Anaesthesia in Patients with Myasthenia Gravis

Myasthenia gravis is an autoimmune disorder of the motor plate. The degree of reduction in the number of functional acetylcholine receptors correlates with the severity of myasthenia gravis as manifested by increasing weakness and fatigue of skeletal muscles. Medical treatment of myas­thenia gravis includes improvement of neuromuscular transmission by anticholinesterases, suppression of the immune system with the use of corticosteroids and immunosuppressive drugs and reduction of the amount of circulating antibodies by plasmapheresis. Myasthenia gravis is frequently associated with an abnormality of the thymus. Transsternal thymectomy reduces the required doses of anticholinesterases and immunosuppressants. This paper presents the anes­thetic management of patients with myasthenia gravis. The anesthetic management of a patient with myasthenia gravis undergoing transsternal thymectomy is also described. This patient received a combination of high thoracic epidural anaesthesia with 0.5% bupivacaine and fentanyl and total intravenous anaesthesia with propofol and remifentanyl. Our experience shows that a com­bination of high thoracic epidural anesthesia and total intravenous anesthesia is an appropriate anesthetic technique for transsternal thymectomy and ensures good hemodynamic stability dur­ing surgery, uneventful recovery and effective post-operative analgesia.