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Heiderich S, Bastian B, Johannsen S, Klingler W, Rüffert H, Schuster F. [Trigger-free anesthesia : Indications and safe application]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01311-2. [PMID: 37382624 DOI: 10.1007/s00101-023-01311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
The safe anesthesiological care of patients with neuromuscular diseases poses a particular challenge for anesthetists. Only a small group of muscle diseases and syndromes are associated with an increased risk of malignant hyperthermia and therefore require trigger-free anesthetic procedures avoiding volatile anesthetics and succinylcholine. These diseases are frequently associated with mutations in the RYR1, CACNA1S or STAC-3 genes. In other neuromuscular diseases, anesthetic-induced rhabdomyolysis can occur. Therefore, volatile anesthetics should be avoided in these patients in addition to the contraindication for succinylcholine. In other neuromuscular diseases the risk of a propofol infusion syndrome or myotonic crises can be elevated or the duration of the effect of non-depolarizing muscle relaxants can be changed in an incalculable way. In every case an individual anesthetic aproach including the avoidance of potential pharmacological or non-pharmacological triggers is essential for the safety of the patients.
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Affiliation(s)
- Sebastian Heiderich
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - Börge Bastian
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Stephan Johannsen
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Werner Klingler
- Fachabteilung für Anästhesie, Intensivmedizin und Schmerztherapie, SRH Kliniken Landkreis Sigmaringen, Sigmaringen, Deutschland
| | - Henrik Rüffert
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Helios Klinikum Schkeuditz, Schkeuditz, Deutschland
| | - Frank Schuster
- Institut für Anästhesiologie, Intensivmedizin und Notfallmedizin, Donau-Isar-Klinikum Deggendorf-Dingolfing-Landau, Deggendorf, Deutschland
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Kishida T, Ishida Y, Okada T, Tsuzuki Y, Kurita K, Uchino H. Successful Perioperative Management of Cochlear Implantation in a Patient With Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-Like Episodes (MELAS). Cureus 2022; 14:e27761. [PMID: 36106294 PMCID: PMC9449252 DOI: 10.7759/cureus.27761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/29/2022] Open
Abstract
Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) is a type of mitochondrial disease that is characterized by stroke-like seizures. For these patients, serious, unexpected complications have occurred during and following anesthetic exposure. Provision of anesthesia is challenging, including the choice of anesthetic agents. We here report a case of general anesthesia management for a patient with MELAS. A 46-year-old woman was diagnosed with MELAS at the age of 40. She subsequently underwent cochlear implantation for hearing loss. Anesthesia was induced with midazolam and maintained with desflurane. In the present case, anesthesia was maintained with inhalation anesthetics to avoid the development of propofol infusion syndrome. Her intraoperative and postoperative courses were uneventful. The anesthesia management of patients with MELAS can be performed safely with carefully planned anesthesia and close monitoring at each step, including the postoperative period.
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Gaik C, Arndt C. [Rhabdomyolysis - the chamaeleon of the intensive care unit]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:502-507. [PMID: 35896388 DOI: 10.1055/a-1872-9968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Myotonia congenita Thomsen is a rare genetic disease caused by mutations in the skeletal muscle chloride channel gene (CLCN1). Although this channelopathy may cause disabling muscle symptoms, patient's daily routine can be almost inconspicuous. Nevertheless, during illness or acute diseases this neuromuscular disease may worsen and get clinically apparent up to severe rhabdomyolysis. Within this case report we describe and discuss the treatment of a patient with Myotonia congenita Thomsen treated at our hospital's intensive care unit. Rhabdomyolysis with acute renal failure and necessity of dialysis during the ICU stay was attributed to the initial reason for emergency hospitalization - an aortic dissection. Nevertheless, in this case the patient's myotonia caused rhabdomyolysis and initially led us on a wrong path. Diagnosis of the real cause of rhabdomyolysis is often difficult, although an early and adequate therapy may prevent complications. This case report demonstrates the importance of a thorough anamnesis with all aspects of the patient's history.
