Expert: Ronald Levy, M.D. - 5/27/2008

Question
QUESTION: Hello. I have two questions. I am wanting to get a deviated septum and fractured nose corrected. Problem is i am terrified of anesthesia and surgery. Recently I read about a deadly condition known as malignant hyperthermia. I felt a little less worried when I read it is very rare. However, when I read about the symptoms I became more concerned once again. I read that the muscles of the body become very rigid. I also read where MH positive individuals tend to be very suseptable to heat stroke.

This has me frightened because I have TERRIBLE problems with heat cramps. I had to give up tennis because my entire body cramped up during a tournament. I had to be brought to a hospital by ambulance and had to stay over night getting pumped with about 8 bags of IV fluid. The doctors were concerned because of excess potassium in my body and abnormal kidney and liver readings. Weeks later I tried to play tennis again and again got heat cramps and had to have an IV.

This makes me seem like I have traits that MH people also have. I read that when an MH episode happens, the persons body becomes "rigid". That sounds a whole lot like the full body cramp I got when I was playing tennis. I am very prone to cramping. Everything from my legs, stomach, and even my chin (when I yawn) cramp regularly. All the doctors have said is drink a lot of fluids but still I have problems and pretty much can't exercise outside for any extended period of time in the summer.

To my knowledge, no one in my family has ever had a severe reaction to anesthesia. I was under general anesthesia one time almost 20 years ago at the age of 19 and did fine as far as I remember. Howver, from what I have read, just because you did not have an MH reaction previously does not mean you are in the clear.

Given my circumstances, how realistic are my fears that I am MH positive? In your opinion, could my extreme heat cramping problems be a sign that I have MH?

My other question concerns breathing under anesthesia. If I am under during rhinoplasty surgery, I know that they will have a breathing tube in me (ugh, that scares me!). But is the tube just a precaution or will I literally stop breathing and be depending on a machine to keep me alive?

Thanks for your time. I am just so scared and the more I read the worse I feel.

ANSWER: Sometimes a little knowledge is dangerous. I think your risks of MH are extremely small. If you have had previous surgeries without MH then it is unlikely that it will suddenly appear, as it is a genetic trait that you either have or don't have. I have never heard of a correlation between MH and heat stroke and even if it does exist, it is probably a one-sided effect (i.e. people with history of MH may be susceptible to heat stroke but that does NOT mean people who have heat stroke are susceptible to MH). The cramping you get in the heat is more likely related to potassium and calcium levels. It is not the same as the rigidity we see in MH. MH is extremely rare. As for the breathing tube, the tube is in place to help you breathe and protect your airway during surgery. If you are pralyzed during the surgery (it can be done with and without paralysis), then you need to the tube to breathe (but it will NOT fall out during surgery). As soon as the surgery is over, the tube is removed.

While is important to be an informed consumer, not everything you read on the internet is accurate and complete. IF you have questions about anesthesia, ask your anesthesiologist. I am sure he/she will be happy to answer your questions.

Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston

---------- FOLLOW-UP ----------

QUESTION: I really appreciate the quick and thorough reply. Do you know if a patient is generally paralyzed during a rhinoplasty?

Also, in your experience have you ever come across patients with panic disorder who have extreme phobias to surgery and anesthesia? What advice could you offer such patients like myself in order to help them get from the point of scheduling surgery to the moment of the surgery without having a nervous breakdown. Rhinoplasty would help my breathing and boost my confidence a ton, but my panic is making me stuck. I just don't know how I am going to be able to get through the wait until surgery. Even worse, I don't know how I am going to avoid a major panic attack the night before and morning of surgery. If I can't eat or drink after midnight, then I assume I can't take valium or anything to calm me until I actually have the IV in me. That leaves a lot of hours where I will be a basket-case. For whatever reason, everything medical causes tremendous anxiety for me. I have fainted more than once when giving blood tests and even passed out from a shot once. For months I have delayed scheduling the surgery because I know the misery I am going to feel waiting for "D-day" in the operating room. If you have any tips to help I would be all ears.

Oh, and one more thing. What is your opinion on the safety of "in office" outpatient surgery. The surgeon I want to use is regarded as one of the better rhinoplasty surgeons in the country. However, he does the general anesthesia in his office. I don't know if he uses an anesthesiologist or a nurse anesthetist. First, is it safe to be at an office rather than a hospital for general anesthesia. Second, should I require an anesthesiologist or is a nurse anesthetist acting on their own acceptable and safe?

You really don't know how much it means to have these questions answered. If I were to go into this much detail with the surgeon, he would think that I was a hypochondraic and might refuse to do the surgery. I am not a hypochondriac, I am just scared and unfortunately have panic disorder which has made a situation that most people feel a bit of anxiety, into a huge mountain of fear for me.

Thanks again. I think this covers about all of my concerns so I will stop bugging you!

Glen

Answer
Paralysis for a rhinoplasty is really anesthesiologist choice. It is not required but it often makes the anesthesia easier to manage. There are many people like yourself who are scared to death of one or more parts of the process. I have had a patient cancel her own case (in the OR) because she was too afraid to have an IV placed! So you are not unusual. While it is true that you need to not eat or drink after midnight, that's true EXCEPT for medications with a sip of water. As for outpatient surgery, I don't recommend it for you if he doesn't use a dedicated anesthesiologist or CRNA. I say this not because I think it is unsafe but rather for your peace of mind that you will have a dedicated specialist looking after you. I would definitely tell your surgeon about your phobia and fears. You will not be the first and it may change how and where he does the procedure. If you can make it to the night before surgery, the pre-meds will make the process of the day much easier. Also, the meds they give you for anxiety also have an amnestic effect, so you likely won't even remember the day of surgery.

Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston