GORAN VRGOČ

GORDANA ŽIDAK

IRA SKOK

MLADEN MIŠKULIN

HRČAK - Portal of Croatian Scientific and Professional Journals

Regional anesthesia for patient with restless legssyndrome: case reportINTRODUCTIONRestless legs syndrome (RLS) or Ekborn syndrome is a common,usually unrecognized neurological disorder with sensory and motorsymptoms (1). It is probably genetically based and affects around 10%of the population, but it is still underdiagnosed, underreported andundertreated. Most often it is idiopathic, however it may be associatedwith iron deficiency, uremia, pregnancy, folate deficiency, diabetes mellitus,rheumatoid arthritis, fibromyalgia, hypothyroidism, Parkinson’s diseaseand depression (2). It is more frequent in middle aged women, but canaffect both sexes as well as children (3). One theory suggests that dop-amine and serotonine imbalance causes RLS, the effect is similar toParkinson’s disease (4). A diagnosis of RLS often relies on the patient’sdescription of symptoms. Patient who suffers from RLS has urge tomove, associated with legs paresthesia and dysesthesia (sensory symp-toms) and voluntary and involuntary leg movements (motor symp-toms) (5). Symptoms usually occurs at rest, in the evening and at nightand are worsened by immobilization, withdrawal of dopaminergicagents, sleep deprivation and blood loss (6). So, it is not a surprise thatacute exacerbation can occur in perioperative settings (7). The pharma-cologic treatment of RLS refers to dopamine precursors (carbidopa--levodopa), dopamine agonists, (pramipexole, ropirinole), opioids, ben-zodiazepines (clonazepam), anticonvulsants (gabapentin) and other drugssuch as carbamazepine, clonidine, propranolol and amantadine whichare mentioned in some smaller studies (8).CASE REPORTA 43-yr-old woman, 162 cm tall, weighing 56 kg, who suffers fromfamilial, idiopathic RLS underwent total hip replacement surgery be-cause of continued pain in her right hip caused by instability of theimplant. She was born with dysplastic hips and her first surgery waswhen she was 12-yr-old. She experienced general anesthesia then andalso for the next three surgeries, twice for endoprothesis of the hip andonce for shoulder arthroscopy. She mentioned that she always needed"more anesthetic". Every time in preoperative settings and also duringthe wakening from general anesthesia, she had an acute exacerbation ofRLS symptoms. It was suicidal-like dysesthesia and pain. She said thatafter the second anesthesia, cramps and leg movements were so strong,that they caused endoprothesis luxation. She also said, that she hasnever remembered the first three postoperative days, because she hasbeen heavily sedated in the ICU room. We talked about other possibleanesthetic techniques for her, because we wanted to avoid this stressfulIRA SKOK1MLADEN MI[KULIN2GORAN VRGO^2GORDANA @IDAK11Clinical hospital "Sveti Duh",Anesthesiology and Intensive Care ClinicSveti Duh 64, 10000 Zagreb, Croatia2Clinical hospital " Sveti Duh",Department of Orthopedic surgerySveti Duh 64, 10000 Zagreb, CroatiaCorrespondence:Ira SkokClinical hospital "Sveti Duh",Anesthesiology and Intensive Care ClinicSveti Duh 64, 10000 Zagreb, CroatiaE-mail: ira.skok@gmail.comReceived May 15, 2013.PERIODICUM BIOLOGORUM UDC 57:61VOL. 115, No 2, 253–255, 2013 CODEN PDBIADISSN 0031-5362Clinical experiencewakening and sedation afterwards. We decided to use spi-nal anesthesia with sedation which would allow her to beawake and conscious. The night before the surgery shetook her usual dose of ropinirole (4 mg) orally, slept for 4hours and the rest of the night she walked. Half an hourbefore the surgery, she received 7.5 mg of midazolamorally. Intratechal anesthesia was performed with 27--gauge cutting-bevel spinal needle. 