quick sheet

Myasthenia gravis

Exquisitely sensitive to nondepolarizers, resistant to succinylcholine, and the real question is postop ventilation.

Top concerns

1.Nondepolarizing NMBDs: profound sensitivity — if needed at all, give small fractions with quantitative monitoring; sugammadex (for rocuronium) is a good fit
2.Succinylcholine: relative resistance (fewer functional receptors) — effective dose is higher (~1.5–2 mg/kg)
3.Predictors of postoperative mechanical ventilation (classic Leventhal set for transsternal thymectomy): disease >6 years, chronic pulmonary disease, pyridostigmine >750 mg/day, vital capacity <2.9 L
4.Continue the patient's anticholinesterase and immunosuppression plan in coordination with neurology; abrupt changes risk myasthenic crisis
5.Distinguish myasthenic vs cholinergic crisis postop (both = weakness); involve neurology early
6.Magnesium, aminoglycosides, and other NMJ-depressant drugs exaggerate weakness

CAUTIONNondepolarizing NMBDs— Fractional dosing + quantitative TOF; often avoidable entirely (volatile or remifentanil-based relaxation).
CAUTIONMagnesium sulfate— Potentiates weakness — dose only with a clear indication.
PREFERTechnique avoiding NMBDs altogether— Deep volatile/remifentanil intubating conditions are a recognized approach.

Bulbar involvement → aspiration risk and weak cough; extubate to a clear, tested strength endpoint, not a clock

Reverse the question: not 'can I intubate?' but 'will they breathe at the end?' — plan extubation criteria preop.
Weakness after reversal isn't always residual block — think crisis, check neurology.

Exquisitely sensitive to nondepolarizers, resistant to succinylcholine, and the real question is postop ventilation.

1.Nondepolarizing NMBDs: profound sensitivity — if needed at all, give small fractions with quantitative monitoring; sugammadex (for rocuronium) is a good fit
2.Succinylcholine: relative resistance (fewer functional receptors) — effective dose is higher (~1.5–2 mg/kg)
3.Predictors of postoperative mechanical ventilation (classic Leventhal set for transsternal thymectomy): disease >6 years, chronic pulmonary disease, pyridostigmine >750 mg/day, vital capacity <2.9 L
4.Continue the patient's anticholinesterase and immunosuppression plan in coordination with neurology; abrupt changes risk myasthenic crisis
5.Distinguish myasthenic vs cholinergic crisis postop (both = weakness); involve neurology early
6.Magnesium, aminoglycosides, and other NMJ-depressant drugs exaggerate weakness

CAUTIONNondepolarizing NMBDs— Fractional dosing + quantitative TOF; often avoidable entirely (volatile or remifentanil-based relaxation).
CAUTIONMagnesium sulfate— Potentiates weakness — dose only with a clear indication.
PREFERTechnique avoiding NMBDs altogether— Deep volatile/remifentanil intubating conditions are a recognized approach.

Bulbar involvement → aspiration risk and weak cough; extubate to a clear, tested strength endpoint, not a clock

Reverse the question: not 'can I intubate?' but 'will they breathe at the end?' — plan extubation criteria preop.
Weakness after reversal isn't always residual block — think crisis, check neurology.