RevBrasAnestesiol.2016;66(4):414---417
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Anesthetic
management
of
a
patient
with
multiple
sclerosis
---
case
report
Eduardo
Barbin
Zuccolotto,
Guilherme
Coelho
Machado
Nunes,
Rafael
Soares
Lopes
Nogueira,
Eugenio
Pagnussatt
Neto
∗,
José
Roberto
Nociti
CentrodeEnsinoeTreinamentoemAnestesiologia(CET-SBA),ClinicadeAnestesiologiadeRibeirãoPreto(CARP), RibeirãoPreto,SP,Brazil
Received20February2014;accepted19March2014 Availableonline25April2016
KEYWORDS
Multiplesclerosis; Urologicsurgery; Propofol; Sevoflurane; Remifentanil
Abstract
Backgroundandobjectives: Multiplesclerosisisademyelinatingdiseaseofthebrainandspinal cord,characterizedbymuscleweakness,cognitivedysfunction,memoryloss,andpersonality disorders.Factorsthatpromotediseaseexacerbation arestress,physicaltrauma,infection, surgery,andhyperthermia.Theobjectiveistodescribetheanestheticmanagementofacase referredtourologicalsurgery.
Casereport: A female patient, 44 years of age, with multiple sclerosis, diagnosed with nephrolithiasis,referred forendoscopicureterolythotripsy. Balanced generalanesthesiawas chosen, with midazolam, propofol and remifentanil target-controlled infusion; sevoflurane via laryngeal mask airway; and spontaneous ventilation. Because the patient had respira-torydifficultypresentingwithchest wallrigidity,itwasdecidedtodiscontinuetheinfusion ofremifentanil.Therewasnoothercomplicationorexacerbationofdiseasepostoperatively.
Conclusion:Theuseofneuromuscularblockers(depolarizingandnon-depolarizing)isaproblem inthesepatients.Astherewasnoneedfor musclerelaxationinthiscase,musclerelaxants wereomitted.Weconcludethatthecombinationofpropofolandsevofluranewassatisfactory, notresultinginhemodynamicinstabilityordiseaseexacerbation.
©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mail:md.eugenio@gmail.com(E.PagnussattNeto). http://dx.doi.org/10.1016/j.bjane.2014.03.013
Anestheticmanagementofapatientwithmultiplesclerosis 415
PALAVRAS-CHAVE
Esclerosemúltipla; Cirurgiaurológica; Propofol;
Sevoflurano; Remifentanil
Controleanestésicodepacientecomesclerosemúltipla---relatodecaso
Resumo
Justificativaeobjetivos: Esclerosemúltiplaédoenc¸adesmielinizantedocérebroedamedula espinhal, caracterizada por fraqueza muscular, disfunc¸ão cognitiva, perda da memória, alterac¸ões de personalidade. Fatores que promovem exacerbac¸ão da doenc¸a são estresse, traumafísico,infecc¸ões,cirurgias,hipertermia.Oobjetivoédescreveraabordagemanestésica deumcasoencaminhadoacirurgiaurológica.
Relatodecaso: Pacientedo sexo feminino,44 anos, portadora de esclerose múltipla, com o diagnóstico de nefrolitíase, é encaminhada a ureterolitotripsia endoscópica. Optou-se por anestesia geral balanceada com midazolam, propofol e remifentanil em infusão alvo-controlada, sevoflurano sob máscara laríngea e ventilac¸ão espontânea. Tendo apresentado dificuldadeventilatóriaportóraxrígido,optou-seporinterromperainfusãoderemifentanil. Nãoseregistraramoutrasintercorrênciasnemexacerbac¸ãodadoenc¸anopós-operatório.
Conclusão:O uso de bloqueadores neuromusculares (tanto despolarizantes como não-despolarizantes) constitui um problema nestes pacientes. Como não havia necessidade de relaxamentomuscularnestecaso,elesforamomitidos.Concluímosqueaassociac¸ãodepropofol esevofluranofoisatisfatória,nãoresultandoeminstabilidadehemodinâmicanemexacerbac¸ão dadoenc¸a.
©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Multiple sclerosis (MS) is a demyelinating disease of the brain and spinal cord (peripheral nerves are not affected), with remissions and chronic relapses or pro-gressive course. It is possibly caused by the interaction between genetic andenvironmental factors, whose exact etiology is unknown. It is characterizedby loss of muscle strength, initiallyreversible; cognitive dysfunction; mem-ory loss; personality changes; and emotional lability.1---5
Symptoms appear between the ages of 20 and 40, with prevalence 8 times higher in females4; nevertheless, in
thecase of malepatients,theexacerbationis potentially more serious, with lower survival rate.6 Associated
con-ditions includeconvulsions and uveitis.Muscle breakdown causes hyperkalemia and the possibilityof neuromuscular blocking agent overdose. Chronic treatment with corti-costeroids predisposes toadrenal suppression and gastric ulceration.4
The clinically establishedfactors fordisease exacerba-tioninclude stress crises andphysical trauma,infections, surgery, hyperthermia, puerperal period.2,5,7 Study aimed
atverifyingwhetheroccupationalexposuretoinhaled anes-thetic agents couldincrease the risk of MS occurrencein professionalsfoundnorelationshipbetweenthisfactorand thedevelopmentofdisease.8
Thetreatmenthasbeendirectedtocontrollingthesigns andsymptomsanddiseaseprogression.Corticosteroidsare the treatment base, thanks toitsimmunomodulatory and anti-inflammatory action. Interferon beta is the agent of choicefor patientswithrelapsing-remitting,or glatiramer acetateasanalternative.Theimmunosuppressant azathio-prineiseffectiveinreducingthefrequencyofrelapses,but notduringadiseaseremission.5
Case
report
Female patient, 44 years old, with severe colic abdomi-nal pain in the right flank withirradiation tothe ventral region. Evaluated by the urology team, the patient was diagnosedwithnephrolithiasisandindicatedforendoscopic ureterolythotripsy.The patientreportedhavingMS,whose symptoms had began ten years ago associated with loss of balance; paresthesia in the right leg; diplopia; and labialcommissuredeviation.Abouttwoyearsago,withthe diagnosisestablished,shebegantobefollowedbya neurol-ogist.Atthattime,shewastakingnatalizumab,gabapentin 300mgday−1,andbaclofen10mgtwicedaily.Thelast
cri-sis happened more than a year ago. The patient denied othercomorbidities,regularuseofothermedications,and history of allergies. She wassubmitted to three previous cesarean sections 25, 22 and 19 years ago, and received spinalanesthesiainthefirsttwoandepiduralblockinthe thirdprocedure.Currently,shecannotwalkduetosevere muscleweaknessinbothlegs.
