Acta Anaesthesiol Scand 2012; 56: 1722 Printed in Singapore.

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2011 The Authors Acta Anaesthesiologica Scandinavica 2011 The Acta Anaesthesiologica Scandinavica Foundation ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2011.02558.x

Review Article

Anesthesia and myasthenia gravis

L. Blichfeldt-Lauridsen and B. D. Hansen
Department of Anesthesiology, Sydvestjysk Sygehus Esbjerg, Esbjerg, Denmark

Myasthenia gravis (MG) is a disease affecting the nicotinic acetylcholine receptor of the post-synaptic membrane of the neuromuscular junction, causing muscle fatigue and weakness. The myasthenic patient can be a challenge to anesthesiologists, and the post-surgical risk of respiratory failure has always been a matter of concern. The incidence and prevalence of MG have been increasing for decades and the disease is underdiagnosed. This makes it important for the anesthesiologist to be aware of possible signs of the disease and to be properly updated on the optimal perioperative anesthesiological management of the myasthenic patient. The review is based on electronic searches on PubMed and a review of the references of the articles. The following keywords were used: myasthenia gravis AND neuromuscular blocking agents, myasthenia gravis AND sevourane, myasthenia gravis AND epidural, myasthenia gravis AND neuromuscular blockade reversal and myasthenia gravis AND pyridostigmine. The articles included were from

reviews and clinical trials written in English. MG patients can easily be anesthetized without need for post-surgery mechanical ventilation whether it is general anesthesia or peripheral nerve block. Volatile anesthesia or the use of an epidural for the patient makes it possible to avoid the use of neuromuscular blocking agents, and when used, it should be in smaller doses and the patient should be carefully monitored. This review shows that with thorough pre-operative evaluation, continuing the daily pyridostigmine and careful monitoring the MG patient can be managed safely.
Accepted for publication 26 August 2011 2011 The Authors Acta Anaesthesiologica Scandinavica 2011 The Acta Anaesthesiologica Scandinavica Foundation

revalence and incidence of myasthenia gravis (MG) have increased, showing an estimated pooled incidence rate of 5.3 per million person-years and an estimated pooled prevalence rate of 77.7 per million, which may be caused by better diagnosis and better treatment.1 The disease no longer only affects young women but mostly the elder population where it is underdiagnosed.2 Treatment of the disease, medical and surgical, has improved through the years, enabling patients with MG to live longer.3 The aim of this review was to search the literature and nd the best way to prepare the patient for surgery, handle the patient intraoperatively and to post-operatively reduce the need for mechanical ventilation.

gravis AND epidural, myasthenia gravis AND neuromuscular blockade reversal and myasthenia gravis AND pyridostigmine. The articles included were from reviews and clinical trials written in English.

Background
Myasthenia gravis is a neuromuscular disease with antibodies against the post-synaptic nicotinic acetylcholine receptor (nAChR) at the neuromuscular junction, decreasing the capacity of the neuromuscular endplate to transmit the nerve signal and causing patients to develop muscle weakness and fatigue. The cause of MG is still unknown, but in many cases there seems to be a connection with the thymus. Patients usually consult a physician when the muscular weakness develops. Improvement in strength after the intravenous injection of edrophonium supports the diagnosis, and a detection of anti-nAChR antibodies or muscle-specic tyrosine kinase (MuSK) antibodies, together with the clinical symptoms, conrms it. Anti-nAChR antibodies are

Methods
The review is based on electronic searches on PubMed and a review of the references of the articles. The following keywords were used: myasthenia gravis AND neuromuscular blocking agents, myasthenia gravis AND sevourane, myasthenia

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L. Blichfeldt-Lauridsen and B. D. Hansen

