What you should know about anesthesia – it could save your life

WHAT YOU SHOULD KNOW ABOUT ANESTHESIA – IT COULD SAVE YOUR LIFE
Nancy Gould and Regis (Gigi) Park


INTRODUCTION
Surgery is a stressful experience. For a patient with mast cell disease, that stress is compounded by the possibility
of complications including anaphylaxis, cardiovascular collapse, increased bleeding and even death. Therefore,
general anesthesia is considered a high-risk procedure in patients with mast cell disease. It is critical that all
members of the patient’s operating team take proper precautions before, during, and after surgery to protect against
potentially life-threatening mast cell activation.
PLANNING FOR SURGERY SHOULD BEGIN AS SOON AS THE NEED FOR SURGERY ARISES
It is imperative that good communication is established between the patient, referring physician, surgeon,
anesthesiologist, nurses, and all others involved in the patient’s care before, during, and after surgery. The surgeon
must be aware of the patient’s mast cell disease and inform themselves of the measures necessary to keep the
patient as free of symptoms as possible. Additionally, the patient should contact the anesthesiologist assigned to
their care as soon as possible after surgery has been scheduled. Both regional and general anesthetics can cause life-
threatening complications. An experienced anesthesiologist is aware of medications known to cause mast cell
degranulation and medications that stabilize mast cells. If the patient is satisfied that their anesthesiologist fully
understands the importance of planning around the mast cell disease, it will go a long way toward calming the
patient, which in turn may reduce mast cell mediator release.

Symptoms should be as well-controlled as possible in the days prior to surgery. The patient should carefully avoid
known triggers of mast cell activity and should take their medications as prescribed. Those medications include H1
and H2 histamine receptor blockers such as Allegra (H1) and Zantac (H2). A mast cell stabilizer such as disodium
cromoglycate or ketotifen, and medications targeting other mast cell mediators should be taken regularly if they are
part of the patient’s normal drug regimen.
The patient’s complete medication list should be reviewed by the surgical team prior to surgery and any necessary
medication changes should be thoroughly discussed with the patient. For example, if the patient regularly takes a
medication in the family known as beta blockers for blood pressure or heart rate abnormality, a change to another
drug should be considered well before surgery is scheduled. Beta blockers are generally avoided in people with
mast cell disease undergoing surgery because they interfere with an important natural control of mast cell
activation. These drugs may also interfere with the use of epinephrine, which may be required if the patient has a
major release of mast cell mediators resulting in low blood pressure during surgery. Other drugs that may interfere
with control of blood pressure during surgery must be carefully reviewed by the patient’s physician before the
surgery.
It may be necessary to perform a “graded challenge” procedure in the hospital under the supervision of an allergist
and an anesthesiologist for certain medications if there is no history of exposure to that medication. This procedure
usually starts with scratching the skin with a small amount of medication followed by injection of increasing
amounts with careful monitoring after each injection. Resuscitation equipment and drugs including epinephrine
must be readily available during the procedure.
PRECAUTIONS TAKEN IN THE HOURS PRIOR TO SURGERY WILL HELP THE PATIENT GO
INTO SURGERY IN THE BEST POSSIBLE CONDITION

For pre-operative control of anxiety and the reduction of mast cell activity, drugs in the valium family (diazepam,
midazolam, lorazepam) are usually effective. Some procedures require the patient not to take anything by mouth
including medications after midnight of the night before the surgery. In this case, H1 and H2 blockers should be
administered intravenously prior to the surgery. The use of corticosteroids, such as prednisone, has also been
suggested although there is no evidence that the short-term use of steroids reduces the ability of mast cells to
release the chemicals contained in their granules. However, corticosteroids may reduce the extent of other
inflammatory reactions that result from mast cell activation.
A tube may be inserted into an artery and attached to a device allowing the anesthesiologist to vigilantly monitor
blood pressure without having to periodically inflate a blood pressure cuff. In addition, a tube is inserted into a vein
and securely taped in place, with intravenous (IV) fluids running to keep the patient well-hydrated in all surgeries
involving general anesthesia or conscious sedation. This tube will also make it possible to immediately administer
any emergency medications that may be needed.

In the operating room, the patient should not be allowed to become either too cold or over-heated. Warm blankets
should be used, and all IV fluids should be warmed before they are given. In addition, there should be a minimum
of noise and bustle around the patient prior to the administration of the anesthetic in order to reduce the possibility
of anxiety-triggered mast cell mediator release.
EMERGENCY SURGERY

An emergency situation may arise in which a person with mast cell disease requires immediate surgery. Wearing a
MedicAlert bracelet could be a life-saver if this happens. Inscriptions vary depending upon the patient’s specific
needs, but generally include the patient’s diagnosis and drug sensitivities. Emergency response team members can
access more detailed information 24 hours a day, 7 days a week from the MedicAlert organization by dialling the
toll-free number on the bracelet. MedicAlert is a non-profit organization serving patients world-wide. There are
nominal membership and annual fees with financial assistance available for those in need. For more information,
please visitor dial 888-633-4298 within the U.S. or 209-668-3333 from outside the U.S.
Alternatively, there are several companies that manufacture and inscribe medical identification jewellery. These
products are available on the internet and are also carried by some jewellery stores and pharmacies. It may be wise
to select jewellery which provides space for a miniature version of the patient’s medical history (often supplied by
the manufacturer as part of the cost) in addition to the inscription. Although these companies do not have a 24 hour
information center, they do not require membership or annual fees and may be preferable for some patients.
It may also be helpful for mast cell patients to carry with them at all times emergency information, written on their
physician’s letterhead, which contains a list of current medications and other instructions for treatment in the event
of severe symptoms.
DURING SURGERY