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Abstract
Neuromuscular diseases (NMD) are a heterogeneous group of motor unit disorders. Common to all is the main clinical symptom of muscle weakness. Depending on entity and phenotype, a broad range of disorders of neuronal, junctional or myocytic structures occurs. In addition to a weakness of the skeletal musculature, NMD can also affect throat musculature, respiratory and heart muscles. The possible consequences are immobility, deformities, tendency to aspiration as well as respiratory and cardiac insufficiency. In the context of surgery and anesthesia, complications that can result from the underlying disease and its interaction with anesthesia must be anticipated and averted. This article describes along the treatment pathway how preoperative evaluation, choice of the anesthetic procedure and postoperative care can be effectively and safely tailored to the needs of patients with NMD. Concise and practical recommendations for carrying out anesthesia for the most important NMDs are presented as well as relevant external sources of practice recommendations.
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Hsieh VC, Niezgoda J, Sedensky MM, Hoppel CL, Morgan PG. Anesthetic Hypersensitivity in a Case-Controlled Series of Patients With Mitochondrial Disease. Anesth Analg 2021; 133:924-932. [PMID: 33591116 DOI: 10.1213/ane.0000000000005430] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Children with mitochondrial disease undergo anesthesia for a wide array of surgical procedures. However, multiple medications used for their perioperative care can affect mitochondrial function. Defects in function of the mitochondrial electron transport chain (ETC) can lead to a profound hypersensitivity to sevoflurane in children. We studied the sensitivities to sevoflurane, during mask induction and maintenance of general anesthesia, in children presenting for muscle biopsies for diagnosis of mitochondrial disease. METHODS In this multicenter study, 91 children, aged 6 months to 16 years, presented to the operating room for diagnostic muscle biopsy for presumptive mitochondrial disease. General anesthesia was induced by a slow increase of inhaled sevoflurane concentration. The primary end point, end-tidal (ET) sevoflurane necessary to achieve a bispectral index (BIS) of 60, was recorded. Secondary end points were maximal sevoflurane used to maintain a BIS between 40 and 60 during the case, and maximum and minimum heart rate and blood pressures. After induction, general anesthesia was maintained according to the preferences of the providers directing the cases. Primary data were analyzed comparing data from patients with complex I deficiencies to other groups using nonparametric statistics in SPSS v.27. RESULTS The median sevoflurane concentration to reach BIS of 60 during inductions (ET sevoflurane % [BIS = 60]) was significantly lower for patients with complex I defects (0.98%; 95% confidence interval [CI], 0.5-1.4) compared to complex II (1.95%; 95% CI, 1.2-2.7; P < .001), complex III (2.0%; 95% CI, 0.7-3.5; P < .001), complex IV (2.0%; 95% CI, 1.7-3.2; P < .001), and normal groups (2.2%; 95% CI, 1.8-3.0; P < .001). The sevoflurane sensitivities of complex I patients did not reach significance when compared to patients diagnosed with mitochondrial disease but without an identifiable ETC abnormality (P = .172). Correlation of complex I activity with ET sevoflurane % (BIS = 60) gave a Spearman's coefficient of 0.505 (P < .001). The differences in sensitivities between groups were less during the maintenance of the anesthetic than during induction. CONCLUSIONS The data indicate that patients with complex I dysfunction are hypersensitive to sevoflurane compared to normal patients. Hypersensitivity was less common in patients presenting with other mitochondrial defects or without a mitochondrial diagnosis.
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Affiliation(s)
- Vincent C Hsieh
- From the Department of Anesthesiology and Perioperative Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Julie Niezgoda
- Department of Pediatric Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Margaret M Sedensky
- From the Department of Anesthesiology and Perioperative Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Charles L Hoppel
- Department of Pharmacology and Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Philip G Morgan
- From the Department of Anesthesiology and Perioperative Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
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van den Bersselaar LR, Snoeck MMJ, Gubbels M, Riazi S, Kamsteeg EJ, Jungbluth H, Voermans NC. Anaesthesia and neuromuscular disorders: what a neurologist needs to know. Pract Neurol 2020:practneurol-2020-002633. [PMID: 33109742 PMCID: PMC8172077 DOI: 10.1136/practneurol-2020-002633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2020] [Indexed: 11/04/2022]
Abstract
Neurologists are often asked for specific advice regarding patients with neuromuscular disease who require general anaesthesia. However, guidelines on specific neuromuscular disorders do not usually include specific guidelines or pragmatic advice regarding (regional and/or general) anaesthesia or procedural sedation. Furthermore, the medical literature on this subject is mostly limited to publications in anaesthesiology journals. We therefore summarise general recommendations and specific advice for anaesthesia in different neuromuscular disorders to provide a comprehensive and accessible overview of the knowledge on this topic essential for clinical neurologists. A preoperative multidisciplinary approach involving anaesthesiologists, cardiologists, chest physicians, surgeons and neurologists is crucial. Depolarising muscle relaxants (succinylcholine) should be avoided at all times. The dose of non-depolarising muscle relaxants must be reduced and their effect monitored. Patients with specific mutations in RYR1 (ryanodine receptor 1) and less frequently in CACNA1S (calcium channel, voltage-dependent, L type, alpha 1S subunit) and STAC3 (SH3 and cysteine rich domain 3) are at risk of developing a life-threatening malignant hyperthermia reaction.
