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Myasthenia Gravis

Myasthenia Gravis is an autoimmune neuromuscular disease caused by antibodies against acetylcholine receptors. It is classified based on the severity and distribution of symptoms, ranging from purely ocular (Class I) to severe generalized weakness (Class III/IV). Abnormal thymus glands are present in 75% of patients and thymectomy often improves symptoms. Treatment includes anticholinesterase medications, immunosuppressants, plasmapheresis, and management of comorbid conditions. Anesthesia management focuses on timing of anticholinesterase doses, potential for respiratory complications, and extubation criteria involving strength and pulmonary function tests.

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450 views4 pages

Myasthenia Gravis

Myasthenia Gravis is an autoimmune neuromuscular disease caused by antibodies against acetylcholine receptors. It is classified based on the severity and distribution of symptoms, ranging from purely ocular (Class I) to severe generalized weakness (Class III/IV). Abnormal thymus glands are present in 75% of patients and thymectomy often improves symptoms. Treatment includes anticholinesterase medications, immunosuppressants, plasmapheresis, and management of comorbid conditions. Anesthesia management focuses on timing of anticholinesterase doses, potential for respiratory complications, and extubation criteria involving strength and pulmonary function tests.

Uploaded by

hollyu
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Myasthenia Gravis

Osserman and Genkins classification:


• Class I—ocular symptoms only
• Class IA—ocular S’s with EMG evidence of peripheral muscle involvement
• Class IIA—mild generalized symptoms
• Class IIB—more severe and rapidly progressive symptoms
• Class III—acute, presenting in weeks to months with severe bulbar symptoms
• Class IV—late in the course of the disease with severe bulbar symptoms and marked
generalized weakness
• autoimmune disease with anti-acetylcholine receptor antibodies, F>M
• Abnormal thymus glands 75% of pts(85% show hyperplasia; 15% thymoma).
75% of pts either go into remission or are improved post-op
• Medical ttt: anticholinesterase, steroids, other immunosuppressant (azathioprine,
cyclophosphamide, cyclosporine)and plasmapheresis.
• underdosage → “myasthenic crisis” whereas overdosage will produce a
“cholinergic crisis.” Excessive doses of cholinesterase inhibitors produce
abdominal cramping, vomiting, diarrhea, salivation, bradycardia, and skeletal
muscle weakness that mimics the weakness of myasthenia , to differentiate
between them→”Tensilon test” 2-10 mg IV Edrophonium→ with M.crisis they
improve, but not with C.crisis.
• Sensitive to NDMR, resistant to Sux→ ↑ dose to 1.5 mg/kg
Anesthesia Management
• best to be done 1st case during the day, avoid pre-med
• Best to hold the AM dose of anticholinesterase, unless the Pt is physically and/or
psych dep
A→ possible mediastinal mass, may need RSI, possible Difficult with other diseases
B→ frequent aspiration, resp failure → PFT
C→ focal myocarditis, A.fib , AV block
D→ steroids (stress dose), immunosuppressant, anticholinesterase(dose), avoid drugs
that may potentiate NMB (aminoglycoside ABx, quinidine, CCB)
H→ anemia, ITP, lymphoma, leukemia
CNS→ MS
M→ thyroid dysfunction ↑ or ↓,
Other→ R. arthritis, SLE, scleroderma
Lab→ CBC, lytes (abnormality may ↑ weakness), PFT, ECG, chest CT, CXR.
• Monitor N. stimulator.
• Post-op problems : pneumonia due to poor coughing, Aspiration, resp failure
Leventhal, assigned a scoring system to four factors they found to be predictive for
requirement of post-op mechanical vent (for transternal thymectomy)
• Duration of >6 years 12 points
• History of chronic obstructive pulmonary disease 10 points
• >750 mg/d pyridostigmine 8 points
• Vital capacity <2.9 liters 4 points
Patients scoring <10 points in their series could be extubated immediately
postoperatively; those scoring >12 points required postoperative ventilatory support.
• Post-op pain Mx best using regional anesthesia
• Have an ICU backup bed ready.
• Extubation criteria
o Awake and responsive, stable V/S, good grip, sustained head left
o Good ABG, on FiO2 < 40%(>90%sat) , with adequate vent and oxy
maintained by the Pt
o –ve inspiratory pressure > -20cmH2O
o VC > 15ml/kg
• Pregnancy may cause exacerbation or remission, with ↑ remission postpartum
• The neonate may have transient MG

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