Continuing Education in Anaesthesia, Critical Care & Pain Advance Access published June 10, 2011

Neuromuscular disorders and anaesthesia.

Part 2: specific neuromuscular disorders
Matrix reference 2A12
Sarah Marsh MB ChB FRCA
Alison Pittard MB ChB FRCA MD FFICM

Key points Neuromuscular disorders are a heterogeneous agents should be avoided due to denervation.
Whilst there are common group of diseases that share a number of impor- There is a risk of aspiration due to upper motor
anaesthetic techniques used tant issues with regard to generic anaesthetic neurone involvement. Care must be taken with
for patients with management. However, it is important to negatively inotropic drugs due to the involve-
neuromuscular disorders, remember that each disease state has its own ment of the myocardium.1 2
knowledge of each disease distinct pathophysiology that requires individu-

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process is vital for optimum ally tailored perioperative care. This article will Post-junctional disorders
management. discuss both hereditary and acquired neuromus-
Neuromuscular disease can cular disorders, paying particular attention to Dystrophicas
be divided into hereditary the specific management of each disease when Duchenne muscular dystrophy. Duchenne
and acquired disorders. undergoing anaesthesia (Tables 1 and 2). muscular dystrophy is the most common child-
hood muscular dystrophy with an incidence of
Multiple anatomical sites
can be affected by 1:3500 live births. It is an X-linked recessive
neuromuscular disease
Individual disorders: hereditary disorder that appears in childhood, with pro-
including pre-junctional, the Pre-junctional disorders gressive wasting and weakness usually of the
neuromuscular junction, and proximal muscles. It becomes fatal by late ado-
post-junctional locations. Peripheral neuropathies lescence from respiratory or cardiac failure.
Charcot-Marie-Tooth. This is a hereditary Sufferers may present with a waddling gait and
Duchenne muscular
condition with chronic peripheral neuromuscu- pseudohypertrophy of calf muscles between the
dystrophy is the most
common childhood lar denervation. This results in atrophy of the ages of 3 and 5. Affected males are often
neuromuscular disorder. muscles leading to spinal and limb deformities. wheelchair bound before their teens and suffer
Muscle weakness occurs as well as sensory dis- from contractures, marked scoliosis, restrictive
Thorough preoperative
turbance. Orthopaedic intervention is often lung function, and cardiomyopathies with up to
assessment and
perioperative planning is required for foot deformities ( pes cavus). 50% of sufferers having a dilated cardiomyopa-
essential to prevent Spinal deformities can result in restrictive lung thy by the age of 15. Death occurs from
morbidity and mortality. dysfunction. cardiac or respiratory failure in the second or
Anaesthetic considerations. Depolarizing third decade.2 – 4
neuromuscular blocking agents should be Those with the disorder lack dystrophin—a
avoided due to the denervation of muscle. protein that helps to anchor muscle cells to the
The effect of non-depolarizing neuromuscular extra-cellular matrix. In 1985, Kunkel and col-
blocking agents may be prolonged. Anaesthesia leagues discovered the gene coding for dystro-
Sarah Marsh MB ChB FRCA
can be maintained with i.v. or volatile agents. phin, which in Duchenne muscular dystrophy is
SpR Anaesthesia and Critical Care
Leeds Teaching Hospital Trust
Respiratory compromise may lead to ventilation defective. This leads to the absence of dystro-
Leeds LS1 3EX postoperatively. Neurological deficits should be phin expressed within the sarcolemma, render-
UK noted before regional anaesthesia.1 ing the sarcolemma weak. Muscle fibres are
Alison Pittard MB ChB FRCA MD then inadequately tethered, and these fibres
FFICM Fredrich’s ataxia. Fredrich’s ataxia is an then become replaced with fibrous connective
Consultant in Anaesthesia and ICM autosomal recessive ataxia. Clinically, features tissue leading to the pseuodhypertrophy seen.
Leeds Teaching Hospital Trust
include skeletal muscle weakness and progress- The sarcolemma also becomes increasingly
Anaesthetic Department
Leeds General Infirmary ive limb ataxia. Myocardial degeneration fre- permeable, with increased intracellular calcium
Leeds LS1 3EX quently occurs resulting in death from levels.4
UK
myocardial failure.
Tel: þ44 113 392 6672
Fax: þ44 113 392 5682 Anaesthetic considerations The diaphragm Becker’s muscular dystrophy. In Becker’s
E-mail: alison.pittard@leedsth.nhs.uk is often impaired and can result in respiratory muscular dystrophy, the dystrophin protein is
(for correspondence) failure. Depolarizing neuromuscular blocking only partially absent. It affects 1 in 30 000
doi:10.1093/bjaceaccp/mkr019
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& The Author [2011]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights
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Neuromuscular disorders and anaesthesia