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Affiliation(s)
- Luuk R van den Bersselaar
- Anaesthesiology, Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
- Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, Netherlands
| | - Marc M J Snoeck
- Anaesthesiology, Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Madelief Gubbels
- Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, Netherlands
| | - Sheila Riazi
- Anesthesiology and Pain Medicine, Malignant Hyperthermia Investigation Unit, University of Toronto, Toronto, Canada
| | | | - Heinz Jungbluth
- Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
- Department of Basic and Clinical Neuroscience, IoPPN, King's College, London, UK
- Randall Division for Cell and Molecular Biophysics, Muscle Signalling Section, King's College, London, UK
| | - Nicol C Voermans
- Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, Netherlands
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Morrison S, Ranger M, Anderson B, Fox S. Anesthetic management of uncorrected tetralogy of fallot and mitochondrial disorder: A role for dexmedetomidine. Paediatr Anaesth 2019; 29:539-540. [PMID: 30592342 DOI: 10.1111/pan.13570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 12/13/2018] [Accepted: 12/24/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Shannon Morrison
- Department of Anaesthesia, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Michael Ranger
- Department of Anaesthesia, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Benjamin Anderson
- Department of Cardiology, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Scott Fox
- Department of Cardiology, Queensland Children's Hospital, Brisbane, Queensland, Australia
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Yamamoto T, Miyazawa N, Yamamoto S, Kawahara H. Anesthetic Management in Mitochondrial Encephalomyopathy: A Case Report. Anesth Prog 2018; 64:235-239. [PMID: 29200367 DOI: 10.2344/anpr-64-03-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
We report on a morbidly obese 16-year-old boy (weight, 116 kg; height, 176 cm; body mass index, 35.5 kg/m2) with mitochondrial encephalomyopathy and a history of cerebral infarction, epilepsy, and severe mental retardation. The patient was scheduled for elective surgery under general anesthesia for multiple dental caries and entropion of the left eye. Preoperative examination results, including an electrocardiogram, were normal. No obvious cardiac function abnormalities were observed on echocardiography. Midazolam (10 mg) was administered orally as premedication 30 minutes before transfer to the operating room; however, the patient was uncooperative, and his body movements were difficult to control upon entering the operating room. This complicated our attempts to establish a peripheral intravenous line and necessitated volatile inhalational induction, followed by maintenance using total intravenous anesthesia. General anesthesia was used to minimize metabolic system stress. We did not use an infusion solution containing sodium lactate. The operation and subsequent clinical course until discharge were uneventful. Because aerobic metabolism is already compromised in patients with mitochondrial encephalomyopathy, anesthetic management should be designed to avoid placing additional stress on the metabolic system.
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Affiliation(s)
- Toru Yamamoto
- Department of Dental Anesthesiology, Tsurumi University School of Dental Medicine, Yokohama, Japan
| | - Noriko Miyazawa
- Department of Anesthesiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shinichi Yamamoto
- Department of Anesthesiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Kawahara
- Department of Dental Anesthesiology, Tsurumi University School of Dental Medicine, Yokohama, Japan
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Silva HCAD, Hiray M, Vainzof M, Schmidt B, Oliveira ASB, Amaral JLGD. Reação atípica à anestesia em distrofia muscular de Duchenne/Becker. Braz J Anesthesiol 2018; 68:404-407. [DOI: 10.1016/j.bjan.2017.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 04/04/2017] [Accepted: 04/17/2017] [Indexed: 10/19/2022] Open
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Kiliç ET, Gerenli N, Akdemir MS, Tastan NO, Atag E. Anesthetic Management in Pediatric Patient for Percutaneous Endoscopic Gastrostomy with Mitochondrial Myopathy: Leigh Syndrome. Anesth Essays Res 2018; 12:276-278. [PMID: 29628597 PMCID: PMC5872881 DOI: 10.4103/aer.aer_200_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Leigh syndrome (LS) is a rare disease mainly affecting the central nervous system due to the abnormalities of mitochondrial energy generation and seen in early childhood with progressive loss of movement, mental abilities, seizures, nystagmus, ophthalmoparesis, optic atrophy, ataxia, dystonia, or respiratory failure. Anesthesia and surgery exacerbate the risks of aspiration, wheezing, and breathing difficulties. Tracheal irritability can be stimulated with the efforts of intubation. We report the anesthetic management of a rare case of an 11-year-old boy with a severe form of LS for percutaneous endoscopic gastrostomy insertion. The patient was closely monitored during the procedure and the postoperative period. Carefully chosen anesthetic agents, good pain control, and close monitoring are essential.
