Surgery, Anesthesia and CFS/FM/MCS
Compiled by Melissa Kaplan
BY CHARLES W. LAPP MD
For Persons With CFS Or Fibromyalgia Who Are Anticipating Surgery
Persons with CFS frequently re-activate latent herpes group viruses, which may produce a mild, subclinical hepatitis with slight elevations of the transaminases. Thus, hepatotoxic anesthetic agents should be avoided because they could potentiate the liver problem or even provoke fulminant hepatitis.
Intracellular magnesium and potassium depletion has been reported in CFS. For this reason, serum magnesium and potassium levels should be checked pre-operatively and these minerals replenished if borderline or low. Intracellular magnesium or potassium depletion could potentially lead to cardiac arrhythmias under anesthesia.
Up to 97% of persons with CFS demonstrate vasovagal syncope (neurally mediated hypotension) on tilt table testing, and a majority of these can be shown to have low plasma volumes,low RBC mass, and venous pooling. Syncope may be precipitated by cathecholamines (epinephrine), sympathomimetics (isoproterenol), and vasodilators (nitric oxide, nitroglycerin, a-blockers, and hypotensive agents). Care should be taken to hydrate patients prior to surgery and to avoid drugs that stimulate neurogenic syncope or lower blood pressure.
Allergic reactions are seen more commonly in persons with CFS than the general population. for this reason, histamine-releasing anesthetic agents (such as pentothal) and muscle relaxants (curare, Tracrium, and Mevacurium) are best avoided if possible. Propofol, midazolam, and fentanyl are generally well-tolerated. Most CFS patients are also extremely sensitive to sedative medications -- including benzodiazepines, antihistamines, and psychotropics -- which should be used sparingly and in small doses until the patient's response can be assessed.
Finally, HPGA Axis Suppression is almost universally present in persons with CFS, but rarely suppresses cortisol production enough to be problematic. Seriously ill patients might be screened, however, with a 24 hour urine free cortisol level (spot or random specimens are usually normal) or Cortrosyn stimulation test, and provided cortisol supplementation if warranted.
Relapses are not uncommon following major operative procedures, and healing is said to be slow but there is no data to support this contention.
BY PAUL CHENEY MD AND PATRICK CLASS MD
"I would recommend that potentially hepatoxic anesthetic gases not be used including Halothane. Patients with Chronic Fatigue Syndrome are known to have reactivated herpes group viruses which can produce mild and usually subclinical hepatitis. Hepatotoxic anesthetic gases may then provoke fulminate hepatitis. Finally, patients with this syndrome are known to have intracellular magnesium and potassium depletion by electron beam x-ray spectroscopy techniques. For this reason I would recommend the patient be given Micro-K using 10mEq tablets, 1 table BID and magnesium sulfate 50% solution, 2cc IM 24 hours to surgery. The intracellular magnesium and potassium depletion can result in untoward cardiac arrhythmias during anesthesia. For local anesthesias, I would recommend using Lidocaine sparingly and without epinephrine."
R. Cheney, MD, PhD, 1992
"Suggestions on anesthesia include using Diprivan (propofol) as the induction agent along with nitrous oxide and isoflurane (Forane) as the maintenance agent. The ones to avoid are histamine releasers that include sodium pentothol as well as a broad group of muscle relaxants in the Curare family, including Tracrium and Mevacurium."
L. Class, MD, 1996
BY MICHAEL J. ROSNER MD
"For those patients with canal stenosis or hypoplastic posterior fossa, the most important component of anesthesia is a neutral neck position and avoidance of hypotension. The former may increase cord compression and the latter may decrease blood flow to the spinal cord. Together, the effect may be severe. This may also be part of the mechanism by which both surgery and trauma are linked in some individuals to the development of their FMS/CFS. I doubt that the specifics of different anesthetic regimes will matter too much beyond the above."
J. Rosner, MD
RECOMMENDATIONS BY GRACE ZIEM PhD AND JAMES
"...Agents whose exposures are associated with symptoms and suspected of causing onset of chemical sensitivity with chronic illness include gasoline, kerosene, natural gas, pesticides (especially chlordane and chlorpyrifos), solvents, new carpet and other renovation materials, adhesives/glues, fiberglass, carbonless copy paper, fabric softener, formaldehyde and glutaraldehyde, carpet shampoos (lauryl sulfate) and other cleaning agents, isocyanates, combustion products (poorly vented gas heaters, overheated batteries), and medications (dinitrochlorobenzene for warts, intranasally packed neosynephrine, prolonged antibiotics, and general anesthesia with petrochemicals). Multiple mechanisms of chemical injury that magnify response to exposures in chemically sensitive patients can include neurogenic inflammation (respiratory, gastrointestinal, genitourinary), kindling and time-dependent sensitization (neurologic), impaired porphyrin metabolism (multiple organs), and immune activation. "
Abstract published in Environmental Health Perspectives, 1997, volume 105 (Suppl 2), pages 417-436. Based on a paper presented at the Conference on Experimental Approaches to Chemical Sensitivity held 20-22 September 1995 in Princeton, New Jersey.
Dr. G. Ziem
by Robert Bennett MD Oregon
Anesthesia Protocol: Patient Cannot Recieve Any Histamine-Releasing Drugs
"I have used the following anaesthesia protocol with success during surgery on CFS patients. First, I perform skin tests for all the agents I am considering using with the patient. With CFS patients, I recommend Diprivan (propofol) as the induction agent; Versed (midazolam), fentanyl (a short-acting narcotic) and droperidol (an anti-nausea agent) during the anaesthetic; and a combination of nitrous oxide, oxygen and iso-flurane (commonly called Forane) as the maintenance agent."
"In contrast to the above agents, there is a group of commonly used anaesthetic agents which are known histamine-releasers and are probably best to be avoided by CFS patients. This group includes the thiobarbiturates such as sodium pentothal, which is probably the most common induction agent, but is a known histamine-releaser. In addition, there are a broad group of muscle relaxants in the Curare family, name Curare, Tracrium and Mevacurium, which are also potent histamine releasers and should be avoided by CFS patients. Since so many of these histamine-releasing agents are commonly used during emergency surgery, it would be advisable for you to wear a medical alert bracelet in the event you are unconscious and would have to have an anaesthetic. I would mention on the bracelet that you cannot receive any histamine-releasing drugs."
Gasnet.org: Anaesthetic Considerations in
the Patient with Rheumatoid Arthritis
John Doyle, PhD, MD
Iontophoresis Reduces Pain Of Needle Sticks For Kids
The pediatric application of iontophoresis, marketed as Numby Stuff(R), is a needle-free method of delivering Iontocaine(R), Iomed's brand of anesthetic medication, directly into the skin using a mild, low-level electric current from a small, battery-powered dose controller. In as little as 10 minutes, the skin and underlying tissue becomes completely numb up to a depth of 10 millimetres, allowing the physician or nurse to proceed with local dermal procedures.
Numby Stuff is currently being used in hospitals nation-wide for the delivery of anesthesia prior to IV starts, drawing blood, performing a minor surgical procedure such as a skin biopsy, port access, performing a lumbar puncture and any other procedure over intact skin where the skin needs to be numbed.
Excerpted from Doctor's Guide.
Articles on other sites
and Anesthesia: What are the risks?
For The Chemically Sensitive
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