
weakness
PRESENTATION OF MG
PREOPERATIVE ASSESSMENT
OSSE R MAN CL ASSI FI C AT I ON
 EPIDEMIOLOGY AND
IMPLIC ATIONS FOR ANESTHESIA

- Prevalence 50- 200 per million population

- Women in 3rd decade , men exhibit 2 peaks ( 3rd and
6th decade)
Implications :
- Increased sensitivity to neuromuscular blockers
- Pulmonary aspiration
- Diminished respiratory strength
- Postoperative ventilation problems
- Slow Post-operative recovery
 PREOPERATIVE ASSESSMENT
H I S TO RY TA K I N G

• Bulbar symptoms
• History of myasthenic crisis
• Respiratory muscle weakness
• Associated diseases, including other autoimmune
diseases.
• MG therapy
 PREOPERATIVE ASSESSMENT

Consult neurology team and pulmonary team :

• Lung function test should be done preoperatively and
blood gas analysis.
• Chest X-Ray or CT-Scan before thymectomy for
detection of tracheal compression or deviated trachea.
 PERIOPERATIVE ASSESSMENT
D RU G T H E R A P Y

What treatment regiment is your patient on ?

• Pyridostigmine often prescribed
• Moderate disease : anticholinesterase drug + immune
modulating therapy ( corticosteroid , azathioprine ,
cyclosporine , cyclophosphamide , IvIg)
• Severe cases with dysphagia and respiratory failure
require plasmapheresis

 PREOPERATIVE CONDITIONS SHOULD BE STABILIZED

 PERIOPERATIVE ASSESSMENT
D RU G T H E R A P Y

• Patients with respiratory and oropharyngeal weakness

should be treated preoperatively with IvIg or
plasmapheresis.
• If strength normalizes , the incidence of postoperative
respiratory complications should be similar to that of a
non myasthenic patient
 PERIOPERATIVE ASSESSMENT
D RU G T H E R A P Y

• The continuation of the daily dose of pyridostigmine

perioperatively is debatable.
• Anticholinesterase medication could be stopped, if this
does not influence the respiratory situation.
• If medication is stopped , it should be restarted when
the patient resumes oral intake postoperatively
 PERIOPERATIVE ASSESSMENT
D RU G T H E R A P Y

• Patients whose treatment for MG includes

glucocorticoids may be at risk for hypothalamic
pituitary axis suppression and adrenal insufficiency.
• For patients who have been
taking prednisone >20 mg/day for three weeks or
more, and for patients with Cushingoid appearance,
stress-dose glucocorticoids should be administered
prior to induction of anesthesia and may require
administration of stress-dose glucocorticoids.
 PERIOPERATIVE ASSESSMENT
D RU G T H E R A P Y

• Patients with involvement of respiratory or bulbar

muscles tend to have a higher risk for aspiration so
pretreatment with metoclopramide or H2 blockers
may be helpful.
 PERIOPERATIVE ASSESSMENT
D RU G T H E R A P Y

• Some MG patients are sensitive to respiratory

depressants and premedication with opioids, BZDs, or
barbiturates should be considered carefully or not at
all.
 ANESTHESIOLOGIC PROCEDURE

• If possible, regional techniques should be preferred.

General anesthesia as balanced or total intravenous
anesthesia can be used if reduced doses of muscle
relaxants are used.
 NEUROMUSCULAR BLOCKADE

Myasthenia gravis patients exhibit a relative

resistance to depolarizing neuromuscular
blocking agents and the dose used may need to
be increased. Conversely, patients show a
sensitivity to non-depolarizing neuromuscular
blocking agents, requiring only 10% of normal
dose.
 MONITORING
NEUROMUSCULAR BLOCKADE

• Monitoring of the neuromuscular blockade is

mandatory:
• electromyogram (EMG)
• Mechanomyogram (MMG)
• Calibrated acceleromyography (AMG)
• Train of four should be performed in the awake
patient preoperatively and the ratio of T4/T1 should
be 1.0. In MG patients the ratio could be < 0.9 and
shows a reduced need for depolarizing muscle
relaxants.
 NON DEPOLARIZING AGENTS

• The myasthenic patient is typically sensitive to nondepolarizing

neuromuscular blockers.
• The use of a small dose for priming or defasciculation may result
in loss of airway protection or in respiratory distress.
• Long-acting muscle relaxants such as dubocurarine, pancuronium,
pipecuronium, and doxacurium, are best avoided in these
patients.
• Intermediate or short-acting nondepolarizing agents can be used
with careful monitoring.
 DEPOLARIZING AGENTS

• Patients with MG show resistance to

depolarizing agents. ED95 of succinylcholine in
MG patients is 2.6 times that in non-
myasthenic patients
 INDUCTION AND
MAINTENANCE

• Inhalational agents – The potent inhaled anesthetics

(isoflurane, sevoflurane, desflurane, halothane) provide
dose-dependent neuromuscular relaxation in patients
with MG .
• May provide adequate relaxation for endotracheal
intubation and surgery, possibly equivalent to the level
of relaxation achieved with NMBAs in normal patients.
• There are many reports of thymectomy performed
with the use of potent inhalational agents, without the
need for NMBAs and muscle strength recovers as the
inhalational agent is eliminated, without the need for
reversal agents.
 INDUCTION AND
MAINTENANCE

●Intravenous agents :
• Can be used with or without small doses of NMBAs.
• Propofol is most commonly used for induction of
anesthesia, as it provides rapid onset, short duration
of action, and suppression of airway reflexes.
• Total intravenous anesthesia (TIVA) with infusions of
propofol and remifentanil has been described for
anesthesia without the use of NMBAs for patients
with MG undergoing thymectomy
 REVERSAL

• Response to reversal of nondepolarizing NMBAs may

be unpredictable, especially for those patients who are
taking anticholinesterase medication .
• If NMBAs are administered, reversal medication
(eg, neostigmine) should be titrated to effect to avoid
cholinergic crisis.
• Sugammadex can be used to reverse neuromuscular
blockade of the steroidal NMBAs
(eg, vecuronium and rocuronium) 2 to 4 mg/kg IV has
been reported to reverse moderate to deep
vecuronium and rocuronium blockade in patients with
MG within four minutes.
• Reversal with sugammadex is not affected by
anticholinesterase medication
 MYASTHENIC CRISIS

• Myasthenic crisis is defined as respiratory

muscle and/or bulbar muscle weakness severe enough
to necessitate intubation or to delay extubation after
surgery.
• If weakness at the end of surgery suggests myasthenic
crisis, delay of extubation is required, as well as intensive
care. Urgent rapid therapy with plasma exchange or
intravenous (IV) immune globulin is often initiated, in
addition to immunomodulating therapy
THANK YOU