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Anesthesia for the patient with myasthenia gravis

Riki Kveraga, MD
John Pawlowski, MD, PhD
Section Editors
Stephanie B Jones, MD
Jeremy M Shefner, MD, PhD
Deputy Editors
Marianna Crowley, MD
John F Dashe, MD, PhD


Myasthenia gravis (MG) is an autoimmune disorder characterized by fatigable weakness of skeletal muscles. Weakness results from an antibody-mediated immunological attack directed at acetylcholine receptors (or receptor-associated proteins) in the postsynaptic membrane of the neuromuscular junction.

Anesthetic concerns for patients with MG include the interactions among the disease, the disease treatment, and the medications used for anesthesia, particularly neuromuscular blocking agents (NMBAs). Patients with MG are unpredictably sensitive to nondepolarizing NMBAs and are resistant to succinylcholine, a depolarizing NMBA.

Lambert-Eaton myasthenic syndrome (LEMS) is a rare autoimmune disorder of the neuromuscular junction, with antibodies directed against the presynaptic voltage-gated calcium channels. It is often associated with an underlying malignancy, most commonly small cell lung cancer, though it is also associated with other autoimmune processes. Patients with LEMS are very sensitive to both depolarizing and nondepolarizing NMBAs.

This topic will discuss the anesthetic management of patients with MG and LEMS. Diagnosis, clinical manifestations, and management of MG and LEMS are discussed in detail separately. (See "Diagnosis of myasthenia gravis" and "Clinical manifestations of myasthenia gravis" and "Treatment of myasthenia gravis" and "Clinical features and diagnosis of Lambert-Eaton myasthenic syndrome" and "Treatment of Lambert-Eaton myasthenic syndrome".)


Preoperative preparation for elective surgery for patients with myasthenia gravis (MG) should be coordinated with the patient’s neurologist. Elective surgery should be performed during a stable phase of the disease, when the patient requires minimal immunomodulatory medication or glucocorticoids, to minimize the chance of postoperative myasthenic crisis. In addition to routine preoperative evaluation, assessment of patients with MG should focus on bulbar and respiratory symptoms, as well as prior history of exacerbations or myasthenic crisis. Surgery should be scheduled as early in the day as possible, when the patient is strongest [1].


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Literature review current through: Aug 2017. | This topic last updated: Mar 07, 2017.
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