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Tanaka A, Cai T, Platten M, Tollinche LE, DeJoy SJ. Anesthetic Management and Neuromonitoring in a Patient with Very Long-Chain Acyl-Coenzyme A Dehydrogenase Deficiency Undergoing Scoliosis Surgery: A Case Report and Review of Literature. Case Rep Anesthesiol 2024; 2024:1050279. [PMID: 38229914 PMCID: PMC10789510 DOI: 10.1155/2024/1050279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/15/2023] [Accepted: 12/16/2023] [Indexed: 01/18/2024] Open
Abstract
Patients with very long-chain acyl-CoA dehydrogenase deficiency (VLCADD) are prone to hypoglycemia and clinical decompensation when metabolic demands of the body are not met. We present a pediatric patient with VLCADD who underwent a posterior spinal fusion for scoliosis requiring intraoperative neurophysiology monitoring. Challenges included minimization of perioperative metabolic stressors and careful selection of anesthetic agents since propofol-based total intravenous anesthesia (TIVA) was contraindicated due to its high fatty acid content. This case is unique due to the sequential use of inhaled anesthetics after TIVA to allow for a rapid wakeup and immediate postoperative physical exam. Additionally, intraoperative neuromonitoring in the setting of VLCADD has not been reported in the literature. With communication among anesthesia, surgery, and neuromonitoring teams before and during the operation, the patient successfully underwent a major surgery without complications. This trial is registered with NCT03808077.
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Affiliation(s)
- Anna Tanaka
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Tim Cai
- Department of Anesthesiology, MetroHealth Medical Center of Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Michael Platten
- Department of Anesthesiology, MetroHealth Medical Center of Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Luis E. Tollinche
- Department of Anesthesiology, MetroHealth Medical Center of Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Samuel J. DeJoy
- Department of Anesthesiology, MetroHealth Medical Center of Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Yu HK, Ok SH, Kim S, Sohn JT. Anesthetic management of patients with carnitine deficiency or a defect of the fatty acid β-oxidation pathway: A narrative review. Medicine (Baltimore) 2022; 101:e28853. [PMID: 35363184 PMCID: PMC9282055 DOI: 10.1097/md.0000000000028853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/28/2022] [Indexed: 01/04/2023] Open
Abstract
Carnitine is essential for the transport of long-chain fatty acids from the cytoplasm to the mitochondrial matrix. The carnitine shuttle transports long-chain fatty acylcarnitine to the mitochondrial matrix. Subsequently, long-chain fatty acyl CoA, which is split from long-chain fatty acylcarnitine by carnitine palmitoyltransferase II, undergoes fatty acid β-oxidation. Acetyl CoA is produced from long-chain fatty acyl CoA via fatty acid β-oxidation and aids in the synthesis of adenosine triphosphate via the tricarboxylic acid cycle and electron transport chain. In addition, in the fasting state, it leads to ketone body production in the liver and glucose production via gluconeogenesis. However, patients with compromised fatty acid β-oxidation, owing to carnitine deficiency as well as defects in carnitine transport and the fatty acid β-oxidation pathway, develop hypoglycemia, cardiomyopathy, arrhythmia, and hypotonia. These conditions are attributed to the accumulation of released fatty acids and acylcarnitine. This review aimed to shed light on the anesthetic management of patients with compromised fatty acid β-oxidation undergoing various surgeries by assessing relevant case reports associated with fatty acid β-oxidation disorder in PubMed. Pre-anesthetic and intraoperative evaluation should include monitoring of glucose and carnitine levels and specific cardiac tests, such as echocardiography. Considering that propofol is dissolved in 10% long-chain fatty acids, propofol infusion should be avoided because of increased long-chain fatty acid loading in patients with compromised fatty acid β-oxidation. Thus, anesthesia using opioids (remifentanil and fentanyl), midazolam, dexmedetomidine, etomidate, and non-depolarizing neuromuscular blocking agents would be appropriate in such patients.