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Affiliation(s)
- Ebru Tarikçi Kiliç
- Departments of Anaesthesiology, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Nelgin Gerenli
- Department of Paediatric Gastroentherology, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Salim Akdemir
- Departments of Anaesthesiology, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Necmi Onur Tastan
- Departments of Anaesthesiology, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Egemen Atag
- Departments of Anaesthesiology, Ümraniye Training and Research Hospital, Istanbul, Turkey
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Parish M, Farzin H. Adult patient with Becker dystrophy undergoing orthopedic surgery: an anesthesia challenge. Int Med Case Rep J 2018; 11:33-36. [PMID: 29497338 PMCID: PMC5818840 DOI: 10.2147/imcrj.s150037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Muscular dystrophies are considered to be a series of neuromuscular diseases with genetic causes and are characterized by progressive muscle weakness and degeneration of the skeletal muscle. The case of an adult man with Becker dystrophy referred for repair of the patella tendon tearing and patella fracture is described. He underwent successful surgery using total intravenous anesthesia without any complications.
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Affiliation(s)
- Masoud Parish
- Anesthesiology Department, Tabriz University of Medical Sciences, Shohada Teaching Hospital, Tabriz, Iran
| | - Haleh Farzin
- Anesthesiology Department, Tabriz University of Medical Sciences, Shohada Teaching Hospital, Tabriz, Iran
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Lilitsis E, Astyrakaki E, Blevrakis E, Xenaki S, Chalkiadakis G, Chrysos E. Anesthetic management of a pediatric patient with Electron Transfer Flavoprotein Dehydrogenase deficiency (ETFDH) and acute appendicitis: case report and review of the literature. BMC Anesthesiol 2017; 17:116. [PMID: 28851284 PMCID: PMC5576333 DOI: 10.1186/s12871-017-0400-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 08/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mitochondria are the energy producing organelles practically in every human cell except erythrocytes. Indeed mitochondria are widespread in high energy requiring organs like brain, heart and muscles. Currently there are no clinical trials supporting with clear evidence which is the most suitable surgical or anesthetic management of a patient with known mitochondrial disease presenting with surgical disorders. This condition poses possible hazardous problems to the medical attention of those patients. CASE PRESENTATION A case of an 8 year old child with known Electron Transfer Flavoprotein Dehydrogenase deficiency (ETFDH deficiency) requiring surgery for acute appendicitis is presented. Our approach for anesthesia revealed a combination of fentanyl, low dose propofol and nitrous oxide. CONCLUSION The choice of the safest pharmacological anesthetic agents for patients with ETFDH deficiency is challenging given that most of the general anesthetic medications have multiple effects on mitochondria, fatty acids metabolism and striated muscles. Anesthetists are expected to individualize anesthetic care for the patient based on current publications for similar cases, medical history and knowledge of pharmacology and physiology.
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Affiliation(s)
- Emmanuel Lilitsis
- Department of Anesthesiology, University Hospital of Crete, Herakllion, Greece
| | - Elisavet Astyrakaki
- Department of Anesthesiology, University Hospital of Crete, Herakllion, Greece
| | - Evaggelos Blevrakis
- Department of Pediatric Surgery, University Hospital of Crete, 71110, Herakllion, Greece
| | - Sofia Xenaki
- Department of Pediatric Surgery, University Hospital of Crete, 71110, Herakllion, Greece
| | - George Chalkiadakis
- Department of Pediatric Surgery, University Hospital of Crete, 71110, Herakllion, Greece
| | - Emmanuel Chrysos
- Department of Pediatric Surgery, University Hospital of Crete, 71110, Herakllion, Greece.