detected in 8085% of patients with MG and are pathognomonic for the disease. In most of the nAChR-positive patients, the thymus is affected either as a thymoma or with abnormal formation in the thymus. The treatment includes thymectomy, which is associated with improvement and even remission of MG.4 Other options of treatment are nonspecic immunosuppressive therapy with steroids, azathioprine, methrotrexate and cyclosporine, immunoglobulins, plasmapheresis and acetylcholinesterase inhibitors.3 Recently, it has been shown that up to 20% of MG patients are nAChR-seronegative and have antibodies against the MuSK instead. MuSK-antibodypositive MG patients often develop prominent oculobulbar muscle weakness but can, just as nAChR-positive MG patients, develop generalized muscle weakness. One of the more practical distinctions between them is the difference in response to treatment. In MuSK-antibody-positive MG patients, cholinesterase inhibitors have no effect or may even worsen the symptoms. In these cases, thymectomy is not indicated, and the patients may be relatively resistant to conventional immunotherapy including immunoglobulins.5 The myasthenic patient is in risk of developing two kinds of crises: the myasthenic and the cholinergic. The myasthenic crisis is an exacerbation of the disease, which can be caused by several different factors including respiratory infections, emotional stress and surgery.6 The patient exhibits exacerbation of the symptoms with increased muscle weakness and respiratory deciency. These crises normally develop during the rst 2 years of the disease. Major predictors for death in these patients are the patients age, time to crisis recognition and the need for endotracheal intubation.7 This type of crisis calls for additional doses of cholinesterase inhibitor and, if the patient does not improve, intravenous immunoglobulins, plasmapheresis and/or endotracheal intubation are needed. The cholinergic crisis occurs when the patient is overdosed with cholinesterase inhibitors and may show symptoms such as excessive salivation, sweating, abdominal cramps, urinary urgency, bradycardia, muscle fasciculations or muscle weakness. The treatment includes endotracheal intubation, atropine and cessation of cholinesterase inhibitors until the crisis is over. The two kinds of crises can be difcult to distinguish, but it may be useful to give a single dose of edrophonium, because symptoms will improve if

the patient has a myasthenic crisis, but they will worsen or be the same if it is a cholinergic crisis.

Myasthenia gravis and neuromuscular blocking agents (NMBA)

Because of the small numbers of normal nAChRs, MG patients present an abnormal reaction to neuromuscular depolarizing blocking agents. When patients are treated with cholinesterase inhibitors, their plasma cholinesterase is also inhibited, which means that inactivation of succinylcholine takes longer and the patients are at risk of having a prolonged blockade. Patients who do not receive cholinesterase inhibitors are relatively resistant to succinylcholine because there are not enough normal nAChRs to cause a depolarization. On the other hand, sensitivity to nondepolarizing NMBA is increased because of the reduced number of receptors. At the end of surgery, trying to reverse the residual block in patients treated with pyridostigmine may be unsuccessful because the acetylcholinesterase is already maximally inhibited by the current use of pyridostigmine.8,9

Pre-operative management of myasthenia gravis

Before the operation, it is important to inform the patient and relatives that stress in form of surgery can worsen symptoms, but that the illness will usually return to baseline. If the patient is having elective surgery, the best time for operation is during a stable phase where the patient is minimally medicated. The patients neurologist should be consulted as to continuation of immunosuppressive medication as it depends on whether the patient is dependent on the medication or not. Most immunosuppressives do not interact with anesthesia aside from azathioprine, which extends the effect of succinylcholine and inhibits nondepolarizing blocking agents. If it is necessary to perform acute surgery, and the patient is having a myasthenic crisis, attempts should be made to optimize the patient, e.g. with plasmapheresis.10 Routine pre-medication with sedatives or opioids should be avoided because of the depressive effect on respiration. Trying to predict which myasthenic patients are at risk of developing post-surgical myasthenic crisis is difcult, and physicians have tried devel-

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Anesthesia and myasthenia gravis

oping scoring systems to predict it before surgery. Leventhal et al. found in 1980 that patients with disease existing for > 6 years, with the presence of previous respiratory problems or co-existing lung disease and with pyridostigmine doses > 750 mg/ day and a pre-operative forced vital capacity < 2.9 l, were at risk of a myasthenic crisis post-surgery.11 Two years later, it was shown that the scoring system could not be used for all patients.12 Other physicians found that high pre-operative cholinesterase inhibitor dosage, severe bulbar symptoms and severe myasthenia gravis with previous respiratory crisis and cardiorespiratory disease were risk factors for post-surgical mechanical ventilation.13 In 2004, another study from Japan showed that besides bulbar symptoms and a history of pre-operative myasthenic crisis, a preoperative serum level of antiacetylcholine receptor antibody > 100 nmol/l and intraoperative blood loss > 1000 ml were risk factors of a post-surgical myasthenic crisis.14,15 To summarize, previous respiratory problems and bulbar symptoms were risk factors, but the inuence of the dose of daily pyridostigmine on the need for mechanical ventilation is debatable.