0.5% levobupivacai-ne 3mL was used as a local anesthetic. At the moment thespinal anesthesia started to have the effect, she felt un-controlled desire to move the legs. But she couldn’t. Shedeveloped tachycardia and systolic hypertension at 200mmHg. It lasted for few seconds, because she received150 mg of Propofol iv. and 0.1 mg of Fentanyl iv. She wasbreathing spontaneously and remained haemodynami-cally stable after the induction of anesthesia. Fifteenminutes later, she was fully awake but did not have adesire to move the legs. She received fentanyl boluses andpropofol in continuous infusion at 8 mg/kg/hour, but sheremained conscious and talking. She could not move thelegs, because of the spinal anesthesia, but did not havethe desire to move them as well. Blood loss was monito-red, and transfusion was administered. After the surgery,which lasted for four hours, she could move the legs, butstill did not have the symptoms of RLS. The wholereceived dose of propofol was 600 mg and fentanyl 1.25mg iv. She received fentanyl in continuous infusion 0.1mg/hour until the next day in ICU which had an analgesiceffect and blocked the RLS symptoms. Serum ferritin wasmonitored besides the usual laboratory parameters. It wasless than 50 mg/mL, so she received oral iron (100 mg/d)supplement. The next day she took her usual dose ofropinirole and received Tramadol boluses of 50 mg andwas discharged to the ward. She was satisfied with thiskind of anesthetic regimen and said that she would alwayschoose it for another elective surgery if it is possible.DISCUSSIONAnesthesia and surgery can exacerbate symptoms inpatients with RLS. It is primarily because of associatedconditions that include immobility, stress and blood loss.Use of neuroleptics (droperidol (9), prochlorperazine(10) and other drugs that block central dopamine re-ceptors (metoclopramide, metopimazine, hydroxyzineand promethazine and antidepressants) (11) can alsotrigger acute exacerbation of RLS. If the RLS is known,like in our patient, it is easier to prepare the patient andprevent the risk of worsening the symptoms. But thiscondition is still poorly recognized, because of a variety inpresentation from mild to moderate and severe form.Over the years, it was considered that regional anest-hesia, in this case spinal anesthesia, might worsen oreven cause RLS (12). Researchers are investigating neu-rologic problems that are connected either with the spi-nal cord or the brain, but still the main cause of RLS isunknown (13). Some other studies suggest even im-plantation of the pump for intrathecal drug delivery ofmorphine and bupivacaine which successfully resolvethe symptoms of RLS (14). Our approach was to choosethe best anesthetic technique, taking into considerationpatient’s history and anamnestic details about previousgeneral anesthesia and the type of surgery. It refers to aneed for motor blockade during the surgery and post-operative need for immobilization. We agreed with thepatient that it would be better if she stayed conscious andwe used opioids (15) to achieve that goal. Titration of theopioids in patients with RLS should be addressed indivi-dually, because our patient received much more opioidsthan we expected she could take according to her bodymass. We were monitoring her neurological status andtalked to her all the time about her symptoms, so opioidswere used just to treat symptoms associated to RLS. Itwas relatively easy because we had a cooperative patient.Special attention should be focused on children or de-mented patients who cannot express their feelings and itis hard to know if there are some signs of acute RLSexacerbation.There is a need for a longitudinal cohort studies ofsuch patients to help establish an anesthetic method ofchoice for different procedures. It is very important todiagnose such patients before