Anesthetic Management of a Patient With Multiple Sclerosis

Abstract

A 54-year-old woman diagnosed with multiple sclerosis (MS) at the age of 19 years was scheduled to undergo temporomandibular joint mobilization. She was currently in a remission phase from her MS but with persistent sequelae, including impaired eyesight and muscle weakness of the limbs. In addition, the blood vessels in her upper limbs were compromised by the formation of internal shunts secondary to vascular prosthesis replacements for plasma exchange therapy in MS. After a previous joint mobilization surgery, her temporomandibular joint developed adhesions with resultant trismus. One of the adverse effects of general anesthesia can be exacerbations of MS symptoms. Minimizing mental and physical stress caused by surgical and anesthetic procedures and maintenance of stable body temperature are important considerations. Awake intubation was performed under sedation with midazolam and fentanyl. After intubation, anesthesia was induced with propofol, remifentanil, and rocuronium. Maintenance of anesthesia was achieved with oxygen-N 2 O-sevoflurane, remifentanil, fentanyl, and rocuronium. In this case, no adverse events occurred intraoperatively. However, the patient experienced lingering weakness of the limbs in the postoperative period, and activities of daily living of the patient were affected.Key Words: Multiple sclerosis; Demyelinating encephalomyelitis; Trismus.M ultiple sclerosis (MS) is a demyelinating disease of the central nervous system characterized by varying initial symptoms such as visual impairment, bowel/bladder dysfunction, trigeminal neuralgia, cognitive problems, gait disorder, and motor paralysis. We report a case of a patient with MS who underwent temporomandibular joint (TMJ) mobilization under general anesthesia. CASE REPORTA 54-year-old woman (height, 155 cm; weight, 45 kg) with MS was scheduled for TMJ mobilization under general anesthesia. The patient was diagnosed with MS at the age of 19 years, and reportedly was in remission since the age of 35 years, after multiple episodes of remissions and exacerbations. The MS was treated mainly with steroidpulse, immunoglobulin, and plasma exchange therapy. Although the MS was in a remission phase, she had persisting after-effects, including impaired eyesight due to steroid-induced glaucoma and cataract, and muscle weakness of limbs. She used to walk with the help of a cane, but her activities of daily living had since decreased. In addition, the blood vessels of both upper extremities and the left lower extremity were compromised as a result of formation of internal shunts secondary to vascular prosthesis replacement for plasma exchange therapy and steroid pulse therapy. Her arms and legs appeared edematous. Other medical history included gastroesophageal reflux and history of hypotension. The gastroesophageal reflux was treated with sulpiride (a dopamine antagonist antipsychotic), lansoprazole (a proton pump inhibitor), mosapride citrate (a 5-HT 4 gastroprokinetic), and polaprezinc (a mucosal protective agent), and hypotension was treated with a...

Effectiveness of intravenous sedation for oral surgery in a patient with multiple sclerosis and a past history of posterior reversible encephalopathy syndrome: A case report

“…Additionally, general anesthesia should be avoided as much as possible because it is known to exacerbate MS symptoms. 9 The factors for exacerbation of MS include stress crises following anesthesia and surgery, physical trauma, infections, and hyperthermia. Stress and infections overlap with what should be noted in the perioperative management of PRES.…”

“…Fourth, more consideration should be given to manage MS besides PRES in these cases. Additionally, general anesthesia should be avoided as much as possible because it is known to exacerbate MS symptoms 9 . The factors for exacerbation of MS include stress crises following anesthesia and surgery, physical trauma, infections, and hyperthermia.…”

The Use of Rocuronium and Sugammadex on a Patient with Multiple Sclerosis

“…4 The disease predominantly affects women between 10-60 years old and is most commonly seen between 20-40 years old. 5 This patient has been diagnosed with MS at the age of 19, occasionally has had attacks for 12 years and receives interferon-1a treatment. The literature on the most optimal general anesthesia method in MS is generally limited to the case reports.…”

“…It is reported that general anesthesia and surgical stress may cause exacerbation of MS as well as cases in which no attack is observed in postoperative follow-up. 3,5,6 One of the points to be considered in MS patients is to maintain the body temperature in a stable manner. It is known that the increase in the body temperature causes transmission block in demyelinated axons.…”

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“…A previous study showed that propofol hemisuccinate could suppress autoimmune encephalomyelitis, suggesting its curative effect on acute exacerbations of multiple sclerosis ( Vansant et al, 2009 ). Some case reports also indicated that propofol had certain effects on the treatment of multiple sclerosis ( Ohshita et al, 2017 ). However, the underlying mechanisms are poorly investigated.…”