smaller dose of local anesthesia is required. One concern should be respiratory failure after a blockade of the upper extremity to which MG patients are more vulnerable.21

Nondepolarizing neuromuscular blocking agents

In several clinical trials, an increased sensitivity toward nondepolarizing NMBA has been found in myasthenic patients as compared with other patients. Different results have, however, been presented and the comparability between the studies is low because of the heterogeneity of the patient groups, such as severity of the disease, which kind of medication they receive and also which kind of pre-operative precautions that have been taken (e.g. some patients received plasmapheresis before operation). It is therefore essential to use neuromuscular monitoring, such as train-of-four (TOF) monitoring during surgery and ensure full recovery (TOF > 90%) prior to terminating the anesthetics. An earlier study showed that the more severe the disease and the higher the dose of pyridostigmin, the more sensitive the patient was toward nondepolarizing NMBA.16 The differences in sensitivity between the different types of nondepolarizing NMBA and MG are very small. Mivacurium is hydrolyzed by plasma cholinesterase which may be inhibited by pyridostigmine. Rocuronium, cisatracurium and veruconium are all intermediate acting NMBA, and they have a similar effect on MG patients. The necessary dose depends on the severity of the disease, which calls for individual judgment. However, roughly 50% of the standard dose is probably adequate, and nearly all patients have a prolonged recovery.17,2224 In the case of acute intubation, it is recommended to follow the standard procedure for rapid sequence induction (RSI). The Scandinavian clinical practice guidelines on general anesthesia for emergency situations recommend rocuronium 0.91.2 mg/kg for RSI if there are contradictions to using succinylcholine. This dose should be reduced in MG patients.25 Some case reports have described unproblematic RSI intubation of MG patients without NMBA, but this is not recommended due to the small number of studies.2628 The two kinds of MG, the seropositive and the seronegative, show no difference in sensitivity toward NMBA though this has only been tested in one study.29

Neuromuscular blocking agents and pyridostigmine

The continuation of the daily dose of pyridostigmine perioperatively has been questioned. Several studies have tested different types of nondepolarizing NMBA in MG patients, but because of differences in the studies and results, no unanimous and clear answer can be given as to whether to continue the use of pyridostigmine perioperatively.9,1619 Only Tripathi M et al. has shown that patients who do not receive their morning dose of pyridostigmine on the day of surgery are at risk of developing respiratory stress and may need neostigmine20 Discontinuing pyridostigmine can give the advantage of a quicker onset of nondepolarizing NMBA thus requiring a smaller dose of nondepolarizing NMBA. Taking into consideration the risk of respiratory difculties prior to surgery, the advantage does not seem worth it.

Perioperative management
Today many procedures can be performed using peripheral nerve blocks and, where it is possible, it is recommended for MG patients. With the use of ultrasound, nerve block techniques are safer, and a

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L. Blichfeldt-Lauridsen and B. D. Hansen

Myasthenia gravis and the use of volatile anesthetics

It is known that volatile anesthetics cause a reduction in neuromuscular transmission via different pathways, among these is the inhibition of the post-synaptic nAChR.30 There are several studies showing that the use of inhalational anesthesia with sevourane for MG patients makes it possible to avoid NMBA even during induction and intubation.31 A decrease in TOF has been demonstrated in MG patients when sevourane was administrated and a rise in TOF when the administration was stopped.32,33 A similar study was performed where propofol and remifentanil were compared with desurane and remifentanil for MG patients. The group receiving desurane had a signicant decrease in TOF ratio compared with the propofol group.34 In one of the studies, NMBA was needed during surgery to complete the operation. These studies show that as the myasthenic patient is more sensitive to the relaxant effect of volatile anesthetics, a TOF monitor should be used during surgery.

Sugammadex a new option in MG

Recently, sugammadex was introduced a selective NMBA-binding agent designed to reverse the effect of the steroidal NMBA rocuronium, which is also partially effective against vecuronium. Sugammadex decreases the amount of free NMBA molecules after administration by binding the molecules making them ineffective. This makes it possible to reverse a neuromuscular block in 3 min after administration of vecuronium or rocuronium and does not intervene with the nAChR or the anticholinesterases. It might be an option if RSI is needed.41 The use of sugammadex in MG patients has been described in three publications in 2010. Three patients with different stages of MG undergoing elective surgery and who received rocuronium showed faster reversal after administration of sugammadex, with no post-operative complications and were discharged from the hospital only a short time after non-MG patients.4244 The three cases show convincingly that it is possible to reverse a deep neuromuscular blockade quickly even in MG patients, but sugammadex is still new in the world of anesthesiology, and it needs to be examined further in MG patients.

