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Charles W. Lapp,
M.D.
Hunter-Hopkins Center, P.A.
10344 Park Road, Suite 300, Charlotte, NC 28210
Telephone (704) 543 9692
RECOMMENDATIONS
FOR PERSONS WITH CHRONIC FATIGUE SYNDROME
(OR FIBROMYALGIA) WHO ARE ANTICIPATING SURGERY
CFS
is a disorder characterized by severe debilitating fatigue, recurrent
flu-like symptoms, muscle pain, and neurocognitive dysfunction such as
difficulties with memory, concentration, comprehension, recall, calculation
and expression. A sleep disorder is not uncommon. All of these symptoms
are aggravated by even minimal physical exertion or emotional stress,
and relapses may occur spontaneously. Although mild immunological abnormalities
(T-cell activation, low natural killer cell function, dysglobulinemias,
and autoantibodies) are common in CFS, subjects are not immunocompromised
and are no more susceptible to opportunistic infections than the general
population. The disorder is not thought to be infectious, but it is not
recommended that the blood or harvested tissues of patients be used in
others.
Intracellular magnesium and potassium depletion has been reported in CFS.
For this reason, serum magnesium and potassium levels should be checked
pre-operatively and these minerals replenished if borderline or low. Intracellular
magnesium or potassium depletion could potentially lead to cardiac arrhythmias
under anesthesia.
Up to 97% of persons with CFS demonstrate vasovagal syncope (neurally
mediated hypotension) on tilt table testing, and a majority of these can
be shown to have low plasma volumes, low RBC mass, and venous pooling.
Syncope may be precipitated by cathecholamines (epinephrine), sympathomimetics
(isoproterenol), and vasodilators (nitric oxide, nitroglycerin, a-blockers,
and hypotensive agents). Care should be taken to hydrate patients prior
to surgery and to avoid drugs that stimulate neurogenic syncope or lower
blood pressure.
Allergic reactions are seen more commonly in persons with CFS than the
general population. For this reason, histamine-releasing anesthetic agents
(such as pentothal) and muscle relaxants (curare, Tracrium, and Mevacurium)
are best avoided if possible. Propofol, midazolam, and fentanyl are generally
well-tolerated. Most CFS patients are also extremely sensitive to sedative
medications -- including benzodiazepines, antihistamines, and psychotropics
-- which should be used sparingly and in small doses until the patient’s
response can be assessed.
Herbs and complementary and alternative therapies are frequently used
by persons with CFS and FM. Patients should inform the anesthesiologist
of any and all such
therapies, and they are advised to withhold such treatments for at least
a week prior to
surgery, if possible. Of most concern are garlic, gingko, and ginseng
(which increase bleeding by inhibiting platelet aggregation); ephedra
or ma huang (may cause hemodynamic instability, hypertension, tachycardia,
or arrhythmia), kava and valerian (increase sedation), St. John’s
Wort (multiple pharmacological interactions due to induction of Cytochrome
P450 enzymes), and Echinacea (allergic reactions and possible immunosuppression
with long term use). The American Society of Anesthesiologists recommends
that all herbal medications be discontinued 2-3 weeks before an elective
procedure. Stopping kava may trigger withdrawal, so this herbal (also
known as awa, kawa, and intoxicating pepper) should be tapered over 2-3
days.
Finally, HPGA Axis Suppression is almost universally present in persons
with CFS, but rarely suppresses cortisol production enough to be problematic.
Seriously ill patients might be screened, however, with a 24 hour urine
free cortisol level (spot or random specimens are usually normal) or Cortrosyn
stimulation test, and provided cortisol supplementation if warranted.
Those patients who are being supplemented with cortisol should have their
doses doubled or tripled before and after surgery. SUMMARY RECOMMENDATIONS
Insure that serum magnesium and potassium levels are adequate
Hydrate the patient prior to surgery
Use catecholamines, sympathomimetics, vasodilators, and hypotensive agents
with caution
Avoid histamine-releasing anesthetic and muscle-relaxing agents if possible
Use sedating drugs sparingly
Ask about herbs and supplements, and advise patients to taper off such
therapies at least one week before surgery
Consider cortisol supplementation in patients who are chronically on steroid
medications or who are seriously ill.
Relapses are not uncommon following major operative procedures, and healing
is said to be slow but there is no data to support this contention.
I hope that you have found these comments useful, and that they will serve
to reduce the risk of surgical procedures.
Yours
truly,
Charles W. Lapp, MD
Director, Hunter-Hopkins Center
Assistant Consulting Professor at Duke University Medical Center
Diplomate, American Board of Internal Medicine
Fellow, American Board of Pediatrics
American Board of Independent Medical Examiners
Rev
1/2005
BIBLIOGRAPHY
Bates DW, Buchwald D, et al., “Clinical laboratory findings in patients
with CFS,” 1995 Jan 9, Arch Int Med 155:97-103
Klimas NG, Salvato FR, et al., “Immunologic abnormalities in CFS,”
1990 Jun, J Clin Microbiol 28(6): 1403-1410
Caligiuri M, Murray C, Buchwald D, et al., “Phenotypic and functional
deficiency of natural killer cells in patients with CFS,” 1987 Nov
15, J Immunol.;139(10):3306-13
Cox IM, Campbell MJ, Dowson D, “Red blood cell magnesium and CFS,”
1991 Mar 30, Lancet 337: 757-760.
Burnet RB, Yeap BB, Chatterton BE, Gaffney RD, “Chronic fatigue
syndrome: is total body potassium important?” Med J Aust. 1996 Mar
18;164(6):384.
Bou-Houlaigah I et alia, “The relationship between neurally mediated
hypotension and the chronic fatigue syndrome,” JAMA 1995; 274:961-967
Streeten D & Bell DS, “Circulating blood volume in CFS,”
J of CFS 1998; 4(1):3-11
Kowal K, Schacterele RS, Schur PH, Komaroff AL, DuBuske LM, “Prevalence
of allergen-specific IgE among patients with chronic fatigue syndrome,”
Allergy Asthma Proc. 2002 Jan-Feb;23(1):35-39
Ang-Lee MK, Moss J, Yuan CS, “Herbal medications and perioperative
care,” 2001 Jul 11, JAMA 286(2):208-216
Demitrack MA, Dale JK, Straus SE et alia,”Evidence for impaired
activation of the hypothalamic-pituitary-adrenal axis in patients with
chronic fatigue syndrome,”
J Clin Endocrinol Metab. 1991 Dec;73(6):1224-34
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