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Dell’Olio F, Lorusso P, Siciliani RA, Massaro M, Barile G, Tempesta A, Grasso S, Favia G, Limongelli L. Type 1 citrullinemia patient with Brugada pattern undergoing general anesthesia for dental extractions: A case report. Clin Case Rep 2023; 11:e7657. [PMID: 37575462 PMCID: PMC10415584 DOI: 10.1002/ccr3.7657] [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] [Received: 05/11/2023] [Revised: 06/20/2023] [Accepted: 06/24/2023] [Indexed: 08/15/2023] Open
Abstract
Key Clinical Message The perioperative control of ammonia, reduction of stress, and administration of drugs tolerated in type 1 citrullinemia and Brugada pattern allowed the successful and uneventful management of general anesthesia in the study patient. Abstract The aim of this study was to report the targeted perioperative management of general anesthesia (GA) adopted for dental extractions in a rare patient with type 1 citrullinemia and Brugada pattern. A male, Caucasian, adult type 1 citrullinemia patient needed dental extractions under GA. The medical history showed neurodevelopmental impairment, growth retardation, epilepsy, and a Type 2 Brugada electrocardiographic pattern in the second precordial lead. The authors focused the anesthesiologic protocol on the prevention of hyperammonemia and fatal arrhythmias. Changes in diet and 10% glucose solution administration prevented protein catabolism due to the fasting period (ammonia was 44 μmol/L preoperatively and 46 μmol/L postoperatively; glycemia was 120 g/dL preoperatively and 153 g/dL postoperatively). The patient received a continuous electrocardiogram, noninvasive blood pressure, pulse oximeter, entropy monitoring, train-of-four monitoring, and external biphasic defibrillator pads. Midazolam, remifentanil, and dexamethasone were administered for pre-anesthesia; thiopental and rocuronium for induction; remifentanil and desflurane for maintenance; sugammadex for decurarization. After the intraligamentary injection of lidocaine 2% with epinephrine 1:100,000 for local anesthesia, the patient developed a transient Type 1 Brugada pattern that lasted a few minutes. The whole procedure lasted 30 min. The patient's discharge to ward occurred 3 h after the end of GA. The perioperative management of ammonia, reduction of stress, and administration of drugs tolerated in Type 1 citrullinemia and Brugada pattern allowed the successful and uneventful administration of GA in the study patient.
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Affiliation(s)
- Fabio Dell’Olio
- Department of Interdisciplinary Medicine, Complex Operating Unit of OdontostomatologyAldo Moro UniversityBariItaly
| | - Pantaleo Lorusso
- Department of Emergency and Organ Transplantation, Operating Unit of AnesthesiologyAldo Moro UniversityBariItaly
| | - Rosaria Arianna Siciliani
- Department of Interdisciplinary Medicine, Complex Operating Unit of OdontostomatologyAldo Moro UniversityBariItaly
| | - Maria Massaro
- Department of Emergency and Organ Transplantation, Operating Unit of AnesthesiologyAldo Moro UniversityBariItaly
| | - Giuseppe Barile
- Department of Interdisciplinary Medicine, Complex Operating Unit of OdontostomatologyAldo Moro UniversityBariItaly
| | - Angela Tempesta
- Department of Interdisciplinary Medicine, Complex Operating Unit of OdontostomatologyAldo Moro UniversityBariItaly
| | - Salvatore Grasso
- Department of Emergency and Organ Transplantation, Operating Unit of AnesthesiologyAldo Moro UniversityBariItaly
| | - Gianfranco Favia
- Department of Interdisciplinary Medicine, Complex Operating Unit of OdontostomatologyAldo Moro UniversityBariItaly
| | - Luisa Limongelli
- Department of Interdisciplinary Medicine, Complex Operating Unit of OdontostomatologyAldo Moro UniversityBariItaly
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Kim K, Jung SM. Desflurane and remifentanil anesthesia in a child with citrin deficiency: A case report. Medicine (Baltimore) 2022; 101:e28954. [PMID: 35244055 PMCID: PMC8896430 DOI: 10.1097/md.0000000000028954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/11/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Hyperammonemia, metabolic derangement, and/or the prolonged effects of anesthetics may lead to delayed emergence from general anesthesia as well as the onset of type 2 citrullinemia, even in compensated patients with citrin deficiency. PATIENT CONCERN A 5-year-old girl with citrin deficiency was scheduled for blepharoplasty under general anesthesia. She developed hyperammonemia with temporary interruption of medication for a few days before surgery. DIAGNOSIS The patient was genetically diagnosed as citrin deficiency with a mutation in the SLC25A13 gene via newborn screening for metabolic disorders. Her citrulline and ammonia levels were well-controlled with arginine medication and protein-rich diet. Her elevated ammonia level by temporary interruption of medication was corrected with resumption of arginine medication and protein-rich diet before surgery. INTERVENTIONS We used desflurane and remifentanil for general anesthesia to avoid hyperammonemia and delayed emergence. End-tidal desflurane concentration and anesthetic depth were carefully monitored to avoid excessive anesthesia. OUTCOMES She recovered consciousness with slightly increased ammonia level immediately after anesthesia. LESSIONS General anesthesia of the shortest duration with the least metabolized drugs using desflurane and remifentanil, would be beneficial for rapid emergence in surgical patients with citrin deficiency. Maintenance of nitrogen scavenging medication, a protein-rich diet, and serial measurement of ammonia levels in the perioperative period are also important for avoiding hyperammonemia-related neurological dysfunction.