Constant attention from the anesthesiologist is required for the safety of a patient with mast cell disease during
surgery, as some of the early symptoms of mast cell mediator release such as flushing, hives, and early signs of
obstructed breathing can be masked by the surgical drapes covering much of the patient’s skin and by the use of an
airway tube during anesthesia.
Should anaphylaxis occur during surgery, the drug thought to be responsible should be discontinued immediately
and epinephrine should be administered. Airway support with 100% oxygen, IV replacement fluids to compensate
for dilated blood vessels, H1 and H2 antihistamines, bronchodilators, and corticosteroids may also be given.
Continuous IV epinephrine and other “vasopressor drugs” may be necessary to keep blood pressure from falling.
However, it is important to keep in mind that not all hypotensive episodes during surgery are due to mast cell
degranulation and anaphylaxis. A serum tryptase level obtained during the hypotensive episode and its comparison
with pre-surgery or “baseline” level may be helpful to determine whether the episode is due to mast cell
degranulation.
DRUGS

Records from prior surgeries should be examined and drugs tolerated in those procedures should be preferred if
possible. Prior to the administration of any drugs associated with surgery, it is important that an IV is running, that
epinephrine is available for immediate intramuscular (IM) or IV administration, and that emergency equipment is
easily accessible in case of an adverse reaction.
IV preparations without preservative should be used.
Drugs to avoid include ethanol, dextran, and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
and toradol (unless the patient is already successfully taking a drug in this family), polymyxin B, amphoteracin B,
quinine, dextromethorphan, α-adrenergic blockers, β-adrenergic blockers, and anticholinergic drugs as well as
drugs mentioned in specific categories below.
Local anesthetics – True allergic reactions to local anesthetics resulting from mast cell degranulation are thought
to be rare. Skin testing and graded challenge protocols have been published and may be administered by an allergist
prior to the surgery if questions arise regarding the safe use of a local anesthetic in a patient. If possible,
preservative-free local anesthetic should be used in these tests, as the preservative often present in local anesthetics
can cause a mast cell reaction. In general, local anesthetics in the “ester” group should be avoided. This group
includes procaine, chloroprocaine, tetracaine, and benzocaine. Anaphylactic reactions to local anesthetics in the
“amide” group are rare. This group includes lidocaine, mepivacaine, prilocaine, bupivacaine, levobupivacaine, and
ropivacaine.
Muscle relaxants - Muscle relaxants are the most likely group of the anesthetic drugs to cause anaphylaxis.
Succinylcholine, D-tubocurarine, metocurine, doxacurium, atracurium, and mivacurium are more likely to cause a
severe reaction than rocuronium or the so-called nondepolarizing muscle relaxants such as pancuronium or
vercuronium. Some studies have reported increased numbers of anaphylactic reactions to rocuronium, however, so
it may not be appropriate as the first choice for patients with mast cell disease.
Induction drugs - These are medications given to initiate anesthesia. It is rare for mast cell activation to occur in
response to the use of propofol, ketamine, or the benzodiazepine drugs such as midazolam.
Inhaled anesthetics - Sevoflurane is an inhibitor of mast cell activation and is less likely to cause liver damage
than other inhaled anesthetics in this family.
Opiates and opioids - Oral opioid drugs for pain relief may be tolerated by some mast cell disease patients, but
their use should be approached with caution, beginning with very small doses. All drugs in this category are
capable of causing mast cell mediator release.

SUMMARY
Surgery for a person with mast cell disease involves exposure to drugs and conditions that may trigger extensive
mast cell degranulation. It should be emphasized that it is often impossible to predict or avoid the risk of adverse
events which may occur in surgery due to the administration of drugs and the procedure itself. The risk can be
reduced, though, if the mast cell disease is brought to the attention of everyone involved in the patient’s care and
measures are taken to reduce the possibility of mast cell mediator release. Careful planning is important, beginning
from the time a need for surgery has been defined and continuing through the immediate pre-operative period,
anesthesia, surgery, and recovery. The choice of drugs is of major importance, and the anesthesiologist, the
surgeon, the nursing staff, the patient’s physician, and the patient should form a working team to ensure that
surgery presents the fewest possible dangers for the patient.
Neither The Mastocytosis Society nor the authors intend that this information replace medical advice
given by the patient’s doctor. Patients are encouraged to consult with their doctor regarding medications
and procedures related to surgery.
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The authors wish to thank Cem Akin MD, PhD, for his review of this article.

Source: http://www.tmsforacure.org/media/gouldn_anesthesia.pdf