Table 1 Hereditary neuromuscular disease. Key: , must avoid; *, give increased dose; +, give reduced dose; N, normal dose; AIR, anaesthesia-related rhabdomyolysis

Disorder Site DMR NDMR Anti-Chol MH Assoc Comments

Charcot-Marie-Tooth Pre-junc  + No + Thiopental dose

Fredrich’s ataxia Pre-junc + N No Avoid negative inotropes
DMD Post-junc –Absent dystrophin  + ?AIR Resp and Cardiac compromise
BMD Post-junc –reduced dystrophin  + ?AIR Resp and cardiac compromise
MD Post-junc –abnormal Na/Cl channel  +  No Avoid cold, shivering, mechanical, electrical stimulation, PM glucose control
MC Post-junc –abnormal Cl channel  +  No Give Na channel blockers for myotonia contractures
HyperPP Post-junc –abnormal Na channel  + No Avoid potassium, Avoid long fasting
HypoPP Post-junc –abnormal Ca channel  + Yes Maintain normokalaemia, normothermia
Metabolic Post-junc  N No Avoid hypothermia, Substrate infusion
Mitochondrial Post-junc  N No PM, reduce LA, propofol exposure

Table 2 Acquired neuromuscular disease

Disorder Site DMR NDMR Anti-Cholin MH assoc Comment

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MND Pre-junc—UMN/LMN  + No Respiratory compromise
MS Pre-junc—demyelination Caut N No Avoid LA, Avoid hyperthermia
GBS Pre-junc  + No Autonomic instability
DM Pre-junc N N No Autonomic instability, temp control, gastroparesis
MG NMJ—A/b to Ach receptor * +  No Avoid drugs interfering with NM transmission
ELS NMJ—A/b to Ca channel + + No Autonomic dysfunction
CIP/CIM Post-junc—muscle atrophy  + No

men, with milder symptoms than Duchenne muscular dystrophy synapses, as well as from rhabdomyolysis that occurs due to
that runs a more protracted course. The initial presentation tends to damage caused to the muscle cell membrane.2
be in the teenage years. Death secondary to cardiac or respiratory Non-depolarizing neuromuscular blocking agents should be
failure typically occurs in the fourth or fifth decade. Cardiac used sparingly as a delay in onset and offset is seen, potentially
disease in Becker’s muscular dystrophy, like Duchenne muscular leading to a prolonged block. Their use can often be avoided with
dystrophy, usually manifests as a dilated cardiomyopathy and an appropriate i.v. anaesthesia technique. If used however, their
cardiac arrhythmia.4 use should be coupled with neuromuscular monitoring.
Anaesthetic considerations. Particular risks during anaesthesia Inhalation anaesthetics have been implicated in the rhabdomyo-
include postoperative respiratory insufficiency and cardiac dysfunc- lysis seen in Duchenne muscular dystrophy patients secondary to
tion related to cardiomyopathies or arrhythmias. Appropriate pre- their effects of further increasing mycoplasmic calcium. It has
operative assessment should be completed where possible, been difficult to elucidate whether the metabolic reaction seen is
especially before any major surgery. Postoperative ventilatory related to an anaesthesia-related rhabdomyolysis or a true malig-
support must be considered and cardiac monitoring should be con- nant hyperthermia, and may not even occur on every exposure to
tinued into the postoperative period.5 halogenated compounds. Nevertheless, their use in Duchenne mus-
Blood loss may be increased due to smooth muscle and platelet cular dystrophy is advised with extreme caution, with total i.v.
dysfunction. Hypotensive anaesthesia has been recommended to anaesthesia and a clean anaesthetic machine being advisable. For
avoid large blood loss volumes. However, hypovolaemia should be those children where induction using volatile anaesthesia is indi-
avoided due to the relatively fixed cardiac output state secondary cated such as in a difficult airway, then the inhalation agent should
to non-compliant ventricles. In cases where there is felt to be be discontinued as soon as possible with conversion to TIVA and a
potential for hypovolaemia to occur, volume status should be mon- clean anaesthetic machine.2 3
itored invasively.2
Female carriers may show elevated CK levels, mild myopathic Myotonias
changes, and cardiomyopathy. For this reason, it has been The myotonias can be divided into two groups: the dystrophic and
suggested that volatile anaesthesia and depolarizing neuromuscular non-dystrophic group.
blocking agents are avoided if possible.2 In patients with dystrophic myotonias including myotonic dys-
Depolarizing neuromuscular blocking agents must be avoided trophy, muscle wasting and weakness are seen. This is in contrast
due to the extra-junctional synapse development that occurs in to the non-dystrophic myotonias (myotonia congenita and familial
Duchenne muscular dystrophy and Becker’s muscular dystrophy. periodic paralysis) where the main symptom can be prolonged
Catastrophic hyperkalaemia can result from depolarization of the muscle contraction following stimulation.6