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Perioperative considerations in adult mitochondrial disease: A case series and a review of 111 cases. Mitochondrion 2015; 26:26-32. [PMID: 26602285 DOI: 10.1016/j.mito.2015.11.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 11/11/2015] [Accepted: 11/16/2015] [Indexed: 11/24/2022]
Abstract
Mitochondrial disease has been uncommon conditions, still results in death during childhood in many cases. The ideal anesthetic pharmacological management strategy for adult patients with mitochondrial disease is currently unclear. In this study, we presented features of the anesthesia methods employed and the perioperative complications of patients in our institution and in previously published case reports. We report the use of general anesthesia 7 times in 6 adult patients with mitochondrial disease during 2004-2014. All cases were performed with maintained intravenous anesthesia. One case was reintubated on the day after surgery, but the cause of death was not directly related to anesthesia. One hundred and eleven general anesthesia cases in 97 adult patients with mitochondrial disease were described in 83 the literature. Although several severe perioperative complications and deaths have been reported, malignant hyperthermia had not been reported in adult cases, and metabolic disorder called propofol infusion syndrome had also not been reported in adult patients undergone total intravenous anesthesia. Perioperative complications of lactic acidosis were reported more in inhalation anesthesia than intravenous anesthesia. Therefore we recommended intravenous anesthesia rather than inhalation anesthesia for adult mitochondrial disease.
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Ranjan RV, Ramachandran TR, Manikandan S, John R. Limb-girdle muscular dystrophy with obesity for elective cesarean section: Anesthetic management and brief review of the literature. Anesth Essays Res 2015; 9:127-9. [PMID: 25886439 PMCID: PMC4383115 DOI: 10.4103/0259-1162.150184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Limb-girdle muscular dystrophy (LGMD) is an autosomal recessive disorder in which the pelvic or shoulder girdle musculature is predominantly or primarily involved. We report the management of a 27-year-old primigravida with LGMD associated with obesity posted for elective cesarean section. She was successfully managed with epidural anesthesia assisted with noninvasive positive pressure ventilation. She had an uncomplicated intra- and post-operative course.
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Affiliation(s)
- R V Ranjan
- Department of Anaesthesiology and Critical Care, PIMS, Pondicherry, India
| | - T R Ramachandran
- Department of Anaesthesiology and Critical Care, PIMS, Pondicherry, India
| | - S Manikandan
- Department of Anaesthesiology and Critical Care, PIMS, Pondicherry, India
| | - Roshan John
- Department of Anaesthesiology and Critical Care, PIMS, Pondicherry, India
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Mimura T, Imai S, Kawasaki T, Furuya Y, Mori K, Matsusue Y. Late-Emerging Lethal Exacerbation of Cardiomyopathy in a Patient with Mitochondrial Myopathy After Total Hip Arthroplasty: A Case Report. JBJS Case Connect 2014; 4:e105. [PMID: 29252773 DOI: 10.2106/jbjs.cc.n.00043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE Mitochondrial myopathy comprises heterogeneous neuromuscular disorders caused by mitochondrial dysfunction. Acute exacerbation of mitochondrial myopathy infrequently occurs sequentially after perioperative stress. We present an unusual case of a late-emerging and lethal exacerbation of mitochondrial myopathy after total hip arthroplasty. Despite special attention paid to perioperative control, the patient's condition drastically deteriorated on postoperative day thirteen, and she died later as a result of cardiomyopathy. CONCLUSION When performing surgery on a patient with mitochondrial myopathy, the merits of surgery must always surpass the possible grave risk of this condition.
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Affiliation(s)
- Tomohiro Mimura
- Department of Orthopedic Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan.
