Positive malignant hyperthermia susceptibility in vitro test in a patient with mitochondrial myopathy and myoadenylate deaminase deficiency

Perioperative considerations of pyruvate dehydrogenase complex deficiency: a case report of two consecutive anesthesia

BACKGROUND

Pyruvate dehydrogenase complex (PDHC) deficiency is a rare mitochondrial disorder caused by a genetic mutation affecting the activity of the PDHC enzyme, which plays a major role in the tricarboxylic cycle. Few cases of surgery or anesthesia have been reported. Moreover, there is no recommended anesthetic method.

CASE

A 24-month-old child with a PDHC deficiency presented to the emergency room with respiratory failure, mental decline, systemic cyanosis, and lactic acidosis. During hospitalization period, the patient presented with pneumothorax, pneumoperitoneum, and multiple air pockets in the heart. Two surgeries were performed under general anesthesia using an inhalational anesthetic agent. The patient was discharged with home ventilation.

CONCLUSIONS

Anesthesiologists should be wary of multiple factors when administering anesthesia to patients with PDHC deficiency, including airway abnormalities, acid-base imbalance, intraoperative fluid management, selection of appropriate anesthetics, and monitoring of lactic acid levels.

General anesthesia with remimazolam for a pediatric patient with MELAS and recurrent epilepsy: a case report

Background

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a mitochondrial disease. We report here the safe use of remimazolam in a pediatric MELAS patient.

Case presentation

A 10-year-old girl (118 cm, 16 kg) was scheduled for an open gastrostomy to improve nutrition and epileptic seizure control. We induced and maintained general anesthesia with remimazolam, remifentanil, fentanyl, and rocuronium. We also performed a bilateral subcostal transversus abdominis plane block before the surgery. The surgery finished uneventfully. After we discontinued remimazolam administration, the patient woke up immediately but calmly without flumazenil. Epileptic seizures did not occur during intra- and early post-operative periods.

Conclusion

Remimazolam enabled us to provide a pediatric MELAS patient with general anesthesia without causing delayed emergence or epileptic seizures.

Perioperative Management of an Adult Patient With Myoclonic Epilepsy With Ragged Red Fibers Syndrome: A Case Report

Myoclonic epilepsy with ragged red fibers (MERRF) syndrome is a rare mitochondrial disease potentially associated with increased sensitivity to anesthesia and metabolic decompensation. We present the perioperative management in a 59-year-old man with MERRF scheduled for lipomatosis cure under general anesthesia (GA). Following a reduced fasting period, the patient had an uneventful balanced GA with propofol, sevoflurane, and rocuronium. The patient did not present metabolic decompensation nor malignant hyperthermia but prolonged neuromuscular blockade. Propofol and sevoflurane may be used in asymptomatic MERRF adult patients. Such patients present high risk of residual neuromuscular blockade that should be monitored and reversed.

Malignant Hyperthermia Susceptibility and Related Diseases

This review identifies disease states associated with malignant hyperthermia susceptibility based on genotypic and phenotypic findings, and a framework is established for clinicians to identify a potentially malignant hyperthermia–susceptible patient.

Anesthetic Management of a Child With Unspecified Mitochondrial Disease in an Outpatient Dental Setting

Mitochondrial disease (MD) represents a category of metabolic disorders with a wide range of symptoms across a variety of organ systems. It occurs with an incidence of greater than 1:5000 and can be difficult to specifically diagnose because of the variety of clinical presentations and multiple genomic origins. Although phenotypically variable, MD symptoms often include hypotonia, cardiac defects, dysautonomia, and metabolic dysfunction. Mitochondrial disease presents a unique challenge in terms of anesthetic management, as many anesthetic drugs suppress mitochondrial function. Additional considerations may need to be made in order to evaluate the patient's metabolic compensation prior to surgery. This article presents an in-depth discussion of a case involving a nearly 10-year-old boy with a history of an unspecified form of MD, who presented for endodontic treatment of tooth No. 30 under deep sedation. The article also provides a thorough review of the current literature surrounding the anesthetic management of patients with MD.

