Admission Plan
Drugs Contraindicated in Myasthenia
Respiratory Support
.An example of an admission note of myasthenic crisis patient to the ICU:
Assessment:
***-year-old, right-handed woman with:
1. Myathenic Crisis:
Seropositive myasthenia gravis (IIIb) presenting with myasthenic crisis manifested by worsening shortness of breath, dysphagia, diplopia, nasal intonation, and generalized weakness. Home meds:
-Mestinone 120mg 4 times daily
-Prednisone 30mg daily Workup:
-Today’s NIF/FVC: -10*** cmH2O / 30*** ml/kg
-Routine labs CBC/BMP unremarkable
-Prior workup:
-Acetylcholine receptor antibody positive ***
-AChR blocking antibody elevated ***
-Striated muscle ab negative ***
-CT chest with and without contrast negative *** for thymoma Plan
Neurological:
– Neurological checks q4h
– Low threshold for intubation, Oxygen sturation is not a good monitor since MG can maintain good sats. Will follow PFT (FVC/NIF/MEF) q6h.
– Meds:
-Will start on IVIG 0.4gm/kg daily for 5 days (normal kidney functions –> can be given over 3 days)
-Will continue on home dose of Mestinone 120mg q6h
-Will continue on home dose of Prednisone 30mg daily
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Respiratory:
– FVC/NIF/MEF Q4h
– Aspiration precautions, head of bed above 30 degrees
– PRN O2
– Chest PT with vest q4hr
– Baseline CXR
– Suctioning q1-2 hours
– Meds:
– None
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Cardiology:
– Continuous cardiac telemetry
– Meds:
-None
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Renal:
– Renal function normal
– Monitor daily BMP, Mg, Phos while on IVIG
– Meds:
– IVFs NS @ 75/hr
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Gastrointestinal:
– NPO for now till speech evaluation
– Meds:
– Famitidine 20mg tab bid
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Endocrinology:
– FSBS q6hr
– Meds:
– Insulin SS
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Hematology:
– Monitor CBC daily
– SCDs for prophylaxis; Lovenox 40mg SC daily
– Meds:
– Lovenox 40mg SC daily
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Infectious Disease:
– Current access: PIVs
– Meds:
-none
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Prophylaxis:
DVT: SCDs, Lovenox 40mg SC daily
GI: famotidine
____________________________________________________________________________________________
Discharge Planning:
Patient requires ICU (or Step down ***) level of care for monitoring of respiratory functions.
Important Issues for Myasthenic patients
Drugs contraindicated with myasthenia:
Antibiotics: Quinolones – Monobactams – Lactams – Macrolides – Aminoglycozides
Antiarrythmics: Quinine – Quinidine – Procainamide
BP medications: Beta blockers (including timolol eye drops) – Calcium channel blockers
CNS medications: Antiepileptic drugs – Lithium
Local anasthetics: Procainamide
Neuromuscular blocking agents: Succinylcholine – Curare medications
Others: Penicillamine – Steroids (needs supervision) – Iodinated contrast agents – Magnesium containing medications
Patient Friendly List of Medications to Avoid
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Pulmonary function tests for MG/GBS:
– The 20/30/40 role: alarming values if FVC < 20ml/kg or NIF < 30cmH2O or MEP < 40cmH2O. These measures help to guide the level of admission (ICU/step down/floor), not to guide the decision for intubation. If FVC < 20ml/kg –> ICU admission is preferred.
– FVC is the most sensitive measure, NIF/MEP are effort dependent and less reproducible compared to FVC. Moreover NIF/MEP are unreliable if the face mask is leaking.
– Don’t depend on the numbers only for intubation. Patient should be either in respiratory distress while resting in bed without activity or hypercapnic to consider intubation.
Steps for respiratory support:
– No respiratory distress –> no need for respiratory support –> admit to step down
– Mild/Moderate respiratroy distress –> consider BIPAP or Hiflow nasal cannula if BIPAP is contraindicated (secretions – nausea – vomiting). It must be done in ICU for lose monitoring of respiratory distress, if didn’t improve (RR decrease, less use of accessory muscles) –> intubate.
– Severe respiratory distress –> intubation and mechanical ventillation.