Multiple Sclerosis (MS) is an autoimmune process characterized by inflammation and demyelination of axons in the brain and spinal cord (Schneider, 2005). According to Maclean (2010), MS is one of the most common debilitating neurological disorders in young adults. My intent of this research project is to explain the pathophysiological process and become familiar with the implications of anesthesia related to MS. This research will enable me to prepare a safe, individualized anesthetic plan, taking all essential precautions when caring for a patient with multiple sclerosis

Maiden, Timothy B

English

Otterbein University

Otterbein University Digital Commons @ Otterbein Nursing Student Class Projects (Formerly MSN) Student Research & Creative Work Summer 2015 Multiple Sclerosis and the Implications of Anesthesia Timothy B. Maiden Otterbein University, timothy.maiden@otterbein.edu Follow this and additional works at: https://digitalcommons.otterbein.edu/stu_msn  Part of the Medical Pathology Commons, Nervous System Diseases Commons, and the Nursing Commons Recommended Citation Maiden, Timothy B., "Multiple Sclerosis and the Implications of Anesthesia" (2015). Nursing Student Class Projects (Formerly MSN). 127. https://digitalcommons.otterbein.edu/stu_msn/127 This Project is brought to you for free and open access by the Student Research & Creative Work at Digital Commons @ Otterbein. It has been accepted for inclusion in Nursing Student Class Projects (Formerly MSN) by an authorized administrator of Digital Commons @ Otterbein. For more information, please contact digitalcommons07@otterbein.edu. Multiple Sclerosis and the Implications of Anesthesia  Timothy B. Maiden, BSN, RN, CCRN  Introduction References Additional Sources  Otterbein University, Westerville, Ohio  Multiple Sclerosis (MS) is an autoimmune process characterized by inflammation and demyelination of axons in the brain and spinal cord (Schneider, 2005).   According to Maclean (2010), MS is one of the most common debilitating neurological disorders in young adults.  My intent of this research project is to explain the pathophysiological process and become familiar with the implications of anesthesia related to MS.  This research will enable me to prepare a safe, individualized anesthetic plan, taking all essential precautions when caring for a patient with multiple sclerosis.  Symptomology Symptoms associated with MS are expressed with varying degrees of severity and can originate at different times and locations throughout the disease process.  The variability and ambiguous nature of the symptoms pose a challenge to physicians when attempting to diagnose an individual with MS. The symptomology of MS can be categorized as subjective or objective.   Subjective symptoms:  Objective Symptoms:  • Tremors •  Ataxia  • Dysarthria          (Maclean, 2010)  • Pain          • Fatigue • Trigeminal Neuralgia • Muscles Spasms • Weakness • Parasthesias • Cognitive Deficits • Visual Disturbances • Mood Instability • Sexual Dysfunction • Bladder and Bowel Dysfunction                                                (Maclean, 2010)   Pathophysiological Process  Underlying pathophysiology:  The etiology of MS is unclear, however there is speculation that the activation of auto-reactive T lymphocytes occur secondary to the exposure to environmental factors, an infectious process or viruses ( Ward-Abel, Vernon, & Warner, 2014).  After T lymphocytes are activated, they infiltrate the central nervous system (CNS), by breaking through the blood brain barrier.  T lymphocytes also activate an inflammatory cascade, which encompasses CD4+ and  CD8+ T cells, B cells, interleukin 1, 6, and 11,  and tumor necrosis factor, leading to the destruction of oligodendrocytes and myelin (Gupta et al., 2014).  Destruction of oligodendrocytes, cells that produce myelin, inhibits the body’s ability to remyelinate neurons over time, leading to scar tissue formation on the neuron and the development of MS lesions (Schneider, 2005).  Demyelination impedes conduction and transmission of nerve impulses, thus creating cognitive and motor complications throughout the body.                             Significance of pathophysiology related to anesthesia:   The pathophysiological significance of MS is individualistic.  The severity of ones illness ranges from benign symptoms to a debilitating disease process, which guides healthcare providers in their plan of treatment.  The four conceptions that are thought to provoke a relapse of MS symptoms are, infection, the post partum period, high stress environments, and hyperthermia (Ward-Abel et al., 2014).  Therefore, it is paramount that anesthesia providers conduct an extensive review of one’s surgical, medical and family history in order to create a safe plan for anesthesia.  In combination with a detailed history, the nurse anesthetist (NA) must also conduct a thorough head to toe assessment.  The physical assessment provides insight regarding physical frailties, such as respiratory, cardiovascular, neurological or bowel complications that the individual may experience, which further guides the nurse anesthetist’s plan for anesthesia.  Patient education is also vital to the prevention of MS relapse during the pre and postoperative phases.     [How Multiple Sclerosis Works] (2008). Retrieved from http://s.hswstatic.com/gif/multiple-sclerosis-monocytes.jpg Types of Multiple Sclerosis Types of MS Primary progressive Relapsing-remitting Secondary progressive Percentage of people 15 85 N/A Description Symptoms appear and get worse (progression) from the start. Relapses are rare. For those people who have relapses as well as progression from the start, the term ‘progressive relapsing MS’ is used.   Symptoms appear (relapse) then resolve, partially or fully (remission). Relapses last for at least 24 hours, but commonly last for weeks or months. Remissions can last for weeks or even years. A relapse is an episode of neurological disturbance, caused by inflammation or demyelination, which occurs at least 30 days after any previous episode began, lasts at least 24 hours and is not caused by infection or any other known cause (McDonald et al 2001).    