The Outcome of Cochlear Implantation for Mitochondrial Disease Patients With Syndromic Hearing Loss

OBJECTIVES

To evaluate the outcome and to confirm the validity of cochlear implantation for syndromic deafness in patients with mitochondrial disease.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

We reviewed medical charts of 367 cochlear implantation cases at Kyoto University Hospital between 1987 and 2012. We identified five patients with syndromic mitochondrial disease who underwent cochlear implantation surgery. The mean age of the patients (four women and one man) when they underwent surgeries was 44.4 years (range, 30-64 yr; median, 41 yr).

INTERVENTIONS

Therapeutic and rehabilitative.

MAIN OUTCOME MEASURE

In four of five patients, speech perception performance was measured using Japanese vowels, consonant-vowel syllables, and short sentences.

RESULTS

Only 1.4% (5 of 367) of cochlear implantation cases at Kyoto University Hospital underwent cochlear implantation surgery because of syndromic mitochondrial diseases. Four of those patients showed significantly improved speech perception outcomes, and the beneficial effects of the intervention continued long after surgery. One patient could not perform speech perception test presumably because of poor cognitive function.

CONCLUSION

Mitochondrial disease patients who underwent cochlear implantation surgery sustained gains in hearing performance even long after surgery. A single patient showed poor postoperative speech perception associated with cognitive problems. Cochlear implantation for mitochondrial disease patients seems to be a viable treatment option in the absence of significant cognitive impairment.

[Characteristics of anesthesia in patients with MELAS syndrome: Case report of anesthesia in video-assisted thoracoscopy]

The mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) syndrome is a disease triggered by a disorder in energy production within mitochondria. The cause of this syndrome is a mutation in the mitochondrial DNA where in 80% of cases an A-to-G mutation is present at nucleotide 3243 and with a prevalence of 18.4/100,000 in the population. Predominantly affected are organ systems with a high energy metabolism, such as the heart, brain and musculature. During the premedication visit a thorough patient history and examination with respect to neurological impairments must be carried out. Epilepsy and the appropriate permanent medication lead to possible alterations in effectiveness of anesthetics and muscle relaxants which are difficult to predict. An extensive patient cardiac history and a preoperative electrocardiogram (ECG) for an appraisal of possible disorders in the cardiac conduction system and when necessary extended cardiac diagnostics, are recommended. The monitoring must be adapted depending on the functional limitations and the forthcoming intervention and when necessary a postoperative surveillance in an intensive care unit should be initiated. Knowledge of the special features of MELAS syndrome in association with a consideration of the characteristics of anesthesia in MELAS patients and an individually adapted intensified perioperative surveillance, can contribute to a reduction in perioperative morbidity in patients suffering from MELAS syndrome.

General anesthesia for adults with mitochondrial myopathy

We report the case of a 59-year-old woman with mitochondrial myopathy who underwent elective laparoscopic cholecystectomy and hemorrhoidectomy, and we review the literature discussing general anesthesia for adults with mitochondrial myopathy. Our management technique avoids neuromuscular-blocking drugs and uses a modified awake intubation method not previously described in such patients. We hope to improve patient safety by discussing evidence-based anesthetic concerns and complications specific to these uncommon patients and aid practitioners in devising a suitable anesthetic plan.

The peripartum management of a patient with glutaric aciduria type 1

The management of cesarean delivery for a parturient with placenta previa at 36 weeks' gestation and glutaric aciduria type 1 is presented. The management goal was to prevent encephalopathic crisis by ensuring adequate caloric intake with dextrose infusion and to provide carnitine supplementation and adequate anesthesia.

Anesthetic considerations in mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome: a case series

PURPOSE

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome (MELAS) is a rare inherited mitochondrial disorder associated with severe multiorgan pathology and stress-induced episodes of metabolic decompensation and lactic acidosis. The purpose of this case series is to review the medical records of patients with MELAS who underwent anesthetic care at the Mayo Clinic to observe their perioperative responses to anesthesia and to assess outcomes.

PRINCIPAL FINDINGS

From September 1997 to October 2010, nine patients with MELAS were identified who underwent 20 general anesthetics, 12 prior to MELAS diagnosis. Debilitating neurologic symptoms involved eight patients, and three patients had substantial cardiac comorbidities. The patients tolerated commonly used anesthetics and muscle relaxants, including succinylcholine. Lactated Ringer's solution was used frequently. One patient was noted to have elevated postoperative serum lactate, but his serum lactate was chronically elevated. Metabolic acidosis was not observed in any patient. Hyponatremia and hyperkalemia, sometimes profound, were observed in seven patients, but these abnormalities also occurred at times remote from surgery. Two patients developed renal dysfunction following cardiac surgery and abdominal surgery for severe sepsis.

