When living with myasthenia gravis (MG), you may need to be more careful with medical procedures. Surgery often requires local or general anesthesia and sedating medications that prevent you from feeling pain. These medications work by relaxing the skeletal muscles during the procedure. Because MG affects the muscles, there are special considerations for anesthesia.

In this article, we’ll discuss the additional risks of surgery and anesthesia you need to consider with MG. We’ll also cover how to talk to your doctor about preventing complications. If you have additional questions, your nerve specialist (neurologist) can help.

What Is Anesthesia and How Does It Work?

Anesthesia is a medical treatment that prevents pain and discomfort during intensive procedures. Anesthetic drugs work by blocking pain signals in the nerves. Doctors and researchers aren’t quite sure how every type of drug works. However, they believe anesthetic drugs work by:

• Changing neurotransmitter (chemical messenger) levels released by nerve cells
• Changing how well nerve cells move ions (charged particles) in and out of cells

Neurotransmitters are the body’s way of communicating with the brain, nerves, and skeletal muscles. Some of these chemical messengers help send signals, while others inhibit (block) signals. Many anesthetic drugs trigger nerves to release inhibitory chemicals. They inhibit nerve cell activity to reduce pain.

Common Types of Anesthesia

Health care providers can use different types of anesthesia depending on the procedure they’re performing. For example, you may have had local anesthesia injected into your gums to get a cavity filled. Other examples of local anesthesia include numbing eye drops, sprays, and topical lotions.

Regional anesthesia numbs a larger area of the body for surgery. For example, you may have a nerve block for hand surgery. The anesthesiologist numbs a nerve in your arm so you don’t feel any pain. An epidural, such as when delivering a baby, involves a regional anesthesia to numb the lower body by blocking the bottom part of the spinal cord.

If you’re having a major surgery, you’ll receive general anesthesia. You’ll receive a combination of inhaled and intravenous (IV) medication injected into a vein in your arm. You won’t remember anything from the procedure, as general anesthesia makes you unconscious.

Neuromuscular Blocking Agents for Surgery

During general anesthesia, anesthesiologists (anesthesia specialists) use certain medications. Neuromuscular blocking agents (NMBAs) relax the skeletal muscles. They also help with intubation — a procedure to place a breathing tube in the airway for surgery.

Examples of NMBAs that may be used in people with MG include rocuronium and vecuronium. These medications are given through an IV before surgery.

Myasthenia Gravis and Anesthesia: What Are the Risks?

MG is an autoimmune disease that causes muscle weakness and ocular (eye) problems. In MG, the immune system attacks the neuromuscular junction (NMJ). This is where the nerves send chemical signals to communicate with the skeletal muscles. Immune system proteins known as antibodies tag the NMJ for destruction, which blocks messages going from nerves to muscles.

Remember, anesthesia also works by blocking communication between nerves and muscles. Receiving anesthesia while living with MG puts you at risk of complications.

Cholinergic Crisis

Nerves and muscles communicate using the neurotransmitter acetylcholine. This chemical tells the muscles to contract or tighten. In MG, the immune system specifically attacks and destroys acetylcholine receptors. Without enough receptors, the muscles can’t contract, so they become weak.

People with MG often take acetylcholinesterase (AChE) inhibitors to treat muscle weakness. AChE inhibitors raise the amount of acetylcholine in the NMJ. Examples of these medications include pyridostigmine (Mestinon) and neostigmine methylsulfate (Bloxiverz).

Surgeons can use AChE inhibitors to reverse the effects of neuromuscular blockade. However, if the AChE inhibitor dose is too high, it can lead to a cholinergic crisis. This means there is too much acetylcholine in the nervous system. To avoid this complication, you may receive sugammadex instead.

Symptoms of a cholinergic crisis include:

• Trouble breathing
• Increased saliva production and sweating
• Stomach problems, like nausea and vomiting
• Bradycardia (low heart rate)
• Blurry vision

If you begin experiencing signs of a cholinergic crisis, let your doctor or nurse know. They’ll give you medication to treat your symptoms.

Myasthenic Crisis

Surgery and anesthesia can also cause a myasthenic crisis. This complication occurs when your respiratory muscles become so weak that you can’t breathe on your own and is called respiratory failure.

You may develop a myasthenic crisis if you’ve:

• Not fully recovered from anesthesia
• Stopped taking your MG treatments for surgery
• Developed an infection
• Taken a medication that can cause a myasthenic crisis

Symptoms of a myasthenic crisis include feeling short of breath and having trouble swallowing. This is a life-threatening event that needs immediate treatment.

Preventing Complications During Surgery With Myasthenia Gravis

Studies from the journal BMJ Open show that the average American will have nine surgeries in their lifetime. Many people with MG have a thymectomy — surgery to remove their thymus. This is because thymomas or thymus tumors play a role in MG symptoms.

If you’re living with MG, you’ll want to be prepared for potential procedures. Here we’ve provided a list of ways to prevent surgical complications.

Having Presurgery Discussions

Let your surgeon and anesthesiologist know you have MG. You may also want to request a surgical team that has experience treating people with this disease. They’ll take extra steps to make sure you’re safe before, during, and after surgery.

Before surgery, your surgical team will talk with your neurologist. They’ll discuss your current symptoms and medications. Your doctors will also create a treatment plan in case of complications. You can also ask questions during your appointment.

Your care team will give instructions on when to stop taking any medications. You’ll likely keep taking your MG treatments until the morning of surgery.

Choosing the Best Procedures and Anesthesia

If possible, ask your surgeon about using local or regional anesthesia. It’s best to avoid the side effects of sedation with MG.

It may not always be best to use local or regional anesthesia. If you need general anesthesia, your anesthesiologist will adjust your medications. Health experts generally recommend against using NMBAs in people with MG. Instead, your anesthesiologist will likely use:

• Inhaled medications to help you relax
• IV medications like propofol to help you fall asleep

Restarting Your Myasthenia Gravis Treatments

After your surgery, your care team may restart your MG treatments. Some medications are associated with an increased risk of complications. For example, you may start taking AChE inhibitors again. However, restarting corticosteroids can cause weakness that may be dangerous after surgery. Your surgical care team will discuss which medications are safe to take after your procedure.

Find Your Team

On MGteam, the social network for people living with myasthenia gravis and their loved ones, members come together to ask questions, give advice, and share their stories with others who understand life with myasthenia gravis.

Have you undergone surgery after receiving a myasthenia gravis diagnosis? What changes did your doctor or surgeon make to ensure your safety? Share your experience in the comments below, or start a conversation by posting on your Activities page.