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Anesthesia Warning

Procedures that require anesthesia, such as extraction of wisdom teeth, cataract surgery, or removal of an inflamed appendix or gallbladder are common enough in the general population to predict that you will likely have one or several procedures after contracting ME/CFS. Unlike the general population, patients with ME/CFS have a specific set of sensitivities that require modification of anesthetic drugs.

Avoid Histamine-Releasers

A study conducted by Fred Friedburg, Lucy Dechene, Maggie McKenzie and Robert Fontanetta in 2000 found that nearly 90% of long-term ME/CFS patients suffered from allergies. Histamines are part of the inflammatory immune response to infection, and are responsible for some of the weakness, exhaustion, and malaise experienced by normally healthy people when they become ill. As these are symptoms experienced by most ME/CFS patients, an increase in histamine levels will only make them feel worse. In fact, Lucy Dechene, Ph.D., has proposed that histamine overproduction can substantially contribute to the development of the ME/CFS’s most significant effects. (3)

Because so many ME/CFS patients not only have allergies, but are sensitive to histamine itself, anesthesiologist Patrick L. Glass, MD of Reno, Nevada recommends against histamine-releasers. This group includes sodium pentothal, which is a thiobarbituate. In fact, Dr. Glass cautions against any drug in the thiobarbituate family, as they are all histamine-releasers. (These can be identified by the inclusion of “thio” – Thiamylal, Thiobarbital – in the name.)

Patients should also avoid muscle relaxants in the Curare family, such as Curare, Tracrium, and Mevacurium, which are also potent histamine-releasers. (9)

These agents should be avoided:

  • Sodium pentothal
  • Thiamylal
  • Thiobarbital
  • Curare
  • Tracrium
  • Mevacurium
  • Atracurium
  • Morphine
  • Meperidine

Recommendations

For ME/CFS patients, Dr. Glass recommends Diprivan (propofol) as the induction agent, Versed (midazolam), fentanyl (a short-acting narcotic) and droperidol (an anti-nausea agent) during the anesthetic.

Avoid Epinephrine (Adrenaline) and Agents That Lower Blood Pressure

Epinephrine (adrenaline) is commonly added to anesthetics. As a vasoconstrictor, epinephrine serves to narrow blood vessels, which helps to maintain blood pressure and prevent excessive bleeding. Epinephrine also prolongs the effect of anesthesia, which means not as much needs to be used.

Epinephrine can produce anxiety and panic attacks in ME/CFS patients. (8) Patients who have had anesthesia with epinephrine have also reported sleeplessness, jitters, and anxiety.

Tilt table testing on ME/CFS patients has shown that a majority of long-term patients experience orthostatic intolerance. POTS (postural orthostatic tachycardia syndrome), black-outs, and feeling light-headed when standing can be caused or exacerbated by cathecholamines, sympathomimetics, and vasodilators (nitric oxide, nitroglycerin, alpha-blockers, and hypotensive agents).

These agents should be avoided:

  • isoproterenol
  • epinephrine
  • nitric oxide
  • nitric oxide
  • nitroglycerin
  • alpha-blockers and hypotensive agents

Avoid Hepatoxic Agents

Dr. Paul Cheney advises against any agent that might be harmful to the liver (hepatoxins). (4) ME/CFS patients are more sensitive to medications than the general population. Dr. Cheney has proposed that a combination of low blood volume and diastolic heart dysfunction hampers patients’ ability to remove drugs from the bloodstream. If a drug that is toxic to the liver is used, a patient with ME/CFS will not be able to clear the drug from the body efficiently. (6,7)

In addition to an inability to quickly remove toxins from the body, people with ME/CFS often have reactivated Epstein-Barr virus (EBV), which places a great deal of strain on the liver. An excess burden of hepatoxic drugs could potentially lead to inflammation of the liver (hepatitis).

These agents should be avoided:

  • Halothane
  • Enflurane
  • Isoflurane
  • Sevoflurane
  • Desflurane

Supplements and Herbs

Herbs and supplements are popular in the ME/CFS community. They are often seen as a milder form of treatment than pharmaceuticals. However, herbs and their formulations (tinctures, extracts) can contain chemicals which can interact with drugs using during surgery.

The American Society of Anesthesiologists recommends that all herbal supplements be discontinued two to three weeks prior to surgery.

Some of the supplements that may cause complications during surgery are:

  • John’s wort (Hypericum perforatum) interferes with metabolism of various drugs used during and after surgery
  • Garlic and ginkgo may worsen bleeding by inhibiting platelet formation
  • Ephedra may cause cardiovascular instability, hypertension, tachycardia, or arrhythmia
  • Ginseng may cause hypoglycemia.
  • Kava and valerian may increase the sedative effect of anesthetics
  • Vitamin E is a blood thinner, and should be discontinued three days prior to surgery

What You Should Do

When asked about allergies, patients with ME/CFS should mention sensitivity to epinephrine. This will become part of your medical record, and will be reported to the anesthesiologist.

Patients should hydrate prior to surgery and avoid drugs or supplements that lower blood pressure (vasodilators such as aspirin, nitroglycerin, vitamin E).

Dr. Cheney advises that because intracellular magnesium and potassium levels are often low in ME/CFS patients, anesthesia can cause cardiac arrhythmias. He recommends giving patients Potassium Chloride (10mEq) extended-release capsules, 1 tablet, twice daily, and magnesium sulphate 50% solution, 2cc. via intramuscular injection 24 hours prior to surgery. For local anesthesia, Dr. Cheney recommends using Lidocaine sparingly and without epinephrine.

Wearable Medical Alerts

If you are a patient who is prone to fainting, or have allergies and chemical sensitivities, it may be a good idea to wear a Medic Alert bracelet.

Medical professionals routinely look for a Medic Alert bracelet or necklace. If you arrive at a hospital unconscious, the hospital can call the phone number on your bracelet. Medic Alert will tell the hospital who your doctor is and how to reach them, plus anything critical in your medical history, including allergies and recommendations regarding anesthesia.

REFERENCES

  1. Friedberg, Fred et al. Symptom patterns in long-duration chronic fatigue syndrome. J Psychosom Res. 2000; 48: 59-68. http://www.ncbi.nlm.nih.gov/pubmed/10750631
  2. Friedberg, Fred, PhD. Characteristics of Long-Duration CFS. CFIDS Chronicle, Fall 2001.
  3. Duchene, Lucy. CFS: Influence of Histamine, Hormones and Electrolytes. CFIDS Chronicle, Summer 1993, pp 31-35.
  4. Advice for PWCs Anticipating Anesthesia or Surgery. http://drlapp.com/resources/advice-for-pwcs-anticipating-anesthesia-or-surgery/
  5. Kaplan, Melissa. Surgery, Anesthesia and CFS/FM/MCS.  http://www.anapsid.org/cnd/drugs/anesthesia.html#anes
  6. Peralta, Ruben, MD Halothane Hepatotoxicity. Medscape. http://emedicine.medscape.com/article/166232-overview
  7. Drug Record. NIH. http://livertox.nih.gov/Desflurane.htm
  8. van Zijderveld GA, Veltman DJ, van Dyck R, van Doornen LJ. Epinephrine-induced panic attacks and hyperventilation. J Psychiatr Res. 1999 Jan-Feb;33(1):73-8.
  9. Sally-Ann Ryder, Carl Waldmann. Anaphylaxis. Contin Educ Anaesth Crit Care Pain (2004) 4 (4): 111-113. doi: 10.1093/bjaceaccp/mkh035 http://ceaccp.oxfordjournals.org/content/4/4/111.full