CONCLUSION

The MELAS patients developed episodes of hyponatremia and hyperkalemia of variable severity unrelated to the timing of surgery, suggesting these patients are prone to major electrolyte disturbances. Given the propensity to develop acid-base disturbances and lactacidemia, it is prudent to review and normalize electrolyte abnormalities and to adjust the anesthetic plan accordingly. Fortunately, the limited data suggest that patients with MELAS tolerate commonly used anesthetic drugs well.

Can inhalation agents be used in the presence of a child with myopathy?

PURPOSE OF REVIEW

Anaesthesia for a child with a muscle disease is always challenging because there is a risk of malignant hyperthermia, rhabdomyolysis or hypermetabolic reaction if a halogenated agent is used. Ongoing progress in genetics helps in clarifying the link between malignant hyperthermia (a calcium channelopathy) and muscle diseases.

RECENT FINDINGS

We provide a summary of the most recent clinical, pathophysiological and genetic information on those risks when the diagnosis is known or suspected preoperatively. Some simple clues are also given to help make a decision in the presence of an infant or child with hypotonia or motor delay but no diagnosis.

SUMMARY

Only a few muscle diseases are really associated with a risk of malignant hyperthermia. The risk of rhabdomyolysis is more difficult to clarify and a multicentric database would be useful to evaluate the risk/benefit ratio of all anaesthetic drugs in patients with muscle diseases.

Total intravenous anesthesia with propofol and remifentanil in a patient with MELAS syndrome -A case report-

A 23-year-old woman with MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes) underwent a laparoscopy-assisted appendectomy. MELAS syndrome is a multisystemic disease caused by mitochondrial dysfunction. General anesthesia has several potential hazards to patients with MELAS syndrome, such as malignant hyperthermia, hypothermia, and metabolic acidosis. In this case, anesthesia was performed with propofol, remifentanil TCI, and atracurium without any surgical or anesthetic complications. We discuss the anesthetic effects of MELAS syndrome.

Drug management in emergent liver transplantation of mitochondrial disorder carriers: review of the literature

BACKGROUND

Mitochondrial respiratory-chain disorders (MRCD) lead to progressive disabling of neurological and cellular conditions that involve muscles, brain, kidney, and liver dysfunction. Affected individuals may need surgery, including orthotopic liver transplantation (OLT). Surgery poses anesthesia challenges because of the prolonged use of anesthetic drugs and sedatives, which may inhibit oxidative phosphorylation, mimic mitochondrial cytopathic disorders, or unveil them ex novo.

MATERIALS AND METHODS

We conducted a multilingual PubMed search of surgical and non-surgical anesthesia reports between the years 1992 and 2008, where anesthetic drugs were used in MRCD patients, especially for those undergoing urgent OLTs.

RESULTS

There were 51 case reports of 210 anesthesia and critical care interventions in patients with MRCD, a large part of them were children. Data pertaining to the safe usage of anesthesia and perioperative drugs were limited and conflicting. We found no article that addressed the issue of perioperative handling of urgent OLT in MRCD patients. We therefore suggest our own - although limited - experience for such occasions.

CONCLUSION

There are no randomized, controlled, trial-based indications regarding safe anesthetic drugs to be used perioperatively in MRCD carriers. Consultation among geneticists, anesthesiologists, intensivists, and surgeons is essential in patients with known/suspected metabolic syndrome for planning appropriate perioperative care.

