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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.57 no.3 Campinas May/June 2007
Subarachnoid anesthesia for cesarean section in a patient with multiple sclerosis. Case report*
Anestesia subaracnoidea para cesárea en paciente portadora de esclerosis múltiple. Relato de caso
Fabiano Timbó Barbosa, TSAI; Ronaldson Correia BernardoII; Rafael Martins da CunhaIII; Maria do Socorro Melo PedrosaIV
da Unidade de Emergência Armando Lages e do Hospital Escola Doutor José
Carneiro; Médico Intensivista da Clínica Santa Juliana; Especialista
em Docência para o Ensino Superior
IIAnestesiologista da Santa Casa de Misericórdia de Maceió
IIIProfessor de Farmacologia do Centro de Ensino Superior de Maceió; Professor Convidado de Farmacologia da Faculdade de Medicina da Universidade de Ciências da Saúde de Alagoas; Anestesiologista do Hospital Unimed Maceió
IVGinecologista Obstetra da Santa Casa de Misericórdia de Maceió
AND OBJECTIVES: Multiple sclerosis is an acquired disease characterized
by demyelinated areas in the brain and spinal cord. The clinical presentation
depends on the anatomical areas involved. The main causes of death are infection,
respiratory failure, and status epilepticus. It affects genetically predisposed
patients after contact with environmental factors, especially viruses. The objective
of this report was to present the anesthetic technique used in a patient with
multiple sclerosis undergoing cesarean section.
CASE REPORT: A 32-year old patient, 60 kg, with multiple sclerosis, treated with methylprednisolone, was admitted to the obstetric ward for a cesarean section. After monitoring, subarachnoid anesthesia was performed with 0.5% hyperbaric bupivacaine (12.5 mg) associated with morphine (0.1 mg). The procedure evolved without any intercurrences and the patient was discharged from the hospital 48 hours after delivery without worsening of her symptoms.
CONCLUSIONS: This case suggests that spinal anesthesia can be administered in patients with multiple sclerosis without the acute worsening of their symptoms in the postoperative period.
Key Words: ANESTHETIC TECHNIQUES, Regional: spinal block; DISEASES: multiple sclerosis.
Y OBJETIVOS: La esclerosis múltiple es una enfermedad adquirida que
se caracteriza por áreas desmielinizadas en el encéfalo y en la
médula espinal. El cuadro clínico depende de las áreas
anatómicas acometidas. Las principales causas de muerte son infección,
falencia respiratoria y estado de mal epiléptico. Ocurre en pacientes
genéticamente predispuestos después del contacto con factores
ambientales, principalmente los virus. El objetivo de este relato fue presentar
la técnica anestésica adoptada en paciente con esclerosis múltiple
sometida a cesárea.
RELATO DEL CASO: Paciente con 32 anos, 60 kg, portadora de esclerosis múltiple, tratada con metilprednisolona, entró en el centro obstétrico para realización de cesárea. Después de la monitorización se realizó anestesia subaracnoidea con bupivacaína a 0,5% hiperbara (12,5 mg) asociada a la morfina (0,1 mg). El procedimiento evolucionó sin interferencias y la paciente recibió su alta hospitalaria 48 horas después del parto sin empeoramiento de los síntomas preexistentes.
CONCLUSIONES: El presente caso nos sugiere que la anestesia raquidea puede ser administrada en paciente portador de esclerosis múltiple sin la incidencia obligatoria de exacerbaciones agudas de los síntomas en el período postoperatorio.
Multiple sclerosis (MS) is an acquired disease of the central nervous system characterized by inflammation and demyelination in the brain and spinal cord 1,2.
It is an autoimmune disease that seems to affect genetically susceptible patients after exposure to environmental factors 2-5, with a greater incidence in women 2,3.
The disease evolves with periods of exacerbations and remissions at unpredictable intervals 3,6,7 and, when only the pregnant patients are taking into consideration, more than half of the exacerbations happen after delivery 3,8, especially in the first three months 3.
The objective of this report was to present the anesthetic technique used in a patient with multiple sclerosis undergoing cesarean section.
A 32-year old patient, weighing 60 kg, diagnosed with multiple sclerosis 15 years before the surgery, was admitted to the obstetric ward for a cesarean section. She was taking oral methylprednisolone (15 mg) until the beginning of the pregnancy, when it was reduced to 5 mg by her physician. In the morning of the procedure, the patient took her regular dose of methylprednisolone.
