- Autoimmune disease characterized by antibody-mediated demyelination in central nervous system, which leads to impaired nerve conduction. Peripheral nerves are not involved
- Combination of genetic and environmental factors
- Age of onset usually 20–40, but can be seen at any age
- Signs and symptoms related to site of CNS affected by demyelination
- Broad spectrum—relapses and remissions, or chronic and progressive
- Variety of triggers, such as stress and heat (fever)
- Many signs and symptoms are possible, but more commonly seen are visual symptoms from optic nerve involvement, skeletal muscle/spasms from spinal cord involvement, bowel/bladder dysfunction, lack of coordination, paresthesias, seizures, depression, autonomic disturbances in advanced disease. Lower extremities more frequently involved than upper extremities
- Diagnosis usually based on cerebrospinal fluid antibodies or magnetic resonance imaging
- MS patients can be treated with a wide variety of medications, some targeting the disease and some targeting specific symptoms:
- Treatment with corticosteroids, interferons (Avonex, Betaseron, Rebif), glatiramer (Copaxone), azathioprine (Imuran), mitoxantrone (Novantrone; cardiotoxic), natalizumab (Tysabri), cyclophosphamide (Cytoxan), and methotrexate
- Symptomatic treatment with baclofen (lioresal), tizanidine (Zanaflex) for muscle spasms, cholinergic medications for urinary symptoms, or antidepressants for mood disturbances
- Thorough history with careful attention to history of relapses, remissions, triggers, typical complaints, and symptoms during exacerbations
- Complete list of medications should be reviewed prior to induction to delineate any potential interactions with anesthetic medications
- Elicit steroid use and potential for adrenal suppression
- Preoperative neurologic exam with focus on visual symptoms as well as skeletal muscle weakness should be performed to establish a baseline
- Elective surgery should not be performed during periods of relapse
- Exacerbations during the perioperative period are possible due to surgical stress, regardless of anesthetic technique or medications
- Succinylcholine is best avoided due to possibility of increased potassium release
- Nondepolarizing NMB: both increased sensitivity and resistance have been described; judicious use with peripheral nerve stimulator is recommended
- Stress-dose steroids if indicated
- Increased temperature can precipitate symptoms, monitor body temperature; avoid hyperthermia
- Spinal anesthesia may increase risk of postoperative exacerbations, maybe because the demyelination makes the CNS more sensitive to LA neurotoxicity, but epidural and peripheral nerve block techniques appear safe
- No evidence that general anesthesia drugs, either injected or inhaled, exacerbate MS
- Autonomic dysfunction should be taken into consideration when monitoring hemodynamics and during fluid management
- Reassess neurologic status
- Look for evidence of relapses, and assess for presence of any potential triggers that may be present in the postoperative environment
- Exercise vigilance with respect to postoperative temperature control
- Communication with surgeon, neurologist, and primary care physician is essential
- Baclofen withdrawal can occur, especially if long-standing therapy, with neuropsychiatric symptoms (hallucinations, anxiety, tremor), and possibly seizures, or even muscle rigidity and hyperthermia resembling neuroleptic malignant syndrome
- Perform both a thorough history of disease progression and neurologic exam prior to surgery
- Spinal anesthesia may increase risk of postoperative exacerbations, but no evidence that general anesthesia, epidural, or PNB exacerbates MS
- Avoid hyperthermia
- Platelet aggregation is increased in MH
- Increased risk of ...
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