Patients with neuromuscular diseases such as myasthenia gravis can present as complicated anesthetic cases. This article reviews anesthetic considerations for optimal perioperative care of patients with myasthenia gravis. The pathophysiology of myasthenia gravis, cholinergic and myasthenic crises, and perioperative management are discussed; this includes the pharmacology of acetylcholinesterase inhibitors vs sugammadex, extubation criteria, pain management, and risk factors for postoperative myasthenic crisis. Anesthesia recommendations include reversal of nondepolarizing neuromuscular blockade agents with sugammadex, obtaining sufficient spontaneous breathing with absolutely no residual curarization before extubation, limited use of opioids and sedatives, avoidance of routine admission to the intensive care unit, and consideration of peripheral nerve blocks for adjunct pain control.
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