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 Neuromuscular disorders and anaesthesia

Myotonic dystrophy. This is an autosomal dominant disorder Familial periodic paralysis

with an incidence of 2.4–5.5 cases per 100 000 in the UK, with the
Hyperkalaemic periodic paralysis (HyperPP). This is characterized
locus for myotonic dystrophy on chromosome 19. Multisystem signs
by episodes of flaccid paralysis. Its locus has been identified on
and symptoms usually manifest in early adulthood. Findings include
chromosome 17 with autosomal dominant penetrance, and affects
myotonia (incomplete muscle relaxation, especially the inability to ‘let
1 in 100 000 people. The paralysis is associated with increased
go’ after a hand grip), muscle wasting, cardiac abnormalities (conduc-
serum potassium concentrations and precipitated by cold, hunger,
tion defects, cardiomyopathy, structural deformities), respiratory
and stress. Respiratory muscles are usually spared. Dysrhythmias
abnormalities (restrictive lung disease and obstructive sleep apnoea),
may occur.
endocrine dysfunction, and intellectual impairment.
The underlying abnormality is a dysfunctional sodium channel,
The underlying pathophysiology is related to abnormal sodium
which following a hyperexcitable period becomes inactive result-
or chloride channels, which results in the muscle being in an
ing in weakness.9
abnormal hyperexcitable state. This results in repetitive action
Anaesthetic considerations. Preoperative potassium depletion
potentials and sustained muscle contraction, manifesting in the
has been recommended with the use of loop diuretics. Any drugs
inability to relax muscle groups.4 5 7
that cause potassium release from cells should be avoided, includ-
Anaesthetic considerations. Factors that may precipitate myoto-

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ing depolarizing neuromuscular blocking agents, as should
nias must be avoided where possible. These include hypothermia,
potassium-containing fluids. ECG monitoring should be continu-
shivering, and mechanical and electrical stimulation.
ous, and calcium should be available for the emergency treatment
There may be increased sensitivity to sedatives and analgesics,
of hyperkalaemic-induced weakness. Fasting should be minimized
due to the respiratory involvement and therefore these agents
and glucose containing fluids infused during fasting periods.
should be used judiciously.
Hypothermia should be avoided. HyperPP patients may remain
Depolarizing neuromuscular blocking agents may induce gener-
paralysed for hours after surgery, but good perioperative care
alized muscular contractures and are therefore not recommended.
should help to negate this risk.2 9
Non-depolarizing neuromuscular blocking agents are not associated
The use of volatile agents and non-depolarizing neuromuscular
with myotonias; however, the use of anti-cholinesterase drugs may
blocking agents is thought to be safe.
precipitate contractures due to the increased sensitivity to
Hypokalaemic periodic paralysis (HypoPP). This is a different
acetylcholine.
entity to HyperPP. The genetic defect is a rare autosomal dominant
Glucose metabolism may be affected as part of the disease, and
condition that results in defective calcium channels and in most
therefore levels should be monitored perioperatively. Bulbar
cases it is related to mutations within the dihydropyridine receptor
muscle weakness may result in aspiration. Conduction defects may
gene. Patients usually present in the second decade of life with
require access to pacemaker equipment.2 5
severe muscle weakness and asymmetrical muscle paralysis associ-
Myotonia congenita. Myotonia congenita is an autosomal ated with a low serum potassium.
dominant disease linked to chromosome 17, with an incidence of Mutations from another region of the dihydropyridine receptor
2 per 50 000 population. Symptoms are related to widespread gene have been associated with malignant hyperthermia and there
muscle hypertrophy. This results in a more severe state of muscle have been HypoPP patients who have exhibited hypermetabolic
contraction than the other muscular disorders, with significant stiff- states after the administration of malignant hyperthermia triggering
ness on initiating movement. There is characteristically no muscle drugs. There is, therefore, a theoretical risk that malignant
weakness but palatopharyngeal dysfunction can occur, resulting in hyperthermia and HypoPP may be linked in some patients due to
difficulty in swallowing and an aspiration risk. A cardiomyopathy the proximity of their loci within the same gene. However, the
may also be present. location of the loci is separate and there has been no definite link
The defect in myotonia congenita is based around a dysfunc- between the two proven as yet.
tional chloride channel, which reduces chloride conductance. The Anaesthetic considerations. Because of the potential link
muscle fibres become hyperexcitable resulting in myotonic between malignant hyperthermia and HypoPP, the use of volatile
contractures. agents should be left to the discretion of the anaesthetist, with
Anaesthetic considerations. Depolarizing neuromuscular block- knowledge of the risk of a potential hypermetabolic reaction.
ing agents should be avoided due to the intractable myotonias Depolarizing neuromuscular blocking agents should not be
that may be induced. Attempts should be made to avoid cold given. Non-depolarizing neuromuscular blocking agents used
environments, postoperative shivering, and excessive physical should have a short duration.
manipulation. If myotonia is elicited, non-depolarizing neuromus- Perioperative management should be directed towards avoiding
cular blocking agents will not relax the contractions nor does drugs that cause serum potassium shifts including salt and glucose
regional or peripheral nerve block. Sodium channel blockers may loads, maintaining normothermia and ensuring serum potassium is
be useful in breaking the contracture, as may be the topical kept within the normal range. Anxiety can precipitate weakness
administration of local anaesthetic to cut nerve bundles.8 9 and should be avoided if possible.9

