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Lederer D, Weigand MA, Larmann J. [Anesthesia in patients with acute porphyria]. Anaesthesist 2022; 71:321-330. [PMID: 35352131 DOI: 10.1007/s00101-022-01107-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/24/2022]
Abstract
Porphyrias are a group of rare, mostly inherited metabolic disorders of heme biosynthesis. Each type of porphyria results from a specific deficiency of one of the pathway enzymes, causing a characteristic accumulation and excretion of heme precursors. Diagnosis is confirmed by the biochemical detection of these porphyrins and the precursors in urine, feces and blood. Porphyrias can be classified into acute and non-acute forms. The clinical presentation is unspecific and includes acute neurovisceral and/or cutaneous symptoms. The latent phase can evolve into a potentially life-threatening acute crisis, which is often misdiagnosed. The four acute hepatic porphyrias are relevant for anesthesiologists as precipitating factors are commonly found in the perioperative setting. Safe anesthetic management in cases of known porphyria is possible by adherence to current recommendations. The immediate administration of heme arginate as specific treatment for acute attacks is decisive for the outcome.
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Affiliation(s)
- Dominique Lederer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Jan Larmann
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
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Abstract
Despite medical advances, the diagnosis and management of acute intermittent porphyria continues to be challenging. Acute pain is one of the most important clinical manifestations in acute intermittent porphyria, but management and pain assessment have been poorly studied in these patients. The lack of information and evidence based recommendations regarding these topics in the medical literature is certainly surprising. Furthermore, pain management is discussed based on extrapolating concepts adopted for other pain syndromes. An important arsenal of medications, including reportedly safe opioid and non-opioid analgesics, is available for use in this type of patient. In addition to conducting an extensive review of the current literature, the present article aims to show the general aspects of a disease that generates a challenge for the clinician, emphasizing what is related to pain as a cardinal symptom and to create awareness about the need for studies supporting the development of guidelines, based on evidence obtained from analgesic management in patients presenting with this disorder. A systematic assessment directed at understanding the physiopathological processes underlying acute pain combined with a stepwise approach to pain management with safe opioid and non-opioid drugs constitutes the fundamental basis for a successful pain management program in patients with acute intermittent porphyria.
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Saberi K, Salehi M, Rahmanian M, Bakhshandeh AR, Mahlabani M. Anesthetic implication of tricuspid valve replacement in a patient with acute intermittent porphyria. Ann Card Anaesth 2017; 19:367-71. [PMID: 27052088 PMCID: PMC4900341 DOI: 10.4103/0971-9784.179623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Facing a patient with acute intermittent porphyria (AIP), there is narrow safety margin which circumscribe all the therapeutic actions including choice of drugs. This would become even more complicated when it comes to a stressful and drug-dependent process like a cardiopulmonary bypass. According to author's researches, no specific AIP case of tricuspid valve (TV) replacement is reported recently. Furthermore, fast-track anesthesia was safely used in this 37-year-old male known the case of AIP, who was a candidate for TV replacement and removing the port catheter. The patient was extubated subsequently, only 3 h after entering the Intensive Care Unit.
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Affiliation(s)
- Kianoush Saberi
- Department of Anesthesiology, Imam Khomeini Medical and Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Naithani BK, Shah SB, Bhargava AK, Batra V. Anesthesia for hemicolectomy in a known porphyric with cecal malignancy. Saudi J Anaesth 2015; 9:82-5. [PMID: 25558204 PMCID: PMC4279355 DOI: 10.4103/1658-354x.146320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Intraoperative management of a known acute intermittent porphyria patient is a challenge requiring awareness of factors, which trigger an acute crisis, clinical features of a porphyric attack, knowledge of safe pharmacologic intervention, and preparedness for reintubation and ventilatory support. The classical signs of a porphyric crisis such as pain abdomen, vomiting and neuropsychiatric symptoms are masked under general anesthesia and can be confused with postoperative pain and vomiting and postoperative cognitive dysfunction, especially for intra-abdominal surgeries. Eternal vigilance for onset of an acute crisis is imperative. After a crisis of acute intermittent porphyria, residual paresis may persist for years in the absence of further attacks.
