Dear Aboud AlJa'bari,

Total intravenous anesthesia (TIVA) for the management of myasthenics has been reported. In the authors’ experience, hemodynamic instability in older patients makes this approach d i fficult, whereas younger patients usually tolerate it without difficulty. The use of remifentanil as part of T I VA may alleviate some of the hemodynamic instability. When possible, many clinicians prefer to utilize regional or local anesthetic techniques. Regional techniques may reduce or eliminate the need for muscle relaxants in abdominal surgery. Epidural techniques offer the advantage of postoperative pain control with minimal or no opioid use.

O’Flaherty D, Pennant JH, Rao K, et al. Total intravenous anesthesia

with propofol for transsternal thymectomy in myasthenia

gravis. J Clin Anesth 1992; 4:241

For more on this topic, please see the article review contained in the following link:

http://ether.stanford.edu/library/thoracic_anesthesia/Special%20Procedures/Myastenia%20Gravis.pdf

Hoping this will be helpful,

Rafik

In our Center in Accra, Ghana we use TIVA exclusively  and most of our patients are young and tolerate this effectively. We do not use muscle relaxants. Intubation is with Propofol and Fentanyl/alfentanyl which works well for us. Extubation is done early.

Without a doubt TIVA.

There are enough reasons not to use inhalational agents, namely due to their interference with neuromuscular metabolism and function.

Do what you are most familiar with, whether that be TIVA or inhalational. Try to avoid all muscle relaxants with any neuromuscular disorder.

The Myasthenia gravis is a disease course with muscle relaxation. The halogenated perse, accentuate the neuromuscular block. The neuromuscular blockers are´nt contraindicated. They can be used at doses of 25 % of the dosis calculated in patients without this condition. TIVA both hypnotics, opioids and neuromuscular blockers is the technique of choice for these patients, so TIVA use is recommended.

I prefer halogenates  because  the propofol determines  mioglobinuria.  In our center WE use generaly  rocuronium 25%of normal dose, NMT monitoring And sugamnadex to residual neuromuscular blockade.

The halogenates  aren´t contraindicated in myasthenia gravis patients, but  prolong the neuromuscular block.  The fact that use neunromuscular monitorization is an advantage.

I would like to thank you for your answers but I have some comments to share:

-Whenever you decide to give neuromuscular agent ,it should be one tenth of the usual dose.

-Propofol after longtime infusion It will cause myoglobinuria but it's not a common side effect.

- extubation is usually done in ICU after all parameters of extubation are fulfilled and it's not an early time issue.