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Affiliation(s)
- Ho Kyung Yu
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si, Republic of Korea
| | - Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, 15 Jinju-daero 816 beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
| | - Sunmin Kim
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Ju-Tae Sohn
- Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
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Che D, Wang J, Ding Y, Liu R, Cao J, Zhang Y, Hou Y, An H, Gao Z, Zhang T. Mivacurium induce mast cell activation and pseudo-allergic reactions via MAS-related G protein coupled receptor-X2. Cell Immunol 2018; 332:121-128. [DOI: 10.1016/j.cellimm.2018.08.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/27/2018] [Accepted: 08/09/2018] [Indexed: 11/28/2022]
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Kloesel B, Holzman RS. Anesthetic Management of Patients With Inborn Errors of Metabolism. Anesth Analg 2017; 125:822-836. [DOI: 10.1213/ane.0000000000001689] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Welsink-Karssies MM, Polderman JAW, Nieveen van Dijkum EJ, Preckel B, Schlack WS, Visser G, Hollak CE, Hermanides J. Very Long-Chain Acyl-Coenzyme A Dehydrogenase Deficiency and Perioperative Management in Adult Patients. JIMD Rep 2016; 34:49-54. [PMID: 27518779 DOI: 10.1007/8904_2016_6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/24/2016] [Accepted: 07/07/2016] [Indexed: 01/05/2023] Open
Abstract
Surgery and anesthesia pose a threat to patients with very long-chain acyl-CoA dehydrogenase deficiency (VLCADD), because prolonged fasting, stress, and pain are known risk factors for the induction of metabolic derangement. The optimal perioperative management in these patients is unknown and the use of volatile agents and agents dissolved in fatty acids has been related to postoperative metabolic complications. However, the occurrence of metabolic derangement is multifactorial and depends, amongst others, on the severity of the mutation and residual enzyme activity. Current guidelines suggest avoiding both volatile anesthetics as well as propofol, which seriously limits the options for providing safe anesthesia. Therefore, we reviewed the available literature on the perioperative management of patients with VLCADD. We concluded that the use of some medications, such as volatile anesthetics, in patients with VLCADD might be wrongfully avoided and could in fact prevent metabolic derangement by the adequate suppression of pain and stress during surgery. We will illustrate this with a case report of an adult VLCADD patient undergoing minor surgery. Besides the use of remifentanil, anesthesia was uneventfully maintained with the use of sevoflurane, a volatile agent, and continuous glucose infusion. The patient was monitored with a continuous glucose meter and creatinine kinase measurements.
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Affiliation(s)
- M M Welsink-Karssies
- Department of Anesthesiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J A W Polderman
- Department of Anesthesiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | | | - B Preckel
- Department of Anesthesiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - W S Schlack
- Department of Anesthesiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - G Visser
- Department of Metabolic Diseases, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C E Hollak
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - J Hermanides
- Department of Anesthesiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Martin JM, Gillingham MB, Harding CO. Use of propofol for short duration procedures in children with long chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) or trifunctional protein (TFP) deficiencies. Mol Genet Metab 2014; 112:139-42. [PMID: 24780638 PMCID: PMC4121654 DOI: 10.1016/j.ymgme.2014.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/26/2014] [Accepted: 03/26/2014] [Indexed: 11/28/2022]
Abstract
The medication propofol, commonly used for anesthesia, has been avoided in patients with mitochondrial fatty acid oxidation disorders (FAODs) due to concerns that it contains long-chain fatty acids (LCFAs), and because of reports of severe side effects in some critically ill patients receiving high-dose propofol infusions that mimic some of the symptoms regularly found in FAOD patients. In this secondary analysis, we examined the outcomes of 8 children with long-chain 3-hydroxyacyl CoA dehydrogenase (LCHAD) deficiency or trifunctional protein (TFP) deficiency who were repeatedly sedated for an electroretinogram (ERG) as part of a longitudinal study of the progression of chorioretinopathy commonly found in this population. A total of 39 sedated ERG procedures were completed using propofol for sedation. The propofol dosing, estimated total energy needs of the subject, and inpatient dietary intake recording were completed in 32 of these procedures. The LCFAs in the propofol provided approximately 1.0% of the average total daily energy needs. The sedation with propofol resulted in no adverse side effects and was safely used in this short duration procedure.
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Affiliation(s)
- Julie M Martin
- Department of Molecular & Medical Genetics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Melanie B Gillingham
- Department of Molecular & Medical Genetics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA; Graduate Programs in Human Nutrition, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Cary O Harding
- Department of Molecular & Medical Genetics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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Iwata K, Tanabe K, Sugiyama Y, Tanaka M, Takenaka M, Iida H. Anesthetic management for a patient with very-long-chain acyl-coenzyme A dehydrogenase deficiency. J Anesth 2012; 26:957-8. [PMID: 22847608 DOI: 10.1007/s00540-012-1457-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 07/10/2012] [Indexed: 11/29/2022]
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Vellekoop P, Diekman EF, van Tuijl I, de Vries MMC, van Hasselt PM, Visser G. Perioperative measures in very long chain acyl-CoA dehydrogenase deficiency. Mol Genet Metab 2011; 103:96-7. [PMID: 21333574 DOI: 10.1016/j.ymgme.2011.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2011] [Accepted: 01/22/2011] [Indexed: 11/22/2022]
Abstract
Surgical procedures in patients with metabolic disorders require specific anesthetic measures based on the nature of the involved metabolic disorder. Illustrated by the history of two patients, the need for a specific perioperative regimen in patients with very long chain acyl-CoA dehydrogenase deficiency (VLCADD) is discussed. One patient deteriorated, the other patient did well without any specific measurements. Although perioperative metabolic decompensation can currently not be predicted, it is a severe complication which should be avoided. We therefore advise to consider certain perioperative precautions in all VLCADD patients: 1) age and weight adapted glucose infusion, 2) stress avoiding premedication, 3) avoidance of volatile anesthetics, 4) avoidance of long chain fatty acid containing anesthetics and 5) perioperative glucose and CK monitoring.
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Affiliation(s)
- P Vellekoop
- Department of Metabolic and Endocrine diseases, Wilhelmina Children's Hospital, UMC Utrecht, The Netherlands
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