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Burnett B, Schwartz L, Tobias JD. Anaesthesia with dexmedetomidine and remifentanil in a child with mitochondrial myopathy. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2011.10872788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- B Burnett
- Department of Anesthesiology, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - L Schwartz
- Department of Anesthesiology, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - JD Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital
- The Ohio State University, Columbus, Ohio
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Isoflurane anesthetic hypersensitivity and progressive respiratory depression in a mouse model with isolated mitochondrial complex I deficiency. J Anesth 2014; 28:807-14. [PMID: 24522811 DOI: 10.1007/s00540-014-1791-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 01/10/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Children with mitochondrial disorders are frequently anesthetized for a wide range of operations. These disorders may interfere with the response to surgery and anesthesia. We examined anesthetic sensitivity to and respiratory effects of isoflurane in the Ndufs4 knockout (KO) mouse model. These mice exhibit an isolated mitochondrial complex I (CI) deficiency of the respiratory chain, and they also display clinical signs and symptoms resembling those of patients with mitochondrial CI disease. METHODS We investigated seven Ndufs4(-/-) knockout (KO), five Ndufs4(+/-) heterozygous (HZ) and five Ndufs4(+/+) wild type (WT) mice between 22 and 25 days and again between 31 and 34 days post-natal. Animals were placed inside an airtight box, breathing spontaneously while isoflurane was administered in increasing concentrations. Minimum alveolar concentration (MAC) was determined with the bracketing study design, using the response to electrical stimulation to the hind paw. RESULTS MAC for isoflurane was significantly lower in KO mice than in HZ and WT mice: 0.81% ± 0.01 vs 1.55 ± 0.05% and 1.55 ± 0.13%, respectively, at 22-25 days, and 0.65 ± 0.05%, 1.65 ± 0.08% and 1.68 ± 0.08% at 31-34 days. The KO mice showed severe respiratory depression at lower isoflurane concentrations than the WT and HZ mice. CONCLUSION We observed an increased isoflurane anesthetic sensitivity and severe respiratory depression in the KO mice. The respiratory depression during anesthesia was strongly progressive with age. Since the pathophysiological consequences from complex I deficiency are mainly reflected in the central nervous system and our mouse model involves progressive encephalopathy, further investigation of isoflurane effects on brain mitochondrial function is warranted.
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Niezgoda J, Morgan PG. Anesthetic considerations in patients with mitochondrial defects. Paediatr Anaesth 2013; 23:785-93. [PMID: 23534340 PMCID: PMC3711963 DOI: 10.1111/pan.12158] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2013] [Indexed: 12/17/2022]
Abstract
Mitochondrial disease, once thought to be a rare clinical entity, is now recognized as an important cause of a wide range of neurologic, cardiac, muscle, and endocrine disorders . The incidence of disorders of the respiratory chain alone is estimated to be about 1 per 4-5000 live births, similar to that of more well-known neurologic diseases . High-energy requiring tissues are uniquely dependent on the energy delivered by mitochondria and therefore have the lowest threshold for displaying symptoms of mitochondrial disease. Thus, mitochondrial dysfunction most commonly affects function of the central nervous system, the heart and the muscular system . Mutations in mitochondrial proteins cause striking clinical features in those tissues types, including encephalopathies, seizures, cerebellar ataxias, cardiomyopathies, myopathies, as well as gastrointestinal and hepatic disease. Our knowledge of the contribution of mitochondria in causing disease or influencing aging is expanding rapidly . As diagnosis and treatment improve for children with mitochondrial diseases, it has become increasingly common for them to undergo surgeries for their long-term care. In addition, often a muscle biopsy or other tests needing anesthesia are required for diagnosis. Mitochondrial disease represents probably hundreds of different defects, both genetic and environmental in origin, and is thus difficult to characterize. The specter of possible delayed complications in patients caused by inhibition of metabolism by anesthetics, by remaining in a biochemically stressed state such as fasting/catabolism, or by prolonged exposure to pain is a constant worry to physicians caring for these patients. Here, we review the considerations when caring for a patient with mitochondrial disease.
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Affiliation(s)
- Julie Niezgoda
- Department of Pediatric Anesthesiology, Cleveland Clinic, Cleveland, USA
| | - Phil G Morgan
- Department of Anesthesiology and Pain Medicine, University of Washington and Seattle Children’s Hospital, Seattle, USA
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Sarkılar G, Mermer A, Yücekul M, Çeken BM, Altun C, Otelcioğlu Ş. Anaesthetic Management of a Child with Limb-Girdle Muscular Dystrophy. Turk J Anaesthesiol Reanim 2013; 42:103-5. [PMID: 27366400 DOI: 10.5152/tjar.2013.52] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 01/03/2013] [Indexed: 01/01/2023] Open
Abstract
Limb-girdle muscular dystrophies are a group of disorders with wide genetic and clinical heterogeneity. These disorders may lead to an increase in life-threatening complications related to surgery and anaesthesia. In this case, the anaesthetic management of a child with limb-girdle muscular dystrophy is presented.