Epidural anesthesia for MG patients

Regional analgesia may reduce or eliminate the need for muscle relaxants in abdominal surgery. Epidural analgesia also offers the advantage of post-operative pain control with minimal or no opioid use. Epidural analgesia during labor for MG patients have been used with success,35 The use of a high epidural analgesia has been thought to compromise the patients respiratory function thereby increasing the risk of post-operative need for mechanical ventilation. Studies show that this is not the case. It is possible to use the combination of total intravenous/volatile anesthesia and high/low epidural analgesia for surgery. Epidural anesthesia offers a better post-operative pain control and respiratory function, and can minimize the need for NMBA during surgery.3639 Potentiation of neuromuscular blocking drugs by local anesthetics (LAs) in MG is a concern. Ester LAs are metabolized by pseudo cholinesterase, which may give problems in patients taking anticholinesterases so regional or local anesthesia should be performed using reduced doses and preferably with amide local anesthetics. Bupivacaine and Ropivacaine seem to be safe in thoracic epidural for intraoperative and post-operative analgesia in patients having a thymectomy.40

Post-operative management
In MG patients, sufcient spontaneous breathing before extubation is crucial. Different specic criteria before extubation of the myasthenic patient have been proposed, e.g. normal level of consciousness, tidal volume of 5 ml body weight (kg) or more, spontaneous ventilation with PaCO2 of 50 mmHg (6.67 kPa) or less, PaO2 of 90 mmHg (12 m0 kPa) or more and respiratory rate of 30 breaths/min or less,13 but the clinical assessment of respiration, with the criteria routinely used in all patients before extubation, should also be sufcient in myasthenic patients. Most important is to make sure there is no residual curarization before extubation either using a TOF monitor in the unconscious patient or with head lift > 5 s. in the conscious patient. Routine admission to the intensive care unit (ICU) with mechanical ventilation is not recommended because of an increased risk of respiratory insufciency and airway-associated morbidity.

Post-operative analgesia
To the myasthenic patient, optimal pain management is important because stress caused by pain may develop into a myasthenic crisis and an ICU stay.

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Anesthesia and myasthenia gravis

An appropriate solution, whenever possible, is regional analgesia in the form of epidural or peripheral neuromuscular blockade. This way, the patient can avoid opioids and their harmful effect on the respiratory and gastrointestinal function. The quicker the gastrointestinal function is normalized, the quicker the patient can resume their usual oral medication of cholinesterase inhibitors. If intravenous/intramuscular opioids are necessary, small doses of rapid, short-acting opioids should be used until pain relief instead of long lasting medications. Nonsteroidal anti-inammatory drugs can be a suitable option for the MG patient. The antiinammatory effect may reduce the need for opioids but can rarely eliminate it. Most elective MG patients can be discharged without an ICU stay or a consultation with a neurologist, but if the patient begins to develop signs of deterioration or ends up in the ICU, the neurologist should be involved as early as possible.

Conclusion and perspective

Thorough pre-operative evaluation, continuing the daily pyridostigmine, careful monitoring during surgery, sufcient respiration prior to extubation and sufcient respiration and analgesia postsurgery minimize the risk of post-operative mechanical ventilation for MG patients.

Acknowledgements
The authors are very grateful to Christopher Garcia for linguistic assistance in the process of writing the article. Conicts of interest: The authors have no conicts of interest.

References
1. Carr AS, Cardwell CR, McCarron PO, McConville J. A systemic review of population based epidemiological studies in myasthenia gravis. BMC Neurol 2010; 10: 19. 2. Vincent A, Clover L, Buckley C, Grimley Evans J, Rothwell PM, the UK Myasthenia Gravis Survey. Evidence of underdiagnosis of myasthenia gravis in older people. J Neurol Neurosurg Psychiatry 2003; 74: 11058. 3. Gold R, Hohlfeld R, Toyka KV. Progress in the treatment of myasthenia gravis. Ther Adv Neurol Disord 2008; 1: 3651. 4. Gronseth GS, Barohn RJ. Practice parameter: thymectomy for autoimmune myasthenia gravis (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology. Neurology 2000; 55: 715. 5. Farrugia ME, Vincent A. Autoimune mediated neuromuscular junction defects. Curr Opin Neurol 2010; 23: 48995. 6. Oriordan JI, Miller DH, Mottershead JP, Hirsch NP, Howard RS. The management and outcome of patients with myasthenia gravis treated acutely in a neurological intensive care unit. Eur J Neurol 1998; 5: 13742.

