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