the procedure, to take de-tailed, sleep and personal history and then determine themost appropriate anesthetic method. If patients are tak-ing oral therapy, they should take it regularly or evenincrease the dose to 3 to 4 doses per day if the patient isbedridden. All drugs that block central dopamine re-ceptors should be avoided, so for antiemetic drugs we canuse dromperidone or odansetron and for sedative ben-zodiazepine (clonazepam) (16). If the regional anesthe-sia is the chosen strategy, it will be probably necessary touse parenteral opioids to prevent the symptoms of RLS.Maybe one important point is the patient’s need to stayconscious but at the same time to prevent the urge tomove with mild sedation. This balance is not always easyto manage, especially in those patients with RLS, be-cause they do not fit into our body mass pharmacologycalcalculations. We have to adjust dosage individually, butalso have to be aware of potential toxicity of drugs. Ben-zodiazepins could be an alternative, either used in bolu-ses or in continuous infusion and further investigationsshould focus on this combination in similar cases. Wesuggest using regional anesthesia in combination withmild sedation whenever it is possible.REFERENCES1. EKBORN K A 1945 Restless legs syndrome. Acta Med Scand 158(suppl): 1-1232. AVECILLAS J F, GOLISH J A, GIANNINI C, YATACO J 2005Clevelad CJM 72: 769- 7873. BERGER K, LUEDEMANN J, TRENKWALDER C, JOHN U,KESSLER C 2004 Sex and the risk of restless legs syndrome in thegeneral population. Arch Intern Med 164: 196-2024. CONNOR J R, WANG X S, ALLEN R P, BEARD J L, WIESIN-GER J A, FELT B T, EARLEY C J 2009 Altered dopaminergicprofile in the putamen and substantia nigra in restless legs syn-drome. Brain 132: 2403-125. MONTPLAISIR J, BOUCHER S, NICOLAS A, LESPERANCEP, GOSELIN A, ROMPRE P, LAVIGNE G 1998 Immobilizationtests and periodic leg movements in sleep for the diagnosis of restlessleg syndrome. Mov Disord 13: 324-9254 Period biol, Vol 115, No 2, 2013.Ira Skok et al. Regional anesthesia for patient with restless legs syndrome : case report6. EARLEY C J, CONNOR J R, BEARD J L, MALECKI E A, EPS-TEIN D K, ALLEN R P 2000 Abnormalities in CSF concentrationsof ferritin and transferrin in restless legs syndrome. Neurology 54:1698-7007. RAUX M, KARROUM E G, ARNULF I 2010 Case Scenario:Anesthetic implications of restless legs syndrome. Anesthesiology 112:1511-78. TAN E K, ONDO W 2000 Restless legs syndrome: clinical featuresand treatment. Am J Med Sci 319: 397-4039. WARD N G 1989 Akathisia associated with droperidol during epi-dural anesthesia. Anesthesiology 71: 786-710. DROTTS D L, VINSON D R 1999 Prochlorperazine inducesakathisia in emergency patients. Ann Emerg Med 34: 469-7511. LEUTGEB U, MARTUS P 2002 Regular intake of non-opioidanalgesics is associated with an increasd risk of restless legs syn-drome in patients maintained on antidepressants. Eur J Med Res 7:368-37812. Transient restless legs syndrome after spinal anesthesia: A prospec-tive study 2002 Neurology 59: 1705-170713. ALLEN R P, BARKER P B, WEHRL F, SONG H K, EARLEY C J2001 MRI measurement of brain ron in patients with restless legssyndrome. Neurology 56: 263-26514. JAKOBSSON B, RUUTH K 2002 Successful treatment of restlesslegs syndrome with an implanted pump for intratechal drug delivery.Acta Anaesthesiol Scand 46: 114-715. WALTERS A S, WINKELMANN J, TRENKWALDER C et al.2001 Long- term follow- up on restless legs syndrome patientstreated with opioids. Mov Disord 16: 1105-110916. MONTAGNA P, SASSOLI DE BIANCHI L, ZUCCONI M, CI-RIGNOTTA F, LUGARESI E 1884 Clonazepam and vibration inrestless legs Syndrome. Acta Neurol Scand 69: 428-430Period biol, Vol 115, No 2, 2013. 255Regional anesthesia for patient with restless legs syndrome : case report Ira Skok et al.

