Hunter-Hopkins Center, PLLC

Recommendations For Persons With Myalgic Encephalomyelitis /

Chronic Fatigue Syndrome (ME/CFS)  

Who Are Anticipating Surgery or Anesthesia

ME/CFS is a disorder characterized by significant impairment in functional ability accompanied by severe debilitating fatigue, post-exertional malaise, unrefreshing sleep, orthostatic intolerance, recurrent flu-like symptoms, muscle pain, and neurocognitive dysfunction such as difficulties with memory, concentration, comprehension, recall, calculation and expression. All of these symptoms are aggravated for hours, days, or longer following even minimal physical exertion or emotional stress. Relapses may occur spontaneously. ME/CFS patients can also experience light, sound, chemical, and food sensitivities that can trigger a worsening of their symptoms. Although mild immunological abnormalities (T-cell activation, low natural killer cell function, dysglobulinemias, and autoantibodies) are common in ME/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 ME/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 ME/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, (-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 ME/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 ME/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.

HPGA  Axis Suppression is almost universally present in persons with ME/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.

There is a close association of ME/CFS with joint hyperextensibility (“trick joints,” Ehlers-Danlos Syndrome) and Cranio-Cervical Instability (CCI). Symptoms of CCI include headache and suboccipital or neck pain (especially on neck extension), weakness / clumsiness, paresthesias and dysesthesias, gait changes, dizziness or vertigo, and (pre)syncope. Such patients may have a reduced sensitivity to local anesthetics.

Physical findings that suggest the diagnosis of CCI include limited range of motion in the neck, Lhermitte’s sign, hyperreflexia, disequilibrium on tandem stance, the absence of a gag reflex, and a positive Babinski reflex or Hoffman’s sign. Pre- and peri-operatively evaluate for joints that sublux and cranio-cervical instability. Avoid TM joint subluxation, neck extension, and over-extending joints. Take precautions against gastroparesis. Post-operatively maintain hydration and watch for obstructive apnea. Persons with hyperextensibility are at higher risk for coagulation disorders, occult bleeding, and post-dural puncture headaches.

Many persons with ME/CFS resort to dietary supplements and herbals that may interfere with anesthesia, perioperative medications, or recovery. 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). Vitrsmin E and turmeric may increase bleeding. 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.

If the patient is staying overnight in the hospital following surgery, let staff know about the patient’s sleep issues or sensitivities to light, sound, chemicals, food, or temperature so that nighttime disruption and exposure to sensory triggers can minimized where possible. Finally, consider providing intravenous saline to minimize the effects of low blood volume and venous pooling.

For recommendations tailored to children and adolescents, see Rowe et al.

SUMMARY RECOMMENDATIONS

• Insure that serum magnesium and potassium levels are adequate
• Hydrate the patient prior to surgery and post-operatively
• Use catecholamines, sympathomimetics, vasodilators, and hypotensive agents with caution
• Avoid histamine-releasing anesthetic and muscle-relaxing agents if possible. Use sedating drugs sparingly
• Consider cortisol supplementation in patients who are chronically on steroid medications or who are seriously ill.
• Joint hyperextensibility may be associated with apnea, TMJ subluxation, mast cell activation, reduced sensitivity to local anesthesia, gastroparesis, dysautonomia and POTS, and are at higher risk for coagulation disorders, occult bleeding, tracheomalacia, and post-puncture headaches.
• Inquire about herbs and supplements, and advise patients to taper off such therapies at least one week before surgery

Relapses are not uncommon following major operative procedures, and healing is said to be slow but there is no data to support this contention.

Charles W. Lapp, MD

Medical Director, Hunter-Hopkins Center, Charlotte, North Carolina
Former Assistant Consulting Professor at Duke University Medical Center
Diplomate, American Board of Internal Medicine
Diplomate, American Academy of Pediatrics

Fellow, American Academy of Disability Evaluating Physicians

With the assistance of Mary Dimmock.

BIBLIOGRAPHY

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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 al,”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

Rowe PC, Underhill RA, Friedman KJ, et al. “Myalgic encephalomyelitis/chronic fatigue syndrome diagnosis and management in young people: a primer.” Front Pediatr. 2017;5:121. doi:10.3389/fped.2017.00121

Cupp, MJ, 1999, : “Herbal remedies: adverse effects and drug interactions,” AFP 59(5): 1239-1244.