Myasthenia gravis: a careful perioperative anesthetic management of coronary artery bypass grafting.

Nowadays, even hazardous cardiac surgery can be performed on patients with autoimmune diseases like myasthenia gravis. It requires a sensitive perioperative anesthetic approach especially in relation to nondepolarizing muscle relaxant administration. Myasthenic patients produce antibodies against the end-plate acetylcholine receptors causing muscle weakness and sensitivity to nondepolarizing muscle relaxants that could lead to respiratory failure. Perioperative nurse care is critical for uncomplicated course of treatment; therefore, apprehension of surgical procedure should be helpful on an everyday basis. We describe successful management without any pulmonary complications of two patients with myasthenia gravis undergoing coronary artery bypass grafting. In addition, antiacetylcholine receptor antibodies concentrations were evaluated during treatment time. In conclusion, we have found that reduced titrated doses of cisatracurium may be safely used in patients with myasthenia gravis undergoing cardiac surgery without anesthesia and respiratory-related complications.

Clinical practice guideline series update.

Approximately 20 per 100,000 people in the United States are currently living with myasthenia gravis (MG). MG is a chronic condition that occurs in all genders, ethnicities, and ages. The result of a defect at the neuromuscular junction, MG is characterized by fluctuating muscle weakness and fatigue. The purpose of the first edition of this American Association of Neuroscience Nurses' Clinical Practice Guideline is to summarize what is currently known about MG and to provide the reader with nursing-specific recommendations based on supporting evidence from nursing and other disciplines. Nursing Management of the Patient with Myasthenia Gravis includes information on epidemiology; types and classification of MG; pathophysiology; clinical features; clinical course; diagnostic tests; assessment; pharmacological, immunological, and surgical management; and the nurses' pivotal role in the care of the patient with MG.

Experiences of living with myasthenia gravis: a qualitative study with Taiwanese people.

Myasthenia gravis (MG) is an auto-immune, neuromuscular disorder, which presents with symptoms of fluctuating muscle fatigue because of a dysfunction of the neuromuscular junction. This study explores the illness experience of patients with MG, their experiences of illness, its challenges, and their coping and support strategies. In-depth interviews were undertaken with nine participants with MG (six for a generalized type of MG, three for ocular type). Data were subjected to inductive content and thematic analysis. Four themes emerged from MG patients with associated subthemes. They were "perceptions of MG," "challenges of MG, "social support," and "adapting and adjusting to MG." The study reveals the way in which individuals respond to and cope with their diagnosis. The importance of social and peer support is a key factor as well as the development of psychological strategies to live with MG. The recognition that there was a need to recognize the role of Western medicine in controlling their disease was also an important finding.

Diagnostic challenge: Myasthenia gravis in the emergency department.

PURPOSE: To describe an instructive case of neurological disease encountered by a nurse practitioner (NP) student in the emergency department (ED). Characteristics, epidemiology, pathophysiology, diagnostic considerations, and appropriate testing options for myasthenia gravis (MG) are included. DATA SOURCES: Findings from the history, physical examination, and diagnostic testing of a 41-year-old male with neck weakness and pain. Review of published literature about MG. CONCLUSIONS: MG is a pure motor syndrome characterized by fluctuating muscle weakness and fatigue and is exacerbated by sustained muscle use. It is usually caused by an autoimmune process that is chronic and progressive. Multiple patient encounters with the healthcare system often occur prior to diagnosis. Many viable treatment options now exist that can enhance quality of life and improve function. IMPLICATIONS FOR PRACTICE: The NP must include MG in the differential diagnosis with any report of fluctuating muscle weakness or other neurological, upper gastrointestinal, respiratory, or ophthalmic complaint. The key diagnostic finding is a specific muscle weakness that can be reproduced and exacerbated with sustained muscle use. These considerations will lead to earlier diagnosis and treatment.

[An experience of nursing a client with myasthenia gravis].

Myasthenia gravis is an autoimmune disease. It causes the formation of certain antibodies that attack acetylcholine receptors. The consequent reduction in the number of acetylcholine receptors causes impairment in the transduction of neural pulses (Cross, 1999). Clients usually present with ineffective breathing patterns, high risk of aspiration, and activity intolerance. Myasthenia gravis poses a threat not only to the lives of clients, but also of psychological and social impairment. The author describes the nursing evaluation undertaken during the process of caring for a client with myasthenia gravis, and, using Gorden's functional health assessment guide, summarizes six nursing problems, including high risk of aspiration, activity intolerance, knowledge deficit, powerlessness, ineffective breathing pattern and high risk of injury. Nursing intervention using multiple measures improved this client's symptoms of adjustment and understanding of the disease, while also raising the caring ability and quality of life of both client and family.

Fatigue in Myasthenia Gravis patients.