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Affiliation(s)
- Gamze Sarkılar
- Department of Anaesthesiology and Reanimation, Necmettin Erbakan University Faculty of Medicine, Konya, Turkey
| | - Aydın Mermer
- Clinic of Anaesthesia, Viranşehir State Hospital, Şanlıurfa, Turkey
| | - Melike Yücekul
- Department of Anaesthesiology and Reanimation, Necmettin Erbakan University Faculty of Medicine, Konya, Turkey
| | - Bedia Mine Çeken
- Department of Anaesthesiology and Reanimation, Necmettin Erbakan University Faculty of Medicine, Konya, Turkey
| | - Celalettin Altun
- Department of Anaesthesiology and Reanimation, Necmettin Erbakan University Faculty of Medicine, Konya, Turkey
| | - Şeref Otelcioğlu
- Department of Anaesthesiology and Reanimation, Necmettin Erbakan University Faculty of Medicine, Konya, Turkey
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In vitro contracture test results and anaesthetic management of a patient with emery-dreifuss muscular dystrophy for cardiac transplantation. Case Rep Anesthesiol 2012; 2012:349046. [PMID: 22973525 PMCID: PMC3438720 DOI: 10.1155/2012/349046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Accepted: 07/31/2012] [Indexed: 11/24/2022] Open
Abstract
Emery-Dreifuss muscular dystrophy (EDMD) is a hereditary neuromuscular disorder characterized by slowly progressive muscle weakness, early contractures, and dilated cardiomyopathy. We reported an uneventful general anaesthesia using total intravenous anaesthesia (TIVA) for cardiac transplantation in a 19-year-old woman suffering from EDMD. In vitro contracture test results of two pectoralis major muscle bundles of the patient suggest that exposition to triggering agents does not induce a pathological sarcoplasmic calcium release in the lamin A/C phenotype. However, due to the lack of evidence in the literature, we would recommend TIVA for patients with EDMD if general anaesthesia is required.
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Terkawi AS, Wani TM, Al-Shuaibi KM, Tobias JD. Anesthetic considerations in Leigh disease: Case report and literature review. Saudi J Anaesth 2012; 6:181-5. [PMID: 22754450 PMCID: PMC3385266 DOI: 10.4103/1658-354x.97037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Leigh disease is an extremely rare disorder, characterized by a progressive neurodegenerative course, with subacute necrotizing encephalomyelopathy. It usually presents in infancy with developmental delay, seizures, dysarthria, and ataxia. These patients may also develop episodes of lactic acidosis that usually lead to respiratory failure and death. Due to the rarity of the condition, the most appropriate anesthetic plan remains unclear. We present a patient with Leigh disease, who required general anesthesia. The pathogenesis of the disease is discussed and previous reports of perioperative care from the literature are reviewed.
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Moitra VK, Gabrielli A, Maccioli GA, O’Connor MF. Anesthesia advanced circulatory life support. Can J Anaesth 2012; 59:586-603. [PMID: 22528163 PMCID: PMC3345112 DOI: 10.1007/s12630-012-9699-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 03/14/2012] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The constellation of advanced cardiac life support (ACLS) events, such as gas embolism, local anesthetic overdose, and spinal bradycardia, in the perioperative setting differs from events in the pre-hospital arena. As a result, modification of traditional ACLS protocols allows for more specific etiology-based resuscitation. PRINCIPAL FINDINGS Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient's comorbidities and coexisting anesthetic or surgically related pathophysiology. When the health care provider identifies the probable cause of arrest, the practitioner has the ability to initiate medical management rapidly. CONCLUSIONS Recommendations for management must be predicated on expert opinion and physiological understanding rather than on the standards currently being used in the generation of ACLS protocols in the community. Adapting ACLS algorithms and considering the differential diagnoses of these perioperative events may prevent cardiac arrest.