Malignant hyperthermia susceptibility in a patient with mitochondrial disorder

Occasionally, patients with mitochondrial disorder (MID) develop malignant hyperthermia (MH)-like reactions or show an abnormal halothane-caffeine in-vitro contracture test. In a 66 year old Caucasian male with facial dysmorphism, epilepsy, chronic muscle cramps, repeatedly elevated creatine-kinase, Dupuytren contracture, and hypertrophic cardiomyopathy, a MID was found upon the clinical presentation, blood chemical investigations, and the muscle biopsy findings. Upon request of the anesthesiologists prior to surgery of a hernia cicatrices a halothane-caffeine in-vitro contracture test was carried out according to the protocol of the European MH Group (EMHG), showing abnormal hypercontractility to halothane and caffeine, resulting in the diagnosis susceptible MH according to the EMHG guidelines. Subsequent general anesthesia was carried out without complications by avoiding volatile anesthetics and succinylcholine. In the past the patient had already tolerated four procedures under general anesthesia, without any complication. MIDs may be associated with an abnormal halothane-caffeine in-vitro contracture test. Though previous general anesthesias had been carried out without major complications, it cannot be ruled out that MH-like manifestations may develop during future anesthesias if trigger agents are not avoided.

The risk of malignant hyperthermia in children undergoing muscle biopsy for suspected neuromuscular disorder

BACKGROUND

It is assumed that those children with known or suspected neuromuscular disorders (NMD) are at increased risk for malignant hyperthermia (MH). Despite the lack of conclusive data, most of these children are managed with a nontriggering anesthetic. This study examined the risk of MH in children exposed to a triggering anesthetic while undergoing muscle biopsy for suspected NMD.

METHODS

Between 1992 and 2005, the medical records of 351 children under 21 years of age were identified as having undergone muscle biopsy for suspected NMD. Of these, only 274 received a volatile anesthetic agent or succinylcholine and were included for study. Records were examined for evidence of MH or rhabdomyolysis.

RESULTS

No patient exhibited signs or symptoms suggestive of MH. One patient was found, by muscle biopsy, to have evidence of rhabdomyolysis prior to exposure to a volatile anesthetic. Of 274 patients, only three received succinylcholine. None developed MH or rhabdomyolysis. The estimated risk of a patient with suspected NMD developing MH as a result of exposure to volatile anesthetic agents during muscle biopsy is 1.09% or less.

CONCLUSION

The estimated risk of MH or rhabdomyolysis is 1.09% or less in a diverse population of children with suspected NMD.

Anesthesia-related morbidity and mortality after surgery for muscle biopsy in children with mitochondrial defects

BACKGROUND

Children with mitochondrial defects (MD) may have an increased risk for cardiorespiratory and neurological complications from anesthesia. The aim of this study was to determine the incidence of perioperative complications and adverse events in children with MD.

METHODS

We performed a retrospective review of the anesthesia, surgical and medical records of 155 children up to 10 years who underwent a diagnostic surgical muscle biopsy for suspected mitochondrial and muscle disorders between 1999 and 2003. The data of the 122 patients where a definite MD diagnosis was found were analyzed. Anesthesia was conducted according to the discretion of the attending staff. In children with MD the activity of the different complexes of the oxidative phosphorylation system was measured.

RESULTS

From the preoperative assessment, signs of encephalopathy were most frequent (n = 93), followed by muscle weakness (n = 32), lactic acidosis (n = 15), cardiomyopathy and/or conduction defects (n = 10) and chronic respiratory problems (n = 7). The mean age of the children with MD was 32.4 months (SD = 26.9). The mean duration of anesthesia was 36.0 min (SD = 12.6) and the mean length of stay in the recovery room was 33.0 min (SD = 24.0). There were no major changes in heart rate or blood pressure which required pharmacological intervention during anesthesia or postanesthesia care unit (PACU) stay. A short episode of SpO2 <80% with airway obstruction occurred once in the PACU. Biochemical analysis in the children with a MD showed an isolated deficiency of one of the five protein complexes of oxidative phosphorylation in 42 children, a combination of complex deficiencies in 41 and no definite localization in 39 children.

CONCLUSION

With standard preoperative assessment, monitoring and anesthesia management, there were no major peroperative and postoperative anesthesia-related complications in children undergoing surgical muscle biopsy with a MD diagnosis.

Anesthetic management of a patient with MERRF syndrome

There are several specific considerations regarding anesthesia in patients with mitochondrial disease. We describe the successful administration of a combined general and epidural anesthesia with sevoflurane maintenance in a patient with myoclonic epilepsy with ragged red fibers (MERRF syndrome) scheduled for surgical treatment of bilateral clubfoot.