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Regional anesthesia for patient with restless legs syndrome: case report

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Regional anesthesia for patient with restless legssyndrome: case reportINTRODUCTIONRestless legs syndrome (RLS) or Ekborn syndrome is a common,usually unrecognized neurological disorder with sensory and motorsymptoms (1). It is probably genetically based and affects around 10%of the population, but it is still underdiagnosed, underreported andundertreated. Most often it is idiopathic, however it may be associatedwith iron deficiency, uremia, pregnancy, folate deficiency, diabetes mellitus,rheumatoid arthritis, fibromyalgia, hypothyroidism, Parkinson’s diseaseand depression (2). It is more frequent in middle aged women, but canaffect both sexes as well as children (3). One theory suggests that dop-amine and serotonine imbalance causes RLS, the effect is similar toParkinson’s disease (4). A diagnosis of RLS often relies on the patient’sdescription of symptoms. Patient who suffers from RLS has urge tomove, associated with legs paresthesia and dysesthesia (sensory symp-toms) and voluntary and involuntary leg movements (motor symp-toms) (5). Symptoms usually occurs at rest, in the evening and at nightand are worsened by immobilization, withdrawal of dopaminergicagents, sleep deprivation and blood loss (6). So, it is not a surprise thatacute exacerbation can occur in perioperative settings (7). The pharma-cologic treatment of RLS refers to dopamine precursors (carbidopa--levodopa), dopamine agonists, (pramipexole, ropirinole), opioids, ben-zodiazepines (clonazepam), anticonvulsants (gabapentin) and other drugssuch as carbamazepine, clonidine, propranolol and amantadine whichare mentioned in some smaller studies (8).CASE REPORTA 43-yr-old woman, 162 cm tall, weighing 56 kg, who suffers fromfamilial, idiopathic RLS underwent total hip replacement surgery be-cause of continued pain in her right hip caused by instability of theimplant. She was born with dysplastic hips and her first surgery waswhen she was 12-yr-old. She experienced general anesthesia then andalso for the next three surgeries, twice for endoprothesis of the hip andonce for shoulder arthroscopy. She mentioned that she always needed"more anesthetic". Every time in preoperative settings and also duringthe wakening from general anesthesia, she had an acute exacerbation ofRLS symptoms. It was suicidal-like dysesthesia and pain. She said thatafter the second anesthesia, cramps and leg movements were so strong,that they caused endoprothesis luxation. She also said, that she hasnever remembered the first three postoperative days, because she hasbeen heavily sedated in the ICU room. We talked about other possibleanesthetic techniques for her, because we wanted to avoid this stressfulIRA SKOK1MLADEN MI[KULIN2GORAN VRGO^2GORDANA @IDAK11Clinical hospital "Sveti Duh",Anesthesiology and Intensive Care ClinicSveti Duh 64, 10000 Zagreb, Croatia2Clinical hospital " Sveti Duh",Department of Orthopedic surgerySveti Duh 64, 10000 Zagreb, CroatiaCorrespondence:Ira SkokClinical hospital "Sveti Duh",Anesthesiology and Intensive Care ClinicSveti Duh 64, 10000 Zagreb, CroatiaE-mail: ira.skok@gmail.comReceived May 15, 2013.PERIODICUM BIOLOGORUM UDC 57:61VOL. 115, No 2, 253–255, 2013 CODEN PDBIADISSN 0031-5362Clinical experiencewakening and sedation afterwards.We decided to use spi-nal anesthesia with sedation which would allow her to beawake and conscious. The night before the surgery shetook her usual dose of ropinirole (4 mg) orally, slept for 4hours and the rest of the night she walked. Half an hourbefore the surgery, she received 7.5 mg of midazolamorally. Intratechal anesthesia was performed with 27--gauge cutting-bevel spinal needle. 0.5% levobupivacai-ne 3mLwas used as a local anesthetic. At themoment thespinal anesthesia started to have the effect, she felt un-controlled desire to move the legs. But she couldn’t. Shedeveloped tachycardia and systolic hypertension at 200mmHg. It lasted for few seconds, because she received150 mg of Propofol iv. and 0.1 mg of Fentanyl iv. She wasbreathing spontaneously and remained haemodynami-cally stable after the induction of anesthesia. Fifteenminutes later, she was fully awake but did not have adesire tomove the legs. She received fentanyl boluses andpropofol in continuous infusion at 8mg/kg/hour, but sheremained conscious and talking. She could not move thelegs, because of the spinal anesthesia, but did not havethe desire to move them as well. Blood loss was monito-red, and transfusion was administered. After the surgery,which lasted for four hours, she could move the legs, butstill did not have the symptoms of RLS. The wholereceived dose of propofol was 600 mg and fentanyl 1.25mg iv. She received fentanyl in continuous infusion 0.1mg/hour until the next day in ICUwhich had an analgesiceffect and blocked the RLS symptoms. Serum ferritin wasmonitored besides the usual laboratory parameters. It wasless than 50 mg/mL, so she received oral iron (100 mg/d)supplement. The next day she took her usual dose ofropinirole and received Tramadol boluses of 50 mg andwas discharged to the ward. She was satisfied with thiskind of anesthetic regimen and said that she would alwayschoose it for another elective surgery if it is possible.DISCUSSIONAnesthesia and surgery can exacerbate symptoms inpatients with RLS. It is primarily because of associatedconditions that include immobility, stress and blood loss.Use of neuroleptics (droperidol (9), prochlorperazine(10) and other drugs that block central dopamine re-ceptors (metoclopramide, metopimazine, hydroxyzineand promethazine and antidepressants) (11) can alsotrigger acute exacerbation of