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Affiliation(s)
- Vivek K. Moitra
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY USA
| | - Andrea Gabrielli
- Anesthesia Department, University of Florida, Gainesville, FL USA
| | | | - Michael F. O’Connor
- Department of Anesthesia and Critical Care, University of Chicago, 5841 S Maryland Ave, MC 4028, Chicago, IL 60637 USA
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Lerman J. Perioperative management of the paediatric patient with coexisting neuromuscular disease. Br J Anaesth 2012; 107 Suppl 1:i79-89. [PMID: 22156273 DOI: 10.1093/bja/aer335] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Children with neuromuscular diseases present a wide range of clinical manifestations and clinical implications for the anaesthesiologist. Neuromuscular diseases in children affect muscle strength by either directly weakening the muscle fibrils or indirectly by a degenerative nerve supply and weak neuromuscular junction. Of the more than 200 neuromuscular disorders known, the vast majority are genetic in origin. This review focuses on four of the more common neuromuscular disorders with emphasis on their pathophysiology and clinical implications for anaesthesiologists: malignant hyperthermia, the muscular dystrophies (Duchenne's, Becker's, and Emery-Dreifuss), mitochondrial disorders, and cerebral palsy.
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Affiliation(s)
- J Lerman
- Department of Anaesthesia, Women and Children's Hospital of Buffalo, State University of New York at Buffalo, 219 Bryant St, Buffalo, NY 14222, USA.
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Levine M, Brown DFM. Succinylcholine-induced hyperkalemia in a patient with multiple sclerosis. J Emerg Med 2011; 43:279-82. [PMID: 22142672 DOI: 10.1016/j.jemermed.2011.06.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 05/16/2011] [Accepted: 06/11/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Succinylcholine administration is associated with hyperkalemia in patients with a variety of medical conditions, including many neuromuscular disorders. Nonetheless, there is a paucity of literature describing hyperkalemia after the administration of succinylcholine to patients with multiple sclerosis. CASE REPORT This case report describes a 38-year-old woman with multiple sclerosis who developed life-threatening hyperkalemia after the administration of succinylcholine during rapid sequence intubation. CONCLUSION This case highlights the potential for iatrogenic hyperkalemia after succinylcholine in patients with neurologic diseases, including multiple sclerosis.
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Affiliation(s)
- Michael Levine
- Department of Emergency Medicine, Section of Medical Toxicology, University of Southern California, Los Angeles, California 90033, USA
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Marsh S, Ross N, Pittard A. Neuromuscular disorders and anaesthesia. Part 1: generic anaesthetic management. ACTA ACUST UNITED AC 2011. [DOI: 10.1093/bjaceaccp/mkr020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Anaesthesia in children with inherited neuromuscular diseases. SRP ARK CELOK LEK 2010; 138:768-76. [DOI: 10.2298/sarh1012768s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Children with inherited neuromuscular diseases often require anaesthesia for
diagnostic or therapy procedures. These patients have an increased risk of
perioperative complications due to the nature of the disease and medications
administered during anaesthesia. Many anaesthetics and muscle relaxants can
aggravate the underlying disease and trigger life-threatening reactions
(cardiorespiratory complications, malignant hyperthermia). Besides, the
neuromuscular disorders are associated with atypical and undesirable
responses to drugs used during anaesthesia and the perioperative period. The
paper presents pathophysiological basis of inherited/genetic neuromuscular
diseases and specific anaesthesiological problems. The recommendations are
suggested with the aim to make the perioperative course in children optimally
safe.
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Giessler GA, Mayer T, Trupkovic T. [Burn trauma--Part 2. Anesthesiological, surgical and intensive care management]. Anaesthesist 2009; 58:474-84. [PMID: 19384454 DOI: 10.1007/s00101-009-1535-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
After initial stabilization of burn victims at the scene and in the trauma room, a tight cooperation and communication between anesthesiologists, plastic surgeons and intensive care specialists is needed for further therapy. Interdisciplinary communication about preoperative planning, timing of necrectomy and intensive care therapy is vital regarding functional and aesthetic outcome and survival rate. During burn surgery attention has to be paid to excessive blood loss and the danger of hypothermia. The main problems of intensive care therapy involve the evaluation of volume status, high demands for analgesia and sedation, high incidence of septic multiorgan failure and therapy and prophylaxis of the effects of hypermetabolism.
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Affiliation(s)
- G A Giessler
- Abt. für Plastische, Hand- und Rekonstruktive Mikrochirurgie, Berufsgenossenschaftliche Unfallklinik Murnau, Professor Kuentscher Str. 8, 82418 Murnau am Staffelsee, Deutschland.
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