The patient was admitted to the operating room in a wheelchair,lucidandoriented,withhemodynamicstability, spontaneousventilation and adequate periodof preoper-ativefasting. After peripheral vein catheterizationin the right upper limb and routine monitoring (pulse oximetry, cardioscopy,noninvasivebloodpressure,capnometry), gen-eralanesthesiawasinducedusingthebalancedtechnique: midazolam0.02mgkg−1,followedbyremifentanilin
target-controlledinfusion(3ngmL−1),propofolintarget-controlled
infusion(3ngmL−1),andsevoflurane1.0MACunder
416 E.B.Zuccolottoetal.
procedurelasted60min.Therewerenocomplications intra-operatively, and at the end of surgery, she was taken to thepost-anestheticcareunit,awakenandwithstableand asymptomaticvitalconditions.There wasnoexacerbation ofMSpostoperatively.
Discussion
Anestheticandperioperativestressarefactorsthatcan trig-ger exacerbation crisis of MS; therefore, individuals with MS subjected to a surgical-anesthetic procedure are at increased risk of neurological dysfunction compared with individualswithoutMS.1
Case reports and retrospective studies are limited in determiningtheeffectsofanesthetictechniquesand peri-operativemanagement ofpatients withMS.The available datadonotsupportthehypothesisthatanesthesiamaybe associatedwithnewdemyelinatinglesionsinpatientswith MS.2
Neuraxial blockade in patients with MS is controver-sialduetothepotentialneurotoxicityoflocalanesthetics, particularly in demyelinated nerves.2,4 However, several
retrospective studies donot report significant increase in exacerbations when localanesthetics areadministered in the epiduralor subarachnoid space.2,6,9 But, in case of a
preciseindicationforperformingneuraxialblockade,some authorshavetheopinionthattheepiduraltechniqueshould bepreferred.4,10
Perioperativehyperthermiamaybeacauseofrecurrence andpostoperativeexacerbationofMSbecauseitaltersnerve conductionindemyelinatedregions.4,6Inourcase,we
per-formvolume replacement with cold solutions, as well as coolingthepatient.
Intravenousinductionagentsorinhalationanestheticsdo notappeartohaveadverseeffectsonnerveconductionand theavailableliteraturedoes notassociatethem with pro-gressionofMS.2Inmostcasereports,sevofluranewasused
foranestheticmaintenancewithoutreferenceto postopera-tiveexacerbationsofthedisease.11,12
The use of neuromuscular blockers is a problem: suc-cinylcholine should be avoided due the occurrence of hyperkalemia;non-depolarizingagents shouldbeavoided, especially in cases of large muscular destruction, and whennecessary,itshouldbeusedunderstrictmonitoring.6
Because the procedure did not require muscle relax-ation,andairway managementoccurred without tracheal intubation,wedidnotuseneuromuscularblockers. Pharma-cologictreatmentofspasticityincludestheuseofbaclofen andtizanidinesystemically, botulinumtoxin, alcohol, and phenol locally, with the first two considered first-line treatment.8,13Theuseofbaclofentocontrolmusclespasms,
aswasthecasewiththispatient,isappropriatealthoughit candecreasemusclemass.6Venousthrombosisisarisk
fac-torinpatientswithexacerbatedMSafterspinalpunctureor usinghighdosesofcorticosteroids,andprophylactic treat-mentis indicated.10 Itwasnotthe case withour patient.
Thediseasehasperiodsof exacerbationandremissions at unpredictable intervals, and when only pregnant women are considered, more than half of relapses occur in the postpartum period, usually within the first 3 months.9,14
This risk is not related to the type of anesthetic tech-nique or parity.14 Some case reports have shown good
results withsubarachnoidblock for cesarean section with nosignsofMSexacerbation,eveninpatientsfollowedfor up to 12 months after the procedure.9,15,16 Others attest
that thewell performed epiduralblock is associatedwith minimal risk of postpartum exacerbation.10,17 There is no
consensusonthebesttechniqueforpregnantwomenwith MS.
Despitethelowlevelofevidence,therearesomestudies that supportthepreoperative use of anxiolytictocontrol emotional disturbances that cantrigger exacerbations,as wellastheadequatecontrolofpostoperativepain.6
Conclusion
Regionalorneuraxialanesthesiadoesnothaveabsolute con-traindicationforpatientswithMS,butlowerconcentrations of local anesthetics and care in handling them are par-ticularly important. These patients have a higher risk for autonomicdysfunction,andtheyshouldbestrictlyfollowed. Those with the disease at a more advanced stage areat increasedriskforperioperativedepression,hypoventilation, atelectasis,andsleepapnea.Theuseofdepolarizing neu-romuscularblockersshouldbeavoidedandnon-depolarizing agentsshouldbeusedundermonitoring.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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