More than 65% of people who are initially diagnosed with relapsing-remitting MS will enter this phase within  15 years of being diagnosed (Koch et al 2008). Secondary progression occurs when someone has a sustained progression of MS without any relapses having taken place. Some people may continue  to have relapses.     (MacLean, 2010) Implications for Anesthesia  According to Schneider (2005), the stress of surgery and use of anesthetic agents will not lead to an exacerbation of MS symptoms, yet the complications of surgery, such as infection and hyperthermia have the potential to trigger a relapse.  The anesthesia provider must consider the individual’s severity of debilitation when devising an anesthetic plan.  If the patient has respiratory weakness secondary to MS, then the NA would likely elect to place the patient under general anesthesia, to mechanically ventilate the patient (Schneider, 2005).  Depending on the severity of weakness the patient may be difficult to extubate immediately after the operation, so a plan should be made with the intensive care team for postoperative care.   Temperature control is crucial for all MS patients.  Demyelinated axons are sensitive to increases in a patient’s body temperature, further blocking the conduction of nerve impulses (Schneider, 2005).  Studies show that an increase of 1° C can be significant and exacerbation of symptoms could ensue (Schneider, 2005).  Therefore, the NA should have a cooling blanket under the patient prior to positioning for surgery.   Knowing an individual’s degree of illness enables the NA to choose the appropriate neuromuscular blocking agent.  Individuals who exhibit extreme muscle weakness and atrophy are known to release excessive potassium from their cells after administration of succinylcholine, which could be devastating to an individual with MS who also has heart disease (Schneider, 2005). Nondepolarizing neuromuscular blocking agents have been proven to be safe for administration, but the effects can be prolonged or resistant depending once again, on the individual’s degree of neuromuscular involvement (Schneider, 2005).   Important considerations when discussing regional anesthesia, often used during labor and delivery, cesarean sections, and orthopedic cases is the use of epidural versus spinal approaches to anesthesia.  Studies have shown that the use of spinal anesthesia has led to exacerbations in MS symptoms along with having a higher risk of nerve damage (Schneider, 2005).  Epidural anesthesia and peripheral nerve blocks are safe, effective and are the preferred routes of regional anesthesia, when caring for a patient with MS (Schneider, 2005).   Lastly, bowel dysfunction is a major problem for some individuals with MS.  It is well known that general anesthesia often creates a temporary postoperative ileus.  Consequently, it is important for the NA to ensure the patient is on a bowel regimen including ambulation, stool softeners, and prokinetic medications if needed.    Conclusion  In conclusion, Multiple Sclerosis is an autoimmune process leading to the demyelination of axons, which slows the conduction and transmission of nerve impulses throughout the body.  A wide array of neuromuscular complications can occur secondary to neuronal damage.  Nurse anesthetists must create an anesthetic plan for each MS patient he or she encounters individually, depending on the patient’s complications and degree of disease progression. Gupta, S., Ahsan, I., Mahfooz, N., Abdelhamed, N., Ramanathan, M., Guttman, B.          (2014). Osteoporosis and Multiple Sclerosis: Risk Factors,         Pathophysiology, and Therapeutic Interventions. CNS Drugs, 28(8), 731-742.          doi:10.1007/s40263-014-0173-3  MacLean, R. (2010). Multiple Sclerosis: Understanding a Complex Neurological          Condition. Nursing Standard, 24(28), 50-56. Retrieved from          http://www.ncbi.nlm.nih.gov/pubmed/20391676  Schneider, K. (2005). AANA Journal Course 2: Update for Nurse Anesthetists. An          Overview of Multiple Sclerosis and Implications for Anesthesia. AANA          Journal, 73(3), 217-224. Retrieved from          https://www.aana.com/newsandjournal/Documents/p217-224.pdf  Ward-Abel, N., Vernon, K., & Warner, R. (2014).  An exciting era of treatments for          relapsing-remitting multiple sclerosis.  British Journal of Neuroscience          Nursing, 10(1), 21-28.       Acar, A., Nuri, Deniz M., Erhan, E., Ugur, G. (2013). Anesthetic Technique in a          Patient with Multiple Sclerosis Scheduled for Laparoscopic Nephrectomy for         A Renal Tumor: A Case Report. Anesth Pain, 2(3), 138-140.          Doi: 10.5812/aapm.7550 Barker, N. (2013). The challenges that clinicians and patients face when selecting         First-line treatments for multiple sclerosis. British Journal of Neuroscience         Nursing, 9(6), 267-272.  English, C., & Aloi, J. J. (2015). New FDA-approved disease-modifying therapies for          Multiple Sclerosis.  Clinical Therapeutics, 37(4), 691-715.         doi: http://dx.doi.org/10.1016/j.clinthera.2015.03.001 Marsh, S., & Pittard, A. (2011). Neuromuscular Disorders and Anaesthesia. Part 2:           Specific Neuromuscular Disorders. Continuing Education in Anaesthesia,           Critical Care & Pain, 11(4), 119-123. doi:10.1093/bjaceaccp/mkr019  Strickland, K., & Baguley, F. (2015). The role of the community nurse in care         provision for people with multiple sclerosis. British Journal of Community         Nursing, 20(1), 6-10. doi: 10.12968/bjcn.2015.20.1.6 Ward-Abel, N., & Hall, J. (2012). Sexual Dysfunction in Multiple Sclerosis: Part 1.           British Journal of Neuroscience Nursing, 8(1), 32-38.   MS Lesions It is our duty as healthcare providers to educate our patients to ensure they have the information necessary to make informative decisions, preventing postoperative complications and decreasing the risk for exacerbation of symptoms related to MS.  [Brain MRI Image] (2015). Retrieved from    http://www.hindawi.com/journals/cripe/2012/684064.fig.002.jpg 

Multiple Sclerosis and the Implications of Anesthesia

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Multiple Sclerosis and the Implications of Anesthesia

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