Periodic Paralysis and Anesthesia
Article and Compilation
Hypokalemic Periodic Paralysis and Anesthesia
According to the National Journal of Maxillofacial Surgery, “pre-operative stress along with necessary fasting and administration of dextrose containing fluids” precipitates attacks. “The guidelines for care include control of plasma potassium, avoidance of large glucose and salt loads, maintenance of body temperature, acid-base balance, and careful use of neuromuscular blocking agents. Good pre-medication to allay anxiety, avoidance of stress and adequate analgesia is vital in preventing an attack. Fluctuations in electrolytes, infection, and pain can lead to paralysis in the post-operative period. Hypokalemia manifests earlier than paralysis and so its correction can prevent paralysis. Dextrose containing solutions administered during surgery should be avoided...” 6, 7, 8
This information was found in Miller’s Anesthesia written by Ronald D. Miller:
”Management of HypoPP patients should focus on avoiding triggers and medications causing shift of potassium. General anesthesia, postoperative stress, glucose-containing intravenous solutions, and long-acting neuromuscular blockers are associated with postoperative paralytic events.138 Epidural analgesia has been shown to reduce both pain-related hyperventilation and serum catecholamines, thereby minimizing changes in serum potassium levels.138” 4
Nothing was written about the use of anesthesia and Hyperkalemic Periodic Paralysis before 2002. Early research concluded that anesthesia might be used without complications if the potassium levels were with-in normal levels prior to surgery, if the carbohydrate levels were up, if anesthetic drugs, which released potassium, were not used and if normal body temperature levels were maintained.
”Potassium, cholinesterase inhibitors, and depolarizing muscle relaxants will aggravate the myotonia in HyperPP patients.65 Prolonged muscle weaken ss has been reported when succinylcholine is used.141 Although one third of patients had no signs of myotonia,142 masseter spasm and respiratory and skeletal muscles stiffness could still occur during intubation and ventilation.65 Therefore, neostigmine and succinylcholine should be contraindicated in HyperPP patients. Ideally, all patients with HyperPP need to be admitted preoperatively so that proper preoperative fasting can be accompanied by the administration of dextrose-containing potassium-free maintenance fluid.143 Postoperatively, HyperPP patients may remain paralyzed for up to several hours. Preventive measures such as maintaining normal body temperature and low serum potassium levels and avoiding hypoglycemia are helpful in limiting such paralysis.144 Although patients with sodium channel pathology have often been considered to be susceptible to MH, (Malignant Hyperthermia) there is no increased risk for MH in these patients.145 General anesthesia with and without nondepolarizing muscle relaxants has been shown to have satisfactory outcomes.141,143,144,146 Regional techniques may also be appropriate for this patient group.142,146 Abortion of the hyperkalemic attack may be accomplished by administering glucose, insulin, epinephrine, and calcium supplements, or alternatively, glucagon may be used. β-Adrenergic treatment with metaproterenol has also been shown to prevent attacks and facilitate recovery.” 4,9,10,11
Malignant Hyperthermia (MH)
General Anesthestic considerations for patients with LQTS Management
Topical, regional and local anesthesia may cause potassium to drop in individuals with Hypokalemic Periodic Paralysis, Normokalemic Periodic Paralysis or Andersen-Tawil Syndrome if it contains epinephrine. The most often discussed and utilized local anesthesia is lidocaine. For some individuals it may work well if the epinephrine is removed. For others it may cause hypokalemia or arrhythmia regardless of the epinephrine being removed. For others still, it may not work at all or the usual amount may be needed during a procedure. Lidocaine and other local types of anesthesia need to be used with extreme caution.4
”The anesthetic management of patients with periodic paralysis first involves knowing the patient's history and their particular disease characteristics. The concurrent diseases must be ruled out (such as Andersen's disease). The primary goal of the anesthetic is to avoid events (perioperatively) that are known to precipitate muscle weakness. Electrolytes should be normalized, hypothermia should be avoided and frequent monitoring of the serum potassium level is indicated. The ECG should be constantly monitored for signs of arrthymias. These patients can be considered at risk of MH, thus avoidance of MH triggers is indicated. Use of nondepolarizing muscle relaxants is thought to be acceptable, although abnormal sensitivity to these agents may be encountered and adequate muscle strength must be assured prior to extubation.” 20
References and Links
Hypokalemic Periodic Paralysis
Other medicines used during general surgery are called depolarizing agents (such as Succinylcholine). These medicines act by blocking the signal from the nerve (Acetylcholine) from reaching it's receptor on the muscle. This causes temporary paralysis in patients during surgery, relaxing the muscles to make surgery easier. In patients with ion channel disorders, such as periodic paralysis, this can result in prolonged paralysis...
..After surgery, patients with periodic paralysis have found they woke up in the recovery room and couldn't move; they may not get full strength back for hours or days. The exact cause of the prolonged paralysis with anesthesia in some people with periodic paralysis isn't known. It could be the stress of the surgery and/or any of the anesthetic drugs. It is critical for the medical team to distinguish between a periodic paralysis attack and a malignant hyperthermia reaction as the treatments are completely different.
Added February 25, 2017