7. Alshekhlee A, Miles JD, Katirji B, Preston C, Kaminski HJK. Incidence and mortality rates of myasthenia gravis and myasthenic crisis in US hospitals. Neurology 2009; 72: 1548 54. 8. Wainwright AP, Brodrick PM. Suxamethonium in myasthenia gravis. Anaesthesia 1987; 42: 9507. 9. Eisenkraft JB, Jeffrey Book W, Papatestas AE. Sensitivity to vecuronium in myasthenia gravis: a dose-response study. Can J Anaesth 1990; 37: 3016. 10. Jamal BT, Herb K. Perioperative management of patients with myasthenia gravis: prevention recognition and treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 107: 6125. 11. Leventhal SR, Orkin FK, Hirsh RA. Prediction of the need for postoperative mechanical ventilation in MG. Anesthesiology 1980; 53: 2630. 12. Grant RP, Jenkins LC. Prediction of the need for postoperative mechanical ventilation in myasthenia gravis: thymectomy compared to other surgical procedures. Can Anaesth Soc J 1982; 29: 1126. 13. Turani E, Szathmary I, Molnar J, Szobor A. Myasthenia gravis: prognostic signicance of clinical data in the prediction of postthymectomy respirator crises. Acta Chir Hung 19921993; 33: 35360. 14. Watanabe A, Watanabe T, Obama T, Mawatari T, Ohsawa H, Ichimiya Y, Takahashi N, Kusajima K, Abe T. Prognostic factors for myasthenic crisis after transsternal thymectomy in patients with myasthenic gravis. J Thorac Cardiovasc Surg 2004; 127: 86876. 15. Toker A, Tanju S, Ziyade S, zkan B, Sungur Z, Parman Y, Serdaroglu P, Daymeer F. Early outcomes of video-assisted thoracopic resection of thymus in 181 patients with myasthenia gravis: who are the candidates for the next morning discharge? Interact Cardiovasc Thorac Surg 2009; 9: 9958. 16. Nielsson E, Meretoja OA. Vecuronium dose-response and maintenance requirements in patients with myasthenia gravis. Anesthesiology 1990; 73: 2832. 17. Sanlippo M, Fierro G, Cavalletti MV, Biancari F, Vilardi V. Rocuronium in two myasthenic patients undergoing thymectomy. Acta Anaesthesiol Scand 1997; 41: 13656. 18. Baraka A, Siddik S, Kawkabani N. Cisatracurium in a myasthenic patient undergoing thymectomy. Can J Anaesth 1999; 46: 77982. 19. Baraka A, Taha S, Yazbeck V, Rizkallah P. Vecuronium block in the myasthenic patient. Inuence of anticholinesterases therapy. Anaesthesia 1993; 48: 58890. 20. Tripathi M, Kaushik S, Dubey P. The effect of use of pyridostigmine and requirement of vecuronium in patients with myasthenia gravis. J Postgrad Med 2009; 49: 3115. 21. Sinha A, Ahmad K, Harrop-Grifths W. The use of a vertical infraclavicular brachial plexus block in a patient with myasthenia gravis: effects on lung function. Anesthesia 2001; 56: 16570. 22. Paterson IG, Hood JR, Russel SH, Weston MD, Hirsch NP. Mivacurium in the myasthenic patient. Br J Anaesth 1994; 73: 4948. 23. Sungur Ulke Z, Senturk M. Mivacurium in patients with myasthenia gravis undergoing video-assisted thoracoscopic thymectomy. Br J Anesth 2009; 103: 3101. 24. Baraka A, Haroun-Bizri S, Kawas N. Cisatracurium in the myasthenic patient. Can J Anesth 1999; 46: 77982. 25. Jensen AG, Callese T, Hagemo JS, Hreinsson K, Lund V, Nordmark J. Scandinavian clinical practice guidelines on general anaesthesia for emergency situations. Acta Anaesthesiol Scand 2010; 54: 92250. 26. Politis GD, Tobias JD. Rapid sequence intubation without a neuromuscular blocking agent in a 14-year-old female

