A review of anaesthetic outcomes in patients with genetically confirmed mitochondrial disorders

Mitochondrial disorders are a clinically and biochemically diverse group of disorders which may involve multiple organ systems. General anaesthesia (GA) poses a potential risk of decompensation in children with mitochondrial disorders, and there is little guidance for anaesthetists and other clinicians regarding the optimal anaesthetic agents and perioperative management to provide to patients with mitochondrial disease[15]. The aim of this review was to document adverse events and perioperative complications from GA in patients with genetically confirmed mitochondrial disorders. A retrospective chart review of patients with genetically confirmed mitochondrial disorders who had undergone GA was undertaken. The indication for GA, anaesthetic agents utilised, length of admission and post anaesthetic complications were documented and analysed. Twenty-six patients with genetically proven mitochondrial disease underwent 65 GAs. Thirty-four (52%), received propofol as their induction agent. Thirty-three (51%) patients received sevoflurane for the maintenance of anaesthesia, while 8 (12%) received isoflurane and 24 (37%) received propofol. The duration of most GAs was short with 57 (87%) lasting less than 1 h. Perioperative complications occurred in five patients while under GA including ST segment depression, hypotension and metabolic acidosis in one. All five patients were stabilised successfully and none required ICU admission as a consequence of their perioperative complications. The duration of hospital stay post GA was <24 h in 25 (38%) patients.

CONCLUSION

No relationship between choice of anaesthetic agent and subsequent perioperative complication was observed. It is likely that individual optimisation on a case-by-case basis is more important overall than choice of any one particular technique. What is Known: • General anaesthesia (GA) poses a potential risk of decompensation in children with mitochondrial disorders. • There is a great diversity in the anaesthetic approaches undertaken in this cohort, and little guidance exists for anaesthetists and other clinicians regarding the optimal anaesthetic agents and perioperative management to provide to patients with mitochondrial disease. What is New: • In this study of 26 patients with genetically confirmed mitochondrial disease who underwent 65 GAs, no relationship between choice of anaesthetic agent and subsequent perioperative complication was observed • It is likely that individual optimisation on a case-by-case basis is more important overall than choice of any one particular technique.

Plasma concentrations of nitric oxide products and cognitive dysfunction following coronary artery bypass surgery

BACKGROUND AND OBJECTIVE

Prospective longitudