Amjad, N

Khan, A A

Khan, E I

English

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eCommons@AKUDepartment of Anaesthesia Medical College, PakistanJune 2001Anaesthetic management for a patient with severemultiple sclerosisE I. KhanN AmjadA A. KhanFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesthPart of the Anesthesia and Analgesia Commons, and the Anesthesiology CommonsRecommended CitationKhan, E. I., Amjad, N., Khan, A. A. (2001). Anaesthetic management for a patient with severe multiple sclerosis. Journal of PakistanMedical Association, 51(6), 231-233.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesth/166Anaesthetic Management for a Patient with Severe MultipleSclerosisE.I. Khan,A.A Khan ( Department of Anaesthesia, Aga Khan University Hospital, Karachi. ) N. Amjad ( Department of Anaesthesia, Jinnab Post graduate Medical Centcr, Karachi. ) Introduction Multiple Sclerosis (MS) is a disease of temperate climate. It is rare amongst Asian and African races.Its overall incidence is 0.1-0.4%1. MS is primarily a disease of young adults with the onset ofsymptoms between the ages of 15 and 40 years and often present with a single neurological deficit,usually via a single lesion (55%) in the optic nerve, brain stem and spinal cord2. The effect of surgeryand anesthesia on the course of MS is controversial. Some reports indicate that symptoms of MS areexacerbated by anesthesia, particularly regional anesthesia. A relatively high proportion of patients withMS who receive spinal anesthesia do have an exacerbation of symptoms after surgery. It was suggestedthat demyelinated areas of the spinal cord might be more sensitive to the effects of local anesthetics3,4.However, there is no clear evidence that anesthesia, general or regional contributes to an exacerbationof the disease2.Case Report Twenty one years old girl weighing 45 kg was scheduled for rotation flap in right trochanteric area dueto bedsores. She was diagnosed as a case of multiple sclerosis two years back when she delivered ababy. Four days after delivery she developed progressive weakness in both lower limbs leading tocomplete quadriplegia over a period of one and a half year. Her initial symptoms were blurring ofvision which progressed to complete loss of vision and generalized stiffness of whole body.Her preoperative cardio pulmonary assessment was unremarkable. Laboratory investigations showednormocytic normochromic anaemia. MRI Brain scan showed multiple areas of demyelination in thecentrum semiovale, bilateral basal ganglia, right cerebral peduncle and frontal white matter. EMG andnerve conduction studies were suggestive of a motor axonal neuropathy affecting lower limbs withminimal signs of acute denervation. Visual evoked potential showed bilateral pre chiasmatic opticpathways dysfunction. Brain stem auditory evoked potential was normal.No pre-medication was given. Anaesthesia was induced with sodium thiopentone 5mg/Kg body weight.Atracurium was used for muscle relaxation and pethidine I mg/kg for analgesia. Anesthesia wasmaintained with isoflurance (N20/02 60:40). She remained stable throughout the procedure, surgerylasted for about two hours. Special consideration was given for temperature control which was keptbetween 34-35°C throughout. At the end of the procedure patient was reversed with atropine andneostigmine and shifted to the recovery room with stable vitals.She was followed up and found to be stable with no postoperative deterioration in her symptoms. Shewas anaesthetized with the same technique twice for dressings without any complications and wasdischarged after a month.Discussion Patients with multiple sclerosis coming for surgery should be assessed thoroughly, regarding its onset,progression and relapse, so that post-operative complications could be interpreted. There is anincreased tendency for platelets to aggregate, this may be relevant when the patient smokes or uses oralcontraceptives where there is an increased likehood of post-operative deep venous thrombosis.Prophylactic use of subcutaneous heparin is advisable1. There is an increased incidence of epilepsy inpatients with MS. During examination, particular attention must be paid to the degree of paresis.Kyphoscoliosis may be present and detailed respiratory function testing is indicated if a severe degreeof restrictive lung diseases is suspected. Examination of autonomic nervous system including responseto valsalva maneuver is of particular importance since many of these patients may have labileautonomic nervous system5. Infections are relatively common, particularly UTI. All except the mosturgent surgery should be postponed until the patient is free froni infection1. We did not use anybenzodiazepi nes (d iazepam) are cholinergic agents should be avoided possibility of a rise intemperature1. Papaveretum, Scopolamine and promethazine have been used as premedication6.We used sodium thiopentone for induction. Its deleterious effect on the course of the disease has notbeen substantiated. Phillida has described eight anesthetics shared by three patients, they receivedsodium thiopentone on seven occasions. On no occasion was anesthesia and surgery followed byapparent worsening of the patient’s condition6. Propofol also has been used without any exacerbation insymptoms3. We used atracurium for muscle relaxation. Hyperkalaemia with rise in potassiumconcentration upto 3 mmol/ liter has been reported in MS. The use of suxamethonium should thereforebe avoided1. Patients with MS might also have defective neuromuscular transmission. Due to thedisturbances of blood brain barrier, non-depolarizing muscle relaxant may enter CSF in large amountand can cause CMS symptoms even muscle fasc icu lation. Non-depolarizing relaxants should be usedwith the greatest caution and in the lowest appropriate dose. General anesthesia using muscle relaxantsare likely to lead to difficulty with weaning from mechanical ventilation and a prolonged stay in theICU. We used isoflurane; however there is no direct evidence that any of the currently used volatileanesthetics have deleterious effect on the course of the disease, it may be advisable to avoid enfluraneand halothane. Autonomic dysfunction may exaggerate the hypotensive effects of volatile anesthetics.Acute arterial hypertension is known to impair the blood brain barrier and particularly in associationwith the use of halothane. We used N20 along with oxygen. It has been used without any sequelae7.The implication of N20 in neurological damage arises both from its role in the inhibition of vitamin B12 and its known link with myelopathy and also in immune suppression. It is preferable to avoid N20in MS except for short procedures8. We used pethidine for analgesia which proved safe without anysequelae.Lumbar puncture may itself have little effect on the course of the disease but the opposite view is alsoheld. In a recent review complications following spinal anesthesia were reported in 29 cases, 10 ofwhich were in patients with MS1. However intrathecal diamorphine has been used successfully withoutany exacerbation in symptoms in MS2. Bader at el9 reported that epidural anesthesia for child birth inpatients with MS was not associated with a significantly higher incidence of relapses when comparedwith those patients who received local anesthetsia delivery. However, all women who experiencedpostpartum relapses received concentration of biipivacaine greater than 0.25%9. Monitoring shouldinclude ECG, NIBP, pulse oxymetry and special emphasis should be given to temperature and ET C02monitoring. Temperature in our patient was between 34-35°C. Temperature regulation is critical inpatient with MS. Even a slight increase of 0.5 degree in temperature can lead to the conduction block.Mild depression of bodytemperature by 0.7°C is known to cause transient improvement of the sign andsymptoms. Respiratory muscle weakness and dysfunction may increase the likehood of the need forpostoperative mechanical ventilation. Indeed an elevation of body temperature appears to be the normalresponse to all but the least traumatic surgical procedures. The prophylactic use of antipyretics post-operative may be of value1. In conclusion multiple sclerosis is a relatively common neurologicaldisease but it is unlikely that any one anesthetist will have experience of enough patients to be able todraw valid conclusions as to which drugs are most likely to produce an exacerbation. The effect ofdisease process on the safe conduct of anesthesia and in the choice of anesthetic agent to be used isimportant.References 1.Jones, R. M., Healy. T. E. J, Aaesthesia and demyelinating disease. Anaesthesia, 1 980;35:879-84.2.Làgh J. Fearnley Si, Lupprian KG. Anaesthesia, Intra - Thecal diamorphine during laparotomv in apatient with advanced multiple sclerosis, 1990:43:640,42.3.Moms E, Soar J. Anaesthesia for patients with severe multiple sclerosis. Hospital Medicine:1998:59:744.4.Alderson J.D. Intrathecal diamorphinc and multiple sclerosis. Anaesthesia. 1990:45:1084-85.5.Cartilidage NEF. Autonomic function in multiple sclerosis, Brain, 1972:95:661-64.6.Frost PM. Anaesthesia with multiple sclerosis. Anaesthesia. 1971:26: 104-05.7.Baskett PJF,Armstrong R. Anaesthesia problem in multiple sclerosis. Arc certain agentscontraindicated? Anaesthesia, 1970;25:397-401.8.Watt JWH. Anaesthesia for chronic spinal cord lesions and multiple sclerosis. Anaesthesia, 1 998:53 :825-26.9.Bader AM, Hunt CO, Datta S. et al. Anaesthesia for the obstetric patients with multiple sclerosis. J.Clin. Anaesth., 1988:1:21-24.

Anaesthetic management for a patient with severe multiple sclerosis

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Anaesthetic management for a patient with severe multiple sclerosis

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