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Neuromuscular disorders and anaesthesia

A perioperative attack may result in the need for postoperative There is no sensory loss, which distinguishes motor neurone
ventilation. Cardiac arrhythmias may also occur. disease from multiple sclerosis and other polyneuropathies. It
never affects cranial nerves. Signs include both upper and lower
Metabolic and mitochondrial disorders motor neurone of limbs and bulbar muscles. Fasiculations, weak-
ness, and atrophy are often present.4
Metabolic Anaesthetic considerations. Depolarizing neuromuscular block-
Metabolic myopathies such as acid maltase deficiency are a hetero- ing agents should be avoided. Non-depolarizing neuromuscular
geneous group of conditions that result from an inborn error of blocking agents may be used in reduced doses due to increased
metabolism resulting in skeletal muscle dysfunction. Abnormalities sensitivity. Respiratory complications are common, with the risk of
of metabolism can be related to glycogen, lipid, purine, or mito- postoperative ventilation and subsequent weaning difficulties,
chondrial metabolism. Muscle contraction depends on the supply of infection, and atalectasis.
ATP from three major sources: glycogen, lipid, and purine metab-
olism. If these pathways are interrupted, muscle cramps, myalgia,
and myoglobinuria occurs. Muscle weakness and atrophy develop
Multiple sclerosis
This is the most frequently occurring demyelinating neuromuscular
which can involve both the cardiac and respiratory systems.
disorder. It is a chronic relapsing condition characterized by the

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Anaesthetic considerations. Aggressive metabolic monitoring is
formation of plaques within the brain and spinal cord. These
required in the perioperative phase. Adequate hydration with
plaques cause demyelination around the axons, resulting in weak-
forced diuresis to avoid myoglobinuria is required. Glucose and
ness and spasticity as well as sensory dysfunction.
amino acid infusions should be run to aid muscle metabolism.
Anaesthetic considerations. Local anaesthetics may exacerbate
Hypothermia should be prevented to avoid shivering and increased
symptoms due to the increased sensitivity of demyelinated axons
muscle activity.2 6
to local anaesthetic toxicity.
Non-depolarizing neuromuscular blocking agents may be used
Mitochondrial
in normal doses. Caution should be exercised when using depolar-
These myopathies are related to primary mitochondrial dysfunc-
izing neuromuscular blocking agents if the patient is debilitated.
tion. Mitochondria are the main sites of ATP production from oxi-
Temperature maintenance is important as symptoms can deteriorate
dative phosphorylation. Organs including skeletal muscle that have
with an increase in temperature, as demyelinated axons are also
high energy demands are particularly vulnerable if mitochondrial
more sensitive to heat.
dysfunction is present. Symptoms can range from muscle weakness
and exercise intolerance to heart failure, movement disorders, and
death. Guillain – Barré syndrome
Anaesthetic considerations. These patients are difficult to Guillain– Barré syndrome is an immune-mediated polyneuropathy
anaesthetize, as most anaesthetic drugs have a depressant effect on that often follows a viral or bacterial illness within the preceding 4
mitochondria. Total atrio-ventricular block can occur, so access to weeks. The weakness typically ascends from the legs and is sym-
a temporary pacemaker is required in theatre. Stringent glucose metrical. Sensory and autoimmune dysfunction can also occur.
control is essential, and avoidance of stress, prolonged fasting, and Ascending weakness can lead to respiratory compromise requiring
infusing compound sodium lactate infusions is important. prolonged ventilatory support and bulbar dysfunction.
Respiratory failure can occur postoperatively. There may be Anaesthetic considerations. Rapidly progressing respiratory
impaired swallowing leading to aspiration. muscle weakness may result in intubation and ventilation. Invasive
Low dose volatile inhalation anaesthetic and ketamine have monitoring should be used due to the risk of autonomic instability.
been recommended for anaesthesia in sufferers. Drugs to be The use of depolarizing neuromuscular blocking agents should be
avoided or given in reduced concentrations include local anaes- avoided even following a long period after recovering from the
thetics and propofol due to their depressant effects on mitochon- neurological deficit as the risk of hyperkalaemic cardiac arrest
dria.2 6 after depolarizing neuromuscular blocking agents may persist.
There may be increased sensitivity to non-depolarizing neuromus-
Disorders: acquired cular blocking agents. Epidural anaesthesia may be useful to avoid
postoperative opioid use.
Pre-junctional disorders
Motor neurone disease Peripheral neuropathies: diabetes mellitus
This is a pre-junctional disorder that can affect both the upper Diabetic polyneuropathy may include sensory, motor, and auto-
( primary lateral sclerosis) and the lower ( progressive spinal nomic dysfunction following damage to axons and myelin and can
atrophy) neurones and even both (amyotrophic lateral sclerosis). be widespread or localized to a focal neuropathy. The pathophy-
Loss of innervation to muscle ultimately leads to muscle atrophy siology is unclear to date, but vascular, metabolic, and auto-
and the development of extra-junctional acetylcholine receptors. immune factors have previously been implicated.2 4