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L. Blichfeldt-Lauridsen and B. D. Hansen

patient with myasthenia gravis. Pediatr Anesth 2007; 17: 2858. Fodale V, Pratico C, Piana F, Carosu A, Lucanto T, Copiaglio S, Santamaria LB. Propofol and remifentanil without muscle relaxants in a patient with myasthenia gravis for emergency surgery. Can J Anaesth 2003; 50: 10834. Tagawa T, Sakuraba S, Okuda M. Rapid sequence intubation using Pentax-AWS without muscle relaxants in patients with myasthenia gravis. Acta Anaesthesiol Taiwan 2009; 47: 154 5. Itoh H, Shibata K, Nitta S. Sensitivity to vecuronium in seropositive and seronegative patients with myasthenia gravis. Anesth Analg 2002; 95: 10913. Miller RD. Millers anesthesia. Philadelphia: Churchill Livingstone, 2005: Chapter 13 515516. Kiran U, Choudhury M, Saxena N, Kapoor P. Sevourane as a sole anaesthetic for thymectomy in myasthenia gravis. Acta Anaesthesiol Scand 2000; 44: 3513. Nitahara K, Sugi Y, Higa K, Shono S, Hamada T. Neuromuscular effects of sevourane in myasthenia gravis patients. Br J Anaesth 2007; 98: 33741. Della Rocca G, Coccia C, Diana L, Pompei L, Costa MG, Tomaselli E, Marco PD, Vilardi V, Pietropaoli P. Propofol or sevourane anesthesia without muscle relaxants allow the early extubation of myasthenic patients. Can J Anesth 2003; 50: 54752. Gritti P, Carrara B, Khotcholava M, Bortolotti G, Giardini D, Lanterna LA, Benigni A, Sonzogni V. The use of desurane or propofol in combination with remifentanil in myasthenic patients undergoing a video-assisted thorascopic-extended thymectomy. Acta Anesthesiol Scand 2009; 53: 3809. Almeida C, Coutinho E, Moreira D, Santos E, Aguiar J. Myasthenia gravis and pregnancy: anaesthetic management a series of cases. Eur J Anaesthesiol 2010; 27: 98590. Kirsh JR, Diringer MN, Borel CO, Hanley DF, Merritt WT, Blukley GB. Preoperative lumbar epidural morphine improves postoperative analgesia and ventilatory function after transsternal thymetomy in patients with myasthenia. Crit Care Med 1991; 19: 14749. Mekis D, Kamenik M. Remifentanil and high thoracic epidural anaesthesia: a successful combination for patients with myasthenia gravis undergoing transsternal thymectomy. Eur J Anaesthesiol 2005; 22: 3929. Bagshaw O. A combination of total intravenous anesthesia and thoracic epidural for thymectomy in juvenile myasthenia gravis. Pediatr Anesth 2007; 17: 3704. Tsunezuka Y, Oda M, Matsumoto I, Tamura M, Watanabe G. Extended thymectomy in patients with myasthenia gravis with high thoracic epidural anesthesia alone. World J Surg 2004; 28: 9626. Abel M, Eisenkraft JB. Anesthetic implications of myasthenia gravis. Mt Sinai J Med 2002; 69: 317. Kopman AF. Sugammadex: a revolutionary approach to neuromuscular antagonism. Anesthesiology 2006; 104: 6313. Unterbuchner C, Fink H, Blobner M. The use of sugammadex in a patient with myasthenia gravis. Anaesthesia 2010; 65: 3025. De Boer HD, van Egmond J, Driessen JJ, Booij LHJD. A new approach to anesthesia management in myasthenia gravis: reversal of neuromuscular blockade by sugammadex. Rev Esp Anestesiol Reanim 2010; 57: 1814. Petrun AM, Mekis D, Kamenik M. Successful use of rocuronium and sugammadex in a patient with myasthenia. Eur J Anaesthesiol 2010; 27: 9178.

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Address: Louise Blichfeldt-Lauridsen Department of Anesthesiology Sydvestjysk Sygehus Esbjerg Finsensgade 35 6700 Esbjerg Denmark e-mail: louise@blichfeldtnet.dk

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