Upon arriving at the delivery room, she was monitored with pulse oxymetry, cardioscope, and non-invasive blood pressure; venoclysis with an 18G catheter was done for administration of Ringer's lactate (10 mL.kg-1.h-1)
The patient was placed on the sitting position; thoracolumbar antisepsis was performed, followed by the manual identification of the space between the third and fourth lumbar vertebrae. Subarachnoid anesthesia was done with a 27G Whitacre needle through the medial access, with only one puncture, and the administration of 0.5% hyperbaric bupivacaine (12.5 mg) associated with morphine (0.1 mg).
The procedure developed without intercurrences, and hypotension was treated with titrated doses of metaraminol up to a total of 2 mg and increasing the infusion of the IV solution. After 45 minutes, at the end of the surgical procedure, the patient was transferred to the recovery room, where she remained under observation for three hours. She was discharged from the recovery room after regaining movements in the inferior limbs and was discharged from the hospital on the second postoperative day without clinical signs of exacerbation or signs of new symptoms.
Multiple sclerosis is an acquired disease of the central nervous system (CNS), autoimmune, characterized by inflammation and demyelination, which affects genetically predisposed individuals 1-3.
The incidence varies geographically 6,9. It has an incidence of 1:100,000 in equatorial regions, 6 to 14:100,000 in the south of Europe and in the United States, and from 30 to 80:100,000 in Canada, northern Europe and northern United States 6,9. Epidemiological studies have demonstrated that it is associated with a particular region, as well as with a particular ethnic group, which would indicate the importance of environmental factors in the genesis of the disease 6.
The real cause of MS is unknown 2; however, it is accepted that it is an autoimmune disease and that it would affect predisposed individuals after environmental exposure, especially after exposure to viruses 2,4.
The similarity between the virus and the myelin sheath would produce an immunological cross-reactivity 1. Self-reactive activated T cells would cross the blood-brain barrier, inducing an inflammatory process that would result in the activation of microglial cells and macrophages 4. The latter would cause structural lesions, blocking normal nervous conduction 4. At the beginning, the damaged myelin would be replaced by oligodendrocytes 1, but when those are destroyed, myelin is not replaced any more and the axons would be vulnerable to damaging factors, blocking neuronal transmission 1. The literature does not indicate which viral agent would be more frequently involved in the genesis of the disease.
The disease is characterized by episodes of exacerbation and remission of the clinical signs 1-3,6,7. Remission of the symptoms results in the temporary correction of the chemical and physiological disturbances that interfere with neuronal conduction in partially demyelinated areas 3. Recurrences or exacerbations are secondary to the development of new demyelinated areas 2,4. Residual symptoms eventually persist during the periods of remission 3. The association between fixed neurological deficits and new episodes of exacerbation increase the degree of deficiency of the patient 4.
Some factors have been implicated in the worsening of the disease, such as: emotional stress 6,8-11, surgeries 5,7-9, trauma 5,6,8,9, fever 2,5,8,10,11, postpartum 3,10, water and electrolyte imbalance 5, and infection 5,6,8-11. In the first three months after delivery, the incidence of recurrence is three times higher than in non-pregnant women 3,10. Even an increase of 0.5°C in body temperature is capable of reducing temporarily the neurological function 1,2.
General anesthesia 7,8 and anesthesia of the neuroaxis 7,11 have also been implicated as factors that can induce recurrences, although it is not widely accepted, being still a matter of controversy 1,4,6,12. Perlas and Chan 4 stated that although the postoperative and postpartum recurrences are controversial, they are not affected by the choice of the anesthetic technique.
Clinical manifestations depend on the anatomic area affected 1,2 and can include: reduced visual acuity 6,13, reduced response of the iris to light 13, diplopia 1,6,9, urinary incontinence 1,6,9,13, sexual impotence 13, changes in ambulation and balance 2,6,9, paralysis of the limbs 1, cardiac arrhythmias 1, and trigeminal neuralgia 1. The average time until death is 15 years 2 it and is usually secondary to the paralysis of the respiratory muscles, infection, and status epilepticus 12.
The diagnosis is clinical, but it can be confirmed by laboratory exams, such as study of the spinal fluid and MRI of the head. There is increased IgG in the spinal fluid and the MRI shows plaques that correspond to the demyelinated areas 1-3.