RLS. If the RLS is known,like in our patient, it is easier to prepare the patient andprevent the risk of worsening the symptoms. But thiscondition is still poorly recognized, because of a variety inpresentation from mild to moderate and severe form.Over the years, it was considered that regional anest-hesia, in this case spinal anesthesia, might worsen oreven cause RLS (12). Researchers are investigating neu-rologic problems that are connected either with the spi-nal cord or the brain, but still the main cause of RLS isunknown (13). Some other studies suggest even im-plantation of the pump for intrathecal drug delivery ofmorphine and bupivacaine which successfully resolvethe symptoms of RLS (14). Our approach was to choosethe best anesthetic technique, taking into considerationpatient’s history and anamnestic details about previousgeneral anesthesia and the type of surgery. It refers to aneed for motor blockade during the surgery and post-operative need for immobilization. We agreed with thepatient that it would be better if she stayed conscious andwe used opioids (15) to achieve that goal. Titration of theopioids in patients with RLS should be addressed indivi-dually, because our patient received much more opioidsthan we expected she could take according to her bodymass. We were monitoring her neurological status andtalked to her all the time about her symptoms, so opioidswere used just to treat symptoms associated to RLS. Itwas relatively easy because we had a cooperative patient.Special attention should be focused on children or de-mented patients who cannot express their feelings and itis hard to know if there are some signs of acute RLSexacerbation.There is a need for a longitudinal cohort studies ofsuch patients to help establish an anesthetic method ofchoice for different procedures. It is very important todiagnose such patients before the procedure, to take de-tailed, sleep and personal history and then determine themost appropriate anesthetic method. If patients are tak-ing oral therapy, they should take it regularly or evenincrease the dose to 3 to 4 doses per day if the patient isbedridden. All drugs that block central dopamine re-ceptors should be avoided, so for antiemetic drugs we canuse dromperidone or odansetron and for sedative ben-zodiazepine (clonazepam) (16). If the regional anesthe-sia is the chosen strategy, it will be probably necessary touse parenteral opioids to prevent the symptoms of RLS.Maybe one important point is the patient’s need to stayconscious but at the same time to prevent the urge tomove withmild sedation. This balance is not always easyto manage, especially in those patients with RLS, be-cause they do not fit into our bodymass pharmacologycalcalculations. We have to adjust dosage individually, butalso have to be aware of potential toxicity of drugs. Ben-zodiazepins could be an alternative, either used in bolu-ses or in continuous infusion and further investigationsshould focus on this combination in similar cases. Wesuggest using regional anesthesia in combination withmild sedation whenever it is possible.REFERENCES1. EKBORN K A 1945 Restless legs syndrome. Acta Med Scand 158(suppl): 1-1232. AVECILLAS J F, GOLISH J A, GIANNINI C, YATACO J 2005Clevelad CJM 72: 769- 7873. BERGER K, LUEDEMANN J, TRENKWALDER C, JOHN U,KESSLER C 2004 Sex and the risk of restless legs syndrome in thegeneral population. Arch Intern Med 164: 196-2024. CONNOR J R, WANG X S, ALLEN R P, BEARD J L, WIESIN-GER J A, FELT B T, EARLEY C J 2009 Altered dopaminergicprofile in the putamen and substantia nigra in restless legs syn-drome. Brain 132: 2403-125. MONTPLAISIR J, BOUCHER S, NICOLAS A, LESPERANCEP, GOSELIN A, ROMPRE P, LAVIGNE G 1998 Immobilizationtests and periodic legmovements in sleep for the diagnosis of restlessleg syndrome. Mov Disord 13: 324-9254 Period biol, Vol 115, No 2, 2013.Ira Skok et al. Regional anesthesia for patient with restless legs syndrome : case report6. EARLEY C J, CONNOR J R, BEARD J L, MALECKI E A, EPS-TEINDK, ALLENRP 2000 Abnormalities inCSF concentrationsof ferritin and transferrin in restless legs syndrome. Neurology 54:1698-7007. RAUX M, KARROUM E G, ARNULF I 2010 Case Scenario:Anesthetic implications of restless legs syndrome.Anesthesiology 112:1511-78. TAN E K, ONDO W 2000 Restless legs syndrome: clinical featuresand treatment. Am J Med Sci 319: 397-4039. WARD N G 1989 Akathisia associated with droperidol during epi-dural anesthesia. Anesthesiology 71: 786-710. DROTTS D L, VINSON D R 1999 Prochlorperazine inducesakathisia in emergency patients. Ann Emerg Med 34: 469-7511. LEUTGEB U, MARTUS P 2002 Regular intake of non-opioidanalgesics is associated with an increasd risk of restless legs syn-drome in patients maintained on antidepressants. Eur J Med Res 7:368-37812. Transient restless legs syndrome after spinal anesthesia: A prospec-tive study 2002 Neurology 59: 1705-170713. ALLENR P, BARKER P B, WEHRL F, SONG H K, EARLEY C J2001 MRI measurement of brain ron in patients with restless legssyndrome. Neurology 56: 263-26514. JAKOBSSON B, RUUTH K 2002 Successful treatment of restlesslegs syndromewith an implanted pump for intratechal drug delivery.Acta Anaesthesiol Scand 46: 114-715. WALTERS A S, WINKELMANN J, TRENKWALDER C et al.2001 Long- term follow- up on restless legs syndrome patientstreated with opioids. Mov Disord 16: 1105-110916. MONTAGNA P, SASSOLI DE BIANCHI L, ZUCCONI M, CI-RIGNOTTA F, LUGARESI E 1884 Clonazepam and vibration inrestless legs Syndrome. Acta Neurol Scand 69: 428-430Period biol, Vol 115, No 2, 2013. 255Regional anesthesia for patient with restless legs syndrome : case report Ira Skok et al.

Regional anesthesia for patient with restless legs syndrome: case report

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