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 Neuromuscular disorders and anaesthesia

Anaesthetic considerations. Autonomic instability may occur Failure to wean from a ventilator and limb weakness are common
and therefore invasive monitoring should be considered. signs. The pathophysiology of critical illness polyneuropathy is
Gastropareisis is a feature and care should be taken at induction due to axonal degeneration of both motor and sensory nerve fibres
and in the postoperative period. There is an increased likelihood of with cranial nerves being spared. Myopathic changes occur with
becoming hypothermic and so temperature control is imperative.4 atrophic and occasionally necrotic fibres. It is a frequently occur-
ring condition related to patients with multi-organ failure or sepsis
Neuromuscular junction disorders and is thought to occur in up to 80% of all intensive care
patients.10
Myasthenia gravis
Myasthenia gravis is an autoimmune disease where there are IgG
auto-antibodies produced against the nicotinic Ach receptors Critical illness myopathy
within the neuromuscular junction. The autoantibodies lead to Critical illness myopathy can occur simultaneously with critical
destruction of the receptors. Symptoms include a fatigable weak- illness polyneuropathy. It presents with a diffuse weakness or
ness, which can be localized to specific muscle groups (ocular, flaccid paralysis, which again can compromise weaning. Critical
bulbar, and respiratory) or become widespread. Treatment may illness myopathy is associated with an acute respiratory disorder

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involve cholinesterase inhibitors, plasma exchange, immunosup- and the concomitant use of intra-venous steroids, non-depolarizing
pressants, and i.v. immunoglobulins. Patients may present to anaes- neuromuscular blocking agents and aminoglycosides.
thetists for definitive thymectomy surgery the thymus gland is Diagnosis requires clinical examination, electro-physiological
abnormal in up to 75% of cases, and thought to be the site of the studies, and ultimately a muscle biopsy to determine the under-
abnormal antibody production.4 lying disorder.
Anaesthetic considerations. In contrast to other neuromuscular Anaesthetic considerations. Prevention in intensive care patients
disorders, myasthenia gravis patients exhibit a relative resistance to is paramount as there is no specific treatment. Prolonged infusions
depolarizing neuromuscular blocking agents and the dose used of non-depolarizing neuromuscular blocking agents should be
may need to be increased. Conversely, patients show a sensitivity avoided especially when high dose steroids are used. Due to the
to non-depolarizing neuromuscular blocking agents, requiring only denervation involved, depolarizing neuromuscular blocking agents
10% of normal dose. Cholinesterase inhibitors should be avoided should be avoided to prevent hyperkalaemic cardiac arrest.
as they cannot only prolong the duration of a depolarizing neuro-
muscular blocking agents block, but also precipitate a cholinergic Conflict of interest
crisis. Drugs that interfere with neuromuscular transmission should
be avoided. Postoperative ventilation may be necessary. None declared.

Eaton – Lambert syndrome References

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