Anesthesia Recommendations for Chronic Fatigue Syndrome & Myalgic Encephalomyelitis
Having Chronic Fatigue Syndrome & Myalgic Encephalomyelitis (ME/CFS) does not exempt patients from other illnesses and conditions that may involve surgery. 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.
A study conducted by Fred Friedburg, Lucy Dechene, Maggie McKenzie and Robert Fontanetta in 2000 found that nearly 90% of long-term Chronic Fatigue Syndrome & Myalgic Encephalomyelitis patients suffered from allergies. (1, 2) 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.
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)
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.
Tilt table testing on Chronic Fatigue Syndrome & Myalgic Encephalomyelitis 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. All of these can be caused or exacerbated by cathecholamines (epinephrine), sympathomimetics (isoproterenol), and vasodilators (nitric oxide, nitroglycerin, alpha-blockers, and hypotensive agents).
Epinephrine can also produce panic attacks. (8) ME/CFS patients who have had anesthesia with epinephrine have reported sleeplessness, jitters, and anxiety.
Avoid Hepatoxic Agents
Dr. Paul Cheney advises against any agent that might be harmful to the liver (hepatoxins). (4)
Chronic Fatigue Syndrome & Myalgic Encephalomyelitis patients are more sensitive to medications than healthy people. 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.
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).
Halothane and other inhaled anesthetic agents, such as enflurane, isoflurane, sevoflurane, and desflurane are highly hepatoxic, even in the general population, and should be avoided by patients with ME/CFS. (6,7)
What You Should Do
When asked about allergies, patients with Chronic Fatigue Syndrome & Myalgic Encephalomyelitis 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 Micro-K (potassium) using 10 mEq tablets, 1 tablet, BID and magnesium sulphate 50% solution, 2cc. IM 24 hours prior to surgery. For local anesthesia, Dr. Cheney recommends using Lidocaine sparingly and without epinephrine.
In a Nutshell
- Hydrate before surgery to keep your blood volume up
- Inform your doctor and surgeon that you are sensitive to epinephrine
- Ask your surgeon not to use histamine-releasing agents
- Supplement with potassium and magnesium
- Stop taking vitamin E and other vasodilators three days prior to surgery
- Pass on the above recommendations to your doctor
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.
- 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
- Friedberg, Fred, PhD. Characteristics of Long-Duration CFS CFIDS Chronicle, Fall 2001. http://www.cfids.org/archives/2001rr/2001-rr4-article03.asp
- Duchene, Lucy. CFS: Influence of Histamine, Hormones and Electrolytes. CFIDS Chronicle, Summer 1993, pp 31-35.
- From Doctors, To Doctors and Anesthesiologists. http://www.squidoo.com/anesthesia-with-CFS
- Kaplan, Melissa. Surgery, Anesthesia and CFS/FM/MCS. http://www.anapsid.org/cnd/drugs/anesthesia.html#anes
- Peralta, Ruben, MD Halothane Hepatotoxicity. Medscape. http://emedicine.medscape.com/article/166232-overview
- Desflurane. Drug Record. NIH http://livertox.nih.gov/Desflurane.htm
- 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.