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Affiliation(s)
- B K Naithani
- Department of Anesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Shagun Bhatia Shah
- Department of Anesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - A K Bhargava
- Department of Anesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Vivek Batra
- Department of Anesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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Park EY, Kim YS, Lim KJ, Lee HK, Lee SK, Choi H, Kang MH. Severe neurologic manifestations in acute intermittent porphyria developed after spine surgery under general anesthesia: a case report. Korean J Anesthesiol 2014; 67:217-20. [PMID: 25302100 PMCID: PMC4188770 DOI: 10.4097/kjae.2014.67.3.217] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 08/07/2013] [Accepted: 08/22/2013] [Indexed: 11/21/2022] Open
Abstract
Porphyrias are inherited metabolic disorders resulting from a specific enzyme defect in the heme biosynthetic pathway. Porphyrias are induced by various precipitants. Clinical features include abdominal pain, neurologic manifestations, autonomic neuropathy, and mental disturbance. Diagnosis may be delayed because of variable symptoms that mimic other diseases and because of the rarity of of porphyrias. Although most patients with known porphyria can complete anesthesia and surgery safely, undiagnosed porphyric patients are in danger of porphyric crisis due to inadvertent exposure to precipitating drugs and environment. We report a case of a patient who experienced delayed emergence with neurological disturbance after general anesthesia, ultimately diagnosed as acute intermittent porphyria.
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Affiliation(s)
- Eun Young Park
- Department of Anesthesiology and Pain Medicine, Hallym University College of Medicine, Anyang, Korea
| | - Yi Seul Kim
- Department of Anesthesiology and Pain Medicine, Hallym University College of Medicine, Anyang, Korea
| | - Kyung-Jee Lim
- Department of Anesthesiology and Pain Medicine, Hallym University College of Medicine, Anyang, Korea
| | - Hye Kyoung Lee
- Department of Anesthesiology and Pain Medicine, Hallym University College of Medicine, Anyang, Korea
| | - Soo Kyung Lee
- Department of Anesthesiology and Pain Medicine, Hallym University College of Medicine, Anyang, Korea
| | - Hyun Choi
- Department of Anesthesiology and Pain Medicine, Hallym University College of Medicine, Anyang, Korea
| | - Mae-Hwa Kang
- Department of Anesthesiology and Pain Medicine, Hallym University College of Medicine, Anyang, Korea
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Kumar M, Bose S, Darlong V, Punj J. Congenital erythropoietic porphyria: anesthetic implications. J Anesth 2009; 23:569-71. [PMID: 19921367 DOI: 10.1007/s00540-009-0784-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 04/22/2009] [Indexed: 10/20/2022]
Abstract
Congenital erythropoietic porphyria is a rare error of heme metabolism. Derangement of heme metabolism leads to disfiguration, phototoxicity, and the precipitation of porphyric crises. This case report discusses the myriad perioperative considerations in a patient with congenital erythropoietic porphyria.
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Affiliation(s)
- Mritunjay Kumar
- Department of Anesthesiology and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Minoda Y, Yoshimine K, Higashi M, Nagata E, Ikeda K, Yoshimura N. Anesthetic management of a patient with variegate porphyria. J Anesth 1997; 11:307-308. [PMID: 28921072 DOI: 10.1007/bf02480750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/1997] [Accepted: 07/07/1997] [Indexed: 10/24/2022]
Affiliation(s)
- Yuko Minoda
- Department of Anesthesiology, Kagoshima City Hospital, 20-17 Kajiya-cho, 892, Kagoshima, Japan
| | - Kowa Yoshimine
- Department of Anesthesiology, Kagoshima City Hospital, 20-17 Kajiya-cho, 892, Kagoshima, Japan
| | - Mikiko Higashi
- Department of Anesthesiology, Kagoshima City Hospital, 20-17 Kajiya-cho, 892, Kagoshima, Japan
| | - Eturo Nagata
- Department of Anesthesiology, Kagoshima City Hospital, 20-17 Kajiya-cho, 892, Kagoshima, Japan
| | - Koji Ikeda
- Department of Anesthesiology, Kagoshima City Hospital, 20-17 Kajiya-cho, 892, Kagoshima, Japan
| | - Nozomu Yoshimura
- Department of Anesthesiology and Critical Care Medicine, Kagoshima University School of Medicine, 8-35-1 Sakuragaoka, 890, Kagoshima, Japan
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9
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Yamamori Y, Sumi M, Yamanaka M, Kosaka Y. Safety of isoflurane and epidural anesthesia in a patient with hereditary coproporphyria. J Anesth 1996; 10:80-2. [PMID: 23839560 DOI: 10.1007/bf02482076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/1995] [Accepted: 08/31/1995] [Indexed: 11/30/2022]
Affiliation(s)
- Y Yamamori
- Department of Anesthesiology, Shimane Medical University, 89-1 Enya, 693, Izumo, Japan
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