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Table of Contents
LETTERS TO EDITOR
Year : 2017  |  Volume : 33  |  Issue : 2  |  Page : 279-280

Use of desflurane in a multiple sclerosis patient undergoing ophthalmic surgery: Discussing the individualized care


Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication7-Jul-2017

Correspondence Address:
Sameer Sethi
Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.168200

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How to cite this article:
Gandhi K, Sethi S. Use of desflurane in a multiple sclerosis patient undergoing ophthalmic surgery: Discussing the individualized care. J Anaesthesiol Clin Pharmacol 2017;33:279-80

How to cite this URL:
Gandhi K, Sethi S. Use of desflurane in a multiple sclerosis patient undergoing ophthalmic surgery: Discussing the individualized care. J Anaesthesiol Clin Pharmacol [serial online] 2017 [cited 2019 Aug 24];33:279-80. Available from: http://www.joacp.org/text.asp?2017/33/2/279/168200

Sir,

Multiple sclerosis (MS) represents a constellation of symptoms due to chronic inflammation and demyelination of the brain and spinal cord. These symptoms exacerbate, remit, or progress.[1] Cognitive impairment is common in all courses of MS and is associated with increased interleukin-6 (IL-6) levels.[2] Surgery, anesthesia, pain, and fever/inflammation have been implicated for acute exacerbations.[1]

A 39-year-old Asian female (weight 60 kg), case of relapsing MS for past 14 years presented with rhegmatogenous retinal detachment and vitritis (since 10 days) along with ipsilateral eye cataract. She was planned for phacoemulsification followed by pars plana vitrectomy, scleral buckling and internal tamponade in single sitting. Her other eye had no vision. She suffered multiple relapses and had received interferon, glatiramer. Last relapse was 2 months back for which she received methylprednisolone and baclofen. Currently, she was in incomplete remission and was wheelchair bound. Respiratory and autonomic system examination and laboratory investigations were normal. She was on oral prednisolone 60 mg OD.

General anesthesia with controlled ventilation was chosen due to expected long surgical time. Hydrocortisone 100 mg was given preinduction. Continuous cardiorespiratory monitoring, neuromuscular transmission, and temperature monitoring were initiated. After preoxygenation and preloading, anesthesia was induced with propofol (2 mg/kg) and fentanyl (1.5 μg/kg). Single dose atracurium 20 mg was sufficient for facilitating smooth tracheal intubation and muscle relaxation during entire surgery (3 h). Anesthesia was maintained with 5-6% desflurane in oxygen-nitrous oxide. Intraoperative course and extubation were uneventful. Paracetamol was administered for postoperative analgesia round the clock for a day. Elastic compression stockings were advised in the immediate postoperative period. Intraoperative findings confirmed presence of retinal vasculitis, hence oral and topical steroids were continued in the postoperative period. No exacerbation of MS symptoms occurred in 2 months follow-up.

Perioperative care in MS patients poses challenges because of variable neurological involvement, concurrent long-term immunosuppression treatment, and risk of disease exacerbation. The effects of different anesthetics and anesthesia regimen in terms of rapid awakening with intact cognitive domain and protective immunomodulation have been studied.[3],[4] We used propofol as induction agent that has neuronal protective effect and antioxidant action.[5] Rapid recovery, the benefit of propofol could be jeopardized following prolonged or high-dose infusion.

High levels of IL-6 (cytokine) were correlated with low Mini-mental State Examination scores in MS patients representing impaired cognitive domain.[2] Desflurane is known for rapid recovery and is associated with lesser rise in IL-6 levels.[3] We hypothesized that acute increase in the levels of inflammatory mediators like IL-6 is a possible common factor among all causes of acute exacerbations; hence, desflurane may offer added advantage in presence of appropriate management of other risk factors.

In conclusion, this case underlines the safety of general anesthesia with desflurane in MS patients and warrants carefully individualized perioperative management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Harser SL, Goodin DS. Multiple sclerosis and demyelinating diseases. Harrison's Principles of Internal Medicine. 17th ed., Vol. 2. New York, London: McGraw Hill Medical; 2008. p. 2611-20.  Back to cited text no. 1
    
2.
Patanella AK, Zinno M, Quaranta D, Nociti V, Frisullo G, Gainotti G, et al. Correlations between peripheral blood mononuclear cell production of BDNF, TNF-alpha, IL-6, IL-10 and cognitive performances in multiple sclerosis patients. J Neurosci Res 2010;88:1106-12.  Back to cited text no. 2
    
3.
Baki ED, Aldemir M, Kokulu S, Koca HB, Ela Y, Sivaci RG, et al. Comparison of the effects of desflurane and propofol anesthesia on the inflammatory response and s100ß protein during coronary artery bypass grafting. Inflammation 2013;36:1327-33.  Back to cited text no. 3
    
4.
Shen X, Dong Y, Xu Z, Wang H, Miao C, Soriano SG, et al. Selective anesthesia-induced neuroinflammation in developing mouse brain and cognitive impairment. Anesthesiology 2013;118:502-15.  Back to cited text no. 4
    
5.
Ergün R, Akdemir G, Sen S, Tasçi A, Ergüngör F. Neuroprotective effects of propofol following global cerebral ischemia in rats. Neurosurg Rev 2002;25:95-8.  Back to cited text no. 5
    




 

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