Anesthesia issues in the perioperative management of myasthenia gravis

Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction. Current anesthetic practice may require the use of neuromuscular blocking (NMB) drugs that act at this junction to facilitate control of the airway and allow procedures to be performed on a motionless MG patient. This competes with the goals of rapid emergence and recapture of preoperative muscle strength following anesthesia. In particular, avoiding prolonged periods of postoperative mechanical ventilation is a paramount concern of patients, families, and physicians. Standard anesthetic agents and, if needed, judiciously titrated NMB drugs generally allow safe emergence and immediate extubation for most low-risk MG patients. If necessary, postoperative mechanical ventilation is accomplished with the use of specialized monitoring devices that help monitor awareness and depth of sedation. Currently used intravenous sedatives allow titrated depth of sedation and rapid emergence when extubation is appropriate. Communication to the patient, family, and other caregivers of the goals of the anesthetic plan and of the patient's evolving status are also very important duties of the anesthesiologist.