Myasthenia gravis (MG) is a neuromuscular disorder characterized by muscle weakness and fatigue. When considering anesthesia for patients with myasthenia gravis, there are several important considerations to ensure safe and effective management. These considerations include preoperative evaluation, choice of anesthetic agents, monitoring, and postoperative care.

Preoperative Evaluation:

Detailed History: Obtain a thorough medical history, including the duration and severity of MG symptoms, current medications (especially anticholinesterase drugs such as pyridostigmine), previous surgeries, and any respiratory or swallowing difficulties.

Assessment of Disease Status: Evaluate the current disease status of MG, including the degree of muscle weakness, presence of respiratory compromise, and involvement of bulbar muscles (affecting speech and swallowing).

Medication Management: Review the patient's current medication regimen, especially anticholinesterase drugs. These medications should ideally be continued perioperatively to maintain stable muscle strength and prevent myasthenic crisis.

Choice of Anesthetic Agents:

Induction Agents: Non-depolarizing neuromuscular blocking agents (NMBAs) should be avoided or used with caution in patients with MG due to increased sensitivity and prolonged effects. Short-acting agents, such as rocuronium or mivacurium, may be preferred over longer-acting ones.

Maintenance Agents: Inhalation agents (e.g., sevoflurane, desflurane) or total intravenous anesthesia (TIVA) with propofol or dexmedetomidine are generally safe options. NMBAs should be used cautiously, with neuromuscular monitoring, and reversed appropriately.

Monitoring:

Neuromuscular Monitoring: Train-of-four (TOF) monitoring should be employed to assess the depth of neuromuscular blockade during surgery. This helps guide the administration of NMBAs and their reversal agents, ensuring optimal muscle function.

Respiratory Monitoring: Continuous monitoring of oxygen saturation, end-tidal carbon dioxide, and respiratory rate is essential to detect any respiratory compromise or failure, as MG patients may be at higher risk.

Postoperative Care:

Extubation: Patients should be carefully assessed for adequate muscle strength and respiratory function before extubation. If significant muscle weakness or respiratory compromise is present, postoperative ventilation may be required until the effects of anesthesia and muscle relaxants have worn off.

Pain Management: Choose analgesic agents that minimize respiratory depression. Opioids should be used cautiously, with close monitoring of respiratory status, and non-opioid analgesics (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs) may be preferred.

Postoperative Monitoring: Patients with MG should be closely monitored postoperatively, especially for signs of myasthenic crisis (exacerbation of muscle weakness) or cholinergic crisis (overdose of anticholinesterase drugs).

It is important to note that the anesthetic management of patients with myasthenia gravis should be individualized, taking into account the patient's specific clinical presentation, disease severity, and the surgical procedure being performed. Close communication and collaboration between the anesthesia team, neurologist, and surgeon are crucial for optimal perioperative care.

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