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Chapter: Clinical Cases in Anesthesia : Myasthenia Gravis

How are patients with MG premedicated for surgery?

Optimization of the myasthenic patient’s condition can markedly reduce the risk of surgery. Ideally, surgery is performed during a period of remission when all other medical problems are optimized.

How are patients with MG premedicated for surgery?

 

Optimization of the myasthenic patient’s condition can markedly reduce the risk of surgery. Ideally, surgery is performed during a period of remission when all other medical problems are optimized. Careful preoperative eval-uation of respiratory parameters and bulbar strength are necessary before prescribing premedication. Respiratory muscle strength may be quantified through pulmonary function tests (i.e., tidal volume, vital capacity, maximum breathing capacity, and inspiratory force). Premedication should be used with caution and avoided in patients with bulbar symptoms or respiratory difficulty. Anxiolysis may be achieved with small doses of benzodiazepines in those patients whose myasthenia is under good control. Opioid avoidance is sometimes recommended to prevent depressed respiratory drive from further interfering with the potential for respiratory failure based on myasthenic or cholinergic crisis.

 

Administration of anticholinesterases preoperatively remains controversial. Some authors advocate withholding anticholinesterases before surgical and anesthetic proce-dures that require muscle relaxation. The patient’s baseline weakness facilitates muscle relaxation, requiring little or no exogenous neuromuscular blockade. Withholding anti-cholinesterases decreases the risk of drug interactions later. Such interactions include partial antagonism of non-depolarizing muscle relaxants and prolongation of the action of succinylcholine. Additionally, withholding anti-cholinesterases eliminates cholinergic crisis as a cause of postoperative respiratory failure. This approach does not work well for those patients who are physically or psycho-logically dependent on anticholinesterases. Other authors feel that these drugs may be given preoperatively without interfering significantly with anesthetic and postoperative management.

 

The relative immobility associated with hospitalization and surgery may produce a reduced requirement for anti-cholinesterases.

 

Steroids should be continued in the perioperative period for those patients on chronic therapy.

 

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Clinical Cases in Anesthesia : Myasthenia Gravis : How are patients with MG premedicated for surgery? |


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