Myasthenic CrisisAdded by Matthew M Hastings , last edited by Matthew M Hastings on Feb 01, 2012

Monitoring

• IF IN ANY DOUBT, GO SEE THE PATIENT!!!

• Monitor respiratory parameters every few hours.
  • NIF (it should be more negative than -30 in general)
  • Vital cap (concerning when <10-12 mg/kg)
  • Other ways to assess respiratory status
    • Quality of cough
    • Ability to count out loud in one breath
  • These are partially driven by patient effort, so use these in combination. No single number or sign can substitute for a good exam and your general impression.

Time to move to the ICU?

• If you are worried about the patient's respiratory status at all, get them to the ICU. Myasthenia gravis patients can crash quickly and without much warning!

• Do NOT rely on the O2 sat or ABG to predict a crash. This may not change until it is too late!

• Consider BiPAP in ICU to try to avoid need for intubation.
  

  Work-up

• Perform infectious work-up for every myasthenic crisis with:
  • Blood cultures
  • Urine cultures
  • CXR
• Consider non-contrast chest CT for thymoma

  Treatment

• Acetylcholinesterase Inhibitors
  • Pyridostigmine (Mestinon and Mestinon Timespan (extended release))
    • Symptomatic treatment only.
    • Unnecessary in intubated patients; in fact, increase secretions.
    • You can provide mestinon, but not mestinon timespan, via dobhoff
    • Conversion of PO pyridostigmine:IV pyridostigmine is 30:1
• Glycopyrrolate (Robinul) to decrease secretions
• Steroids
  • High dose steroids can initially cause worsening! But later can help suppress immune response.
  • If already intubated, start high dose steroids (prednisone 60 mg PO qAM or solu-medrol 500 mg IV qAM)
• IVIg
  • Used acutely in crisis or for maintenance
  • Typical load for MG
    • If old, renal insufficiency, or severe cardiac disease & hypertension: 0.5 gram/kg over 4 days
    • If young and no renal or cardiac disease: 1 gm/kg daily x 2 days
  • If the patient has known renal disease and you must use IVIg:
    • Use the lysine based Gammagard formulation
    • Avoid concurrent use of nephrotoxic medications
    • Avoid concurrent IV contrast
    • Aggressively hydrate the patient during IVIg treatments
• Plasmapheresis
  • Used acutely in crisis or for maintenance
  • QOD x 5 treatments, and then reevaluate for need for further series
  • See AIDP section for more information on apheresis.
• Other immunosuppressants for maintenance
  • Mycofenolate mofetil (Cellcept)
  • Azathioprine (Imuran)

Medication Resentment

I have finally figured out I have medication resentment. Never realized at first it was an open category. In my condition as you might expect I take a lot of medications. Some for my core condition of Myasthenia Gravis. And others for side effects and common illnesses . And to add to the equation is the fact that I am a Woman of particular age you might say. 

I have put myself though these little med trials. That is when I stop taking a medication. Some where in the back of my mind I think the condition will rectify itself. And after causing self inflected harm. I can now say that this medication is needed. In my heart of hearts I believe in the healing power of the human body. There are some treatments I have negated for the same reason. Al though I had been told on several occasions that it was the best treatment for me.

I can imagine what you are thinking. Why would someone who should know better do such a thing. And it is simply common sense. Well If i were on the outside of this situation looking in I would say the same. And the answer is Medication resentment. It is a term I have given my condition. And it comes from my on personal observation.

You see prior to my illness I was a member of the medical community. And I understand what it means to need medication. Which is an indication of illness. And for me to have the need for medication meant it was real. And the possibility to require the use of these pills for ever.

Well I have decided to take this resentment and utilize it to my advantage. So I have opted to seek out more natural treatments. Hence foods,herbs,fruits,etc. So to not totally portray my belief in the healing capabilities of the body. I will now try to help supporting it's defense of me. As well as taking on my own plan of Holistic medicine which includes the prescribed medication. (for now that is..(wink) (wink). Until next time,thanks for listening.