Multiple sclerosis is not curable 2,3. Its pharmacological treatment aims at modulating immunologic and inflammatory responses 1. The drugs used most often are immunosuppressants, interferon beta, glatiramir, and corticosteroids 1-3.
Interferon changes the inflammatory response and increases the natural mechanisms that suppress the disease 1. It reduces the frequency and severity of recurrences, slows down disease progression, and reduces the number and volume of new lesions observed on MRI 2. Glatiramir is a mixture of polypeptides that mimics the chemical structure of myelin, deceiving the antibodies 1-3.
Corticosteroids are the main agents used to treat acute exacerbations1,3. Methylprednisolone is the most efficient 2. These drugs restore the blood-brain barrier, decrease edema, and improve nerve conduction 3. Immunosupressants 9 and corticosteroids 3,5,6,9 used chronically should be continued perioperatively. There is no clinical evidence that support the prophylaxis of adrenal insufficiency with the use of corticosteroids in patients with MS 9.
The choice of anesthetic technique should be based on the risks and benefits for each patient 4. In this patient, the absence of contraindications to neuroaxis block, such as coagulopathies, systemic infection, increased intracranial pressure, and the preference of the patient, was considered. After it was explained to her the risks and benefits of each anesthetic technique used in pregnant women and the possibility that her symptoms might worsen postoperatively, she gave her consent for the spinal anesthesia.
The mechanisms by which subarachnoid anesthesia may precipitate the symptoms in the postoperative period are unknown 4. When it happens, symptoms are temporary and reversible, unless they coincide with the development of new demyelinated areas 4. There are no animal or laboratory studies showing that the severity and duration of the neuroaxis block are more intense and last longer in patients with MS than in normal individuals 4.
Epidural anesthesia can also be successfully administered to those patients 14. It has been considered the most innocuous technique 7 because the concentration of the local anesthetic in the white matter of the spinal cord is 3 to 4 times lower than with subarachnoid anesthesia 6,8,10,11. In a study undertaken at the Brigham and Women's Hospital between 1982 and 1987, bupivacaine at a concentration greater than 0.25% caused acute postoperative exacerbation in every patient who received epidural anesthesia 11.
The obstetric patient seems to be more resistant to late postoperative respiratory depression after the administration of hydrophilic opioids to the neuroaxis 15. This protective effect is due to the increased minute ventilation observed during pregnancy secondary to the direct stimulation of the respiratory centers and/or to the increased sensitivity to carbon dioxide caused by progesterone 15. Most cases of severe depression affect patients who received concomitant parenteral opioids or sedatives 16. The addition of opioids to the neuroaxis favors anesthesia in patients with MS 17. In the context of patients with MS, the side effects of morphine do not seem to be exacerbated 1,13.
General anesthesia can also be used in patients with MS, however it deserves some considerations. There are no restrictions to the use of intravenous and inhalational inducing agents 3,6,9, except for nitrous oxide because its inhibition of vitamin B12 and its connection with myelopathy represent contra-indications to its use in those patients 18. In the past, thiopental was implicated in the worsening of symptoms, but after several studies, its use has been liberated 6,9.
The postoperative increase in temperature is almost universal 13. Approximately 75% of patients with fever show worsening of neurological symptoms 6,9. In theory, anticholinergic drugs are contra-indicated 6, although the usual clinical doses do not worsen the symptoms 9.
Succinylcholine may cause severe hyperpotassemia in patients with MS 1,3,7,9. Therefore, it should be used cautiously. The duration of the effects of non-depolarizing neuromuscular blockers may be increased due to the need to block the receptors with extrajunctional proliferation 3. Its use in patients with respiratory difficulties carries the risk of prolonged postoperative mechanical ventilation 1.
The case presented here suggests that subarachnoid anesthesia may be administered to patients with multiple sclerosis without leading to acute exacerbation of the symptoms postoperatively.
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18. Watt JWH Anaesthesia for chronic spinal cord lesions and multiple sclerosis. Anaesthesia, 1998;53:825-826. [ Links ]
Dr. Fabiano Timbó Barbosa
Rua Comendador Palmeira, 113/202 Farol
57051-150 Maceió, AL
em 4 de maio de 2006
Accepted para publicação em 23 de fevereiro de 2007
* Received from Santa Casa de Misericórdia de Maceió-AL