Neuroanaesthesia02 / 14
Multiple sclerosis on fingolimod for laparoscopic hysterectomy34-year-old woman, 62 kg, for elective laparoscopic hysterectomy for fibroids
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Know this first
- Fingolimod's side effects include bradycardia.
- A temperature rise of as little as 1 °C can worsen MS symptoms.
- Neuraxial blocks have a safe record in MS; use the smallest intrathecal dose.
- With motor weakness, avoid suxamethonium: exaggerated potassium release.
- No steroid supplement unless she takes more than 5 mg of prednisone a day.
The patient
34-year-old woman, 62 kg, for elective laparoscopic hysterectomy for fibroids.
Relapsing-remitting multiple sclerosis for 8 years: mild left leg weakness and urinary urgency; last relapse 14 months ago, treated with IV methylprednisolone.
Drugs: fingolimod; no regular steroids.
Vitals: BP 116/70, HR 56, SpO2 99%, RR 12, temperature 36.6 °C.
The examiner asks
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Consider
What are the key issues?
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- A 34-year-old with relapsing MS and a mild leg deficit, for elective laparoscopic hysterectomy. Patient
- I document her baseline now: left leg weakness and bladder urgency, so new deficits stand out. Disease
- Fingolimod slows the heart; her resting rate is already 56.
- Fever, infection and stress can trigger relapse; a 1 °C rise can worsen her symptoms. Stem trigger
- I warn her that surgery may be followed by a relapse, however smooth the anaesthetic. Disease
Prepare
What will you check and discuss beforehand?
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- Baseline ECG for her slow rate on fingolimod; atropine drawn up. Disease
- Fingolimod blunts immunity, so I look for any infection before this elective case.
- She takes no daily steroid, so she needs no steroid supplement.
- If she asks about a spinal: it's been used safely in MS, with a minimal intrathecal dose.
- Temperature probe and warming, aiming for normothermia and no overheating. Stem trigger
Plan
What is your anaesthetic plan?
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- General anaesthesia with rocuronium; no suxamethonium with her leg weakness. Disease
- Relaxant dosed on a quantitative twitch monitor; her weak muscle may respond unpredictably.
- Normothermia throughout; any fever treated early with paracetamol 1 g IV. Stem trigger
- PONV prophylaxis: ondansetron 4 mg and dexamethasone 4–10 mg. After surgery
- After surgery, her legs and bladder are checked against the documented baseline.
Crisis
Two minutes after induction, before insufflation, BP is 80/45, HR 38, and she looks pale. What do you do?
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- Bradycardia algorithm: symptomatic bradycardia after induction, on top of fingolimod. Crisis
- Reversible causes first: check her oxygenation and depth, stop any vagal stimulus.
- Atropine 1 mg IV every 3–5 minutes, maximum 3 mg.
- No response: an infusion of adrenaline 2–10 mcg/min or dopamine 2–10 mcg/kg/min.
- Transcutaneous pacing is the alternative while transvenous pacing is arranged.
- The surgeon waits to insufflate until her rate and pressure recover. Surgery
Crisis
On day 3 she is febrile at 38.6 °C, with new weakness in both legs. What do you do?
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- Fever can block conduction in demyelinated nerves, so this may not be a true relapse. Crisis
- Cool her, give paracetamol, and hunt the source: urine, wound, chest.
- On fingolimod her infection risk is higher: cultures and early antibiotics.
- Compare her legs with the baseline I documented; neurology sees her today. After surgery
- Weakness lasting after the fever settles suggests relapse; steroids are the usual treatment.
Fatal mistakes
- Suxamethonium with her leg weakness.
- Leaving her fever untreated.
- No documented baseline deficit before surgery.
Checked against: Stoelting 8e · Barash 9e · Miller 10e · Faust
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