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Affiliation(s)
- Kanghui Kim
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Sung Mee Jung
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
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Shibuya M, Iwamoto R, Kimura Y, Kamekura N, Fujisawa T. Anesthetic Management of a Patient With Citrullinemia Type I During Dental Treatment. Anesth Prog 2021; 68:158-162. [PMID: 34606567 DOI: 10.2344/anpr-68-02-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/25/2021] [Indexed: 11/11/2022] Open
Abstract
We report a case involving intravenous sedation for third molar extractions in a 32-year-old man with citrullinemia type I (CTLN1), a genetic disorder that affects the urea cycle. The patient was diagnosed with CTLN1 after he exhibited seizures soon after birth and was intellectually disabled because of persistent hyperammonemia, although his recent serum ammonia levels were fairly well controlled. We planned to minimize his preoperative fasting, continue his routine oral medications, and monitor his serum ammonia levels at least twice. Sedation with midazolam and a propofol infusion was planned to suppress his gag reflex and reduce protein hypercatabolism due to stress. Epinephrine-containing local anesthetics, which enhance protein catabolism, were avoided, replaced by plain lidocaine for blocks and prilocaine with felypressin for infiltration anesthesia. No significant elevation in ammonia levels was observed. In patients with CTLN1, sedation can be useful for preventing hyperammonemia. Patients who develop symptomatic hyperammonemia may require urgent/emergent treatment involving other medical specialists. Therefore, preoperative endocrinology consultation, perioperative monitoring of serum ammonia levels, and preemptively coordinating for appropriate care in the event hyperammonemia occurs should all be considered.
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Affiliation(s)
- Makiko Shibuya
- Department of Dental Anesthesiology, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University, Hokkaido, Japan
| | - Rie Iwamoto
- Department of Dental Anesthesiology, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University, Hokkaido, Japan
| | - Yukifumi Kimura
- Department of Dental Anesthesiology, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University, Hokkaido, Japan
| | - Nobuhito Kamekura
- Department of Dental Anesthesiology, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University, Hokkaido, Japan
| | - Toshiaki Fujisawa
- Department of Dental Anesthesiology, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University, Hokkaido, Japan
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Del Río C, Martín-Hernández E, Ruiz A, Quijada-Fraile P, Rubio P. Perioperative management of children with urea cycle disorders. Paediatr Anaesth 2020; 30:780-791. [PMID: 32375202 DOI: 10.1111/pan.13905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Urea cycle disorders are congenital metabolism errors that affect ammonia elimination. Clinical signs and prognosis are strongly influenced by peak ammonia levels. Numerous triggers associated with metabolic decompensation have been described with many of them, including fasting or stress, being related to the perioperative period. AIMS We aimed to assess perioperative complications in pediatric patients with urea cycle disorders requiring general anesthesia in our center. METHODS We reviewed the clinical history of all the pediatric patients with a confirmed urea cycle disorders diagnosis requiring surgery or a diagnostic procedure with anesthesia between January 2002 and June 2018. RESULTS We included 33 operations (major surgery, minor surgery, and diagnostic procedures) carried out on 10 patients via different anesthetic techniques. We observed the following complications: intraoperative hyperglycemia in one case, postoperative vomiting in eight cases, and slightly increased postoperative ammonia levels (54, 59, and 69 µmol/L) with normal preoperative levels in three cases without associated metabolic decompensation. There were two cases of perioperative hyperammonemia (72 and 69 µmol/L) secondary to preoperative metabolic decompensation (137 and 92 µmol/L) with the levels progressively dropping and normalizing in the first 24-48 hours, respectively. CONCLUSIONS Procedures under anesthesia on pediatric patients with urea cycle diseases should be performed by experienced multidisciplinary teams at specialized centers. Perioperative management focused on avoiding catabolism (especially during fasting) and monitoring signs associated with metabolic decompensation to allow for its early treatment should be included in routine anesthetic techniques for children with urea cycle disorders.
