Recommendations For Persons With Myalgic Encephalomyelitis/Chronic Fatigue

Syndrome (ME/CFS) Who Are Anticipating Surgery or Anesthesia

Charles W. Lapp, MD

BACKGROUND ON ME/CFS
ME/CFS is a disorder characterized by significant impairment in function 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 or mental
exertion or emotional stress. Relapses may occur spontaneously. ME/CFS patients can also
experience light, sound, chemical, and food sensitivities, which 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.

GENERAL CONSIDERATIONS FOR SURGERY OR ANESTHESIA IN PEOPLE WITH ME/CFS

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 catecholamines
(epinephrine), sympathomimetics (isoproterenol), and vasodilators (nitric oxide, nitroglycerin,
α-blockers, and hypotensive agents). Care should be taken to hydrate patients prior to and after
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 Mivacurium) 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.
Herbs and complementary and alternative therapies are frequently used by persons with
ME/CFS. 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,

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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). 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.
Finally, Hypothalamic-Pituitary-Gonadal 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.
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.
People with ME/CFS often have comorbidities such as fibromyalgia, postural orthostatic
tachycardia syndrome, mast cell activation syndrome, and joint hyperextensibility. If the patient
has one or more of these comorbidities, surgery and anesthesia guidelines for those conditions
should also be considered.
Relapses are not uncommon following major operative procedures, and healing is said to be
slow but there is no data to support this contention.
For recommendations tailored to children and adolescents, see the 2017 pediatric primer by
Rowe et al.
SUMMARY RECOMMENDATIONS
● Insure that serum magnesium and potassium levels are adequate
● Hydrate the patient prior to and after surgery
● Use catecholamines, sympathomimetics, vasodilators, and hypotensive agents with
caution
● Avoid histamine-releasing anesthetic and muscle-relaxing agents if possible
Use sedating drugs sparingly
● Ask about herbs and supplements, and advise patients to taper off such therapies at
least one week before surgery
● Consider cortisol supplementation in patients who are chronically on steroid
medications or who are seriously ill.

ABOUT THE AUTHOR

Charles W. Lapp, MD
Medical Director, Hunter-Hopkins Center, Charlotte, North Carolina
Former Assistant Consulting Professor at Duke University Medical Center

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Diplomate, American Board of Internal Medicine
Diplomate, American Academy of Pediatrics
Fellow, American Academy of Disability Evaluating Physicians

With the assistance of Mary Dimmick

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