We retrospectively reviewed the hospital records of 53 patients admitted for 73 episodes of myasthenic crisis at Columbia-Presbyterian Medical Center over a period of 12 years, from 1983 to 1994. Median age at the onset of first crisis was 55 (range, 20 to 82), the ratio of women to men was 2:1, and the median interval from onset of symptoms to first crisis was 8 months. Infection (usually pneumonia or upper respiratory infection) was the most common precipitating factor (38%), followed by no obvious cause (30%) and aspiration (10%). Twenty-five percent of patients were extubated at 7 days, 50% at 13 days, and 75% at 31 days; the longest crisis exceeded 5 months. Using survival analysis and backward stepwise Cox regression, we identified three independent predictors of prolonged intubation: (1) pre-intubation serum bicarbonate > or = 30 mg/dl (p = 0.0004, relative hazard 4.5), (2) peak vital capacity day 1 to 6 post-intubation < 25 ml/kg (p = 0.001, relative hazard 2.9), and (3) age > 50 (p = 0.01, relative hazard 2.4). The proportion of patients intubated longer than 2 weeks was 0% among those with no risk factors, 21% with one risk factor, 46% with two risk factors, and 88% with three risk factors (p = 0.0004). Complications independently associated with prolonged intubation included atelectasis (p = 0.002), anemia treated with transfusion (p = 0.03), Clostridium difficile infection (p = 0.01), and congestive heart failure (p = 0.03). Three episodes of crisis were fatal, for a mortality rate of 4% (3/73); four additional patients died after extubation. All seven deaths were due to overwhelming medical comorbidity. Over half of those who survived were functionally dependent (home or institutionalized) at discharge. In addition to prospective controlled studies of immunotherapies, the prevention and treatment of medical complications offers the best opportunity for further improving the outcome of myasthenic crisis.

Thiopentone was the most commonly used anticonvulsant to treat RCSE on admission to PICU. Mortality was low and approximately 1 in 25 showed a new neurological deficit at the 30-day follow-up.

g50 figure 1 Number of ex-premature babies admitted to PICU in the first 2 years of life by gestation. Conclusions Approximately one third of the patients admitted to PICU with RCSE had been treated in the ED appropriately using the APLS algorithm. Thiopentone was the most commonly used first-choice anticonvulsant to treat RCSE on admission to PICU. Mortality was low and approximately 1 in 25 showed a new neurological deficit at the 30-day follow-up. In ED the APLS guidelines were followed precisely in 90 patients (36.7%); 88 patients (35.9%) received an inappropriate dose of benzodiazepine (above guideline dose in 62, below guideline dose in 26). Thirty seven patients (15.1%) received anticonvulsants in the wrong sequence.The mean duration of admission to PICU was 3.7 days (range 1-45, median 2). The mean length of days ventilated (on PICU) was 3.2 days ventilated (range 1-31, median 2).Nine patients died (3.7%). Twenty seven patients (11%) demonstrated a new neurological deficit on discharge from PICU, of whom 10 (4% of the entire cohort) continued to show this deficit at 30 days. Abstract g50 figure 2Percentage of ex-premature babies alive at day 28 of life who are admitted to PICU before their second birthday by gestation. Abstract g50 figure 3Length of stay by gestation, median and IQR.

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