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Affiliation(s)
- Cristina Del Río
- Department of Pediatric Anesthesiology, University Hospital 12 de Octubre, Madrid, Spain
| | - Elena Martín-Hernández
- Unit of Mitochondrial and Inherited Metabolic Diseases, Pediatric Department, University Hospital 12 de Octubre, Madrid, Spain.,National Reference Center, European Reference Network for Hereditary Metabolic Disorders (MetabERN), Madrid, Spain
| | - Alicia Ruiz
- Department of Pediatric Anesthesiology, University Hospital 12 de Octubre, Madrid, Spain
| | - Pilar Quijada-Fraile
- Unit of Mitochondrial and Inherited Metabolic Diseases, Pediatric Department, University Hospital 12 de Octubre, Madrid, Spain.,National Reference Center, European Reference Network for Hereditary Metabolic Disorders (MetabERN), Madrid, Spain
| | - Paloma Rubio
- Department of Pediatric Anesthesiology, University Hospital 12 de Octubre, Madrid, Spain
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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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Choi JJ, Kim HS, Lee KC, Shin Y, Jo YY. Anesthetic experience of an adult male with citrullinemia type II: a case report. BMC Anesthesiol 2016; 16:92. [PMID: 27724842 PMCID: PMC5057249 DOI: 10.1186/s12871-016-0253-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/23/2016] [Indexed: 12/30/2022] Open
Abstract
Background Citrullinemia type II is an autosomal recessive urea cycle disorder and a subtype of citrin deficiency. However, the management of recurrent hyperammonemia with neurologic symptoms in patients with citrullinemia type II is quite different from the management of other types of urea cycle disorders. In pats with citrullinemia type II, regional anesthesia might be a good choice for the early detection of hyperammonemic symptoms and addressing psychic stress. Case presentation A 48-year-old male with adult onset citrullinemia type II was scheduled for urethral scrotal fistula repair. During the first operation, spinal anesthesia with conscious sedation using dexmedetomidine was used, a second operation was performed after confirmation of infection control and a stable neurologic condition. In this patient, dietary planning with close monitoring of serum ammonia level and close observation of neurologic conditions might lead to successful perioperative care. Conclusion For anesthesia of patients with adult onset citrullinemia type II, close monitoring of neurologic signs and serum ammonia are important to reduce neurologic complications induced by hyperammonemia. Regional anesthesia with a proper dietary plan might reduce patient stress and prevent metabolic tragedy.
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Affiliation(s)
- Jung Ju Choi
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, South Korea
| | - Hong Soon Kim
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, South Korea
| | - Kyung Cheon Lee
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, South Korea
| | - Youseok Shin
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, South Korea
| | - Youn Yi Jo
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, South Korea.
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Patel H, Kim J, Huncke TK. General anesthesia in a patient with citrullinemia using Precedex as an adjunct to prevent delayed emergence. J Clin Anesth 2016; 33:403-5. [PMID: 27555199 DOI: 10.1016/j.jclinane.2016.04.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 03/21/2016] [Accepted: 04/24/2016] [Indexed: 11/30/2022]
Abstract
Citrullinemia type I is a rare autosomal recessive genetic condition that causes reduced activity of the enzyme, argininosuccinate synthase, which is needed for proper urea metabolism. The end result is hyperammonemia which can cause life-threatening neurologic symptoms and global developmental delay. Previous case reports of the anesthetic management of patients with citrullinemia describe delayed recovery possibly related to elevated ammonia levels postoperatively or choice of intraoperative anesthetics which have included narcotics. In this case report, we present the anesthetic management of a 16-year-old adolescent girl with citrullinemia type I undergoing a vagus nerve stimulator revision. We used the α-2-adrenergic agonist, dexmedetomidine, as an adjunct to avoid narcotics to prevent delayed emergence. She was admitted for hydration the night before the procedure and had a baseline ammonia level of 33 μmol/L (reference, 9-33 μmol/L). Anesthetic maintenance consisted of 2% sevoflurane, dexmedetomidine 0.5 μg/kg per hour, and intravenous acetaminophen given toward the conclusion of the surgery. The patient awoke immediately at the end of the procedure and was extubated in the operating room. Postprocedure, her ammonia level was less than 9 μmol/L. She appeared to be free of pain, was tolerating gastric tube feeds postprocedure, and was discharged to home on the day of surgery. Effective management of ammonia levels in this patient using preoperative hydration and dexmedetomidine as an adjunct to general anesthesia may have helped to prevent delayed emergence.
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Affiliation(s)
- Hersh Patel
- New York University Medical Center, New York, NY, USA
| | - Jung Kim
- New York University Medical Center, New York, NY, USA
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