The purposes of this study were to validate psychometric properties of the Myasthenia Gravis Fatigue Scale (MGFS) and to use the MGFS to study the relationship of selected demographic and clinical variables to fatigue in a myasthenia gravis (MG) patient population. The MGFS, an existing scale, was developed to measure fatigue severity in MG patients. A convenience sample of 67 MG patients was approached on return visit to the Neuromuscular Disease Clinic. After giving consent, participants filled out four questionnaires: the MGFS, the Chalder Fatigue Scale, the Center for Epidemiologic Studies-Depression Scale, and a Demographic and Clinical Data Form. Participants' muscle weakness was evaluated using the Modified Quantitative MG Score for Disease Severity assessment form (13 muscles tested). Three days after the clinic visit, a copy of the MGFS was mailed to participants to allow retest at 5 to 7 days after initial testing. Findings showed that the MGFS demonstrated adequate internal consistency and test-retest reliability. In addition, the fatigue severity (MGFS) score correlated moderately with depression. We adjusted for the effect of depression and noted a relationship between the fatigue score and two of nine selected demographic and clinical characteristics--activity restriction and number of years since diagnosis. These results lay the groundwork for further investigation of fatigue in MG patients and identification of mitigating or coping methods.

Self-care actions to manage fatigue among myasthenia gravis patients.

Fatigue is the most frequently reported symptom by myasthenia gravis (MG)patients. Despite the prevalence of fatigue, treatment protocols are lacking, thus patients are left to self-manage. The purpose of this study was to describe self-care actions used to manage fatigue among patients with MG. A national sample (N = 250) of MG patients responded to two structured instruments. The Fatigue Survey (FS), modified with permission of authors Hubsky and Sears; and the Myasthenia Gravis Fatigue Scale (MGFS). Both instruments were based on the concept of fatigue. Participants identified three major categories of self-managed actions: mental interventions (76%), physical interventions (78%) and rest/sleep (80%). A subset of the respondents (N = 36) reported using aerobic exercise to attempt to relieve fatigue which is usually contradicted with MG. No significant difference in fatigue scores was found between those reporting aerobic exercise to be helpful and those not finding exercise helpful. However, those utilizing aerobic exercise reported the highest functional status categories. A question arises as to whether aerobic exercise is performed by the least ill MG patients, or aerobic exercise improves functional status. When demographic and functional status variables were associated with fatigue scores and selfcare actions, only gender and functional status were significantly correlated with fatigue score. Effective self-care actions include stress reduction techniques, pacing all activities and increased rest and sleep. Further investigation into the role of aerobic exercise is indicated as a self-care action for MG fatigue.

Myasthenia gravis: pathophysiology, diagnosis and collaborative care.

Myasthenia Gravis (MG) is an autoimmune disorder which compromises neuromuscular transmission. The hallmark of the disorder is fatigue with repetitive activity. Patients may experience symptoms ranging from double vision, ptosis and weak voice to choking, shortness of breath, generalized weakness and respiratory failure. The clinical diagnosis is confirmed by identification of a decremental response to repetitive nerve stimulation by electromyography (EMG), the presence of serum antibodies to the muscle acetylcholine receptor (AChR), or an improvement in strength with administration of intravenous edrophonium. With improvements in critical care and immunosuppressive treatments, MG is rarely the grave disease it once was, but because of the odd fatiguing symptoms and relative rarity of the disorder, patients are frequently misdiagnosed and their special needs overlooked. The nature of MG, with its acute and chronic components, creates complex needs for affected individuals and their families. The advanced practice nurse in collaboration with a neurologist in the outpatient setting is positioned to address these needs in an ongoing case management role.

Nursing care of the patient with myasthenia gravis.

Nursing priorities for patients with acquired autoimmune myasthenia gravis are reviewed. Three key aspects of care are discussed: assessment of weakness, knowledge of treatments and medications, and understanding the need for patient education and support. The article traces these needs throughout the diagnostic process, during hospitalization, including crisis, and subsequent outpatient care. Advances in treatment and their implications for nursing care are emphasized.

Myasthenia gravis and pregnancy.

Pregnancy is certainly an option open to patients with myasthenia gravis. Preconceptional counseling is the ideal, with the goal of discontinuing or reducing corticosteroid medications in patients requiring those agents. Alterations in physiology will require ongoing and careful assessment of the pregnant myasthenic or cholinergic crises. Antenatal testing for fetal well-being may be difficult to interpret. A small number of fetuses with fetal myasthenia gravis will be diagnosed by ultrasound. Attempts may be made to decrease the amount of circulating antibody crossing to the fetus. Interventions may include starting or increasing corticosteroid therapy, therapy with azathioprine, or plasmapheresis. Thymectomy is usually not performed during pregnancy. The intrapartum period will increase fatigue in the mother and may precipitate a myasthenic crisis. Epidural anesthesia is currently the agent of choice for decreasing pain and fatigue. An outlet forceps or vacuum delivery will shorten the second stage of labor in those patients who are unable to push repetitively. Cesarean delivery is preferably avoided in those patients at risk for pulmonary and thrombo-embolic complications. Narcotic and sedative medications may be used in the presence of careful and continuous assessment; they may increase respiratory and muscular symptoms. The postpartum period may be associated with an increase in exacerbations. Support services may help to eliminate or to reduce potent stressors during this time. Medication dosages may need to be adjusted as the mother's body returns to her prepregnant state. Transient, neonatal myasthenia is seen in up to 21% of maternal myasthenic cases, even in those patients with no detectable circulating antibody.

Development of printed teaching materials for neuroscience patients.

Neuroscience nurses are challenged by the current climate of cost containment and the nursing shortage to continue to provide quality patient education. One strategy for meeting this challenge is to follow the process outlined in this overview for the development and use of printed materials.

Myasthenia gravis: the patient in crisis.

Crisis in the myasthenic patient is a life-threatening event. The expertise of the critical care nurse is crucial to the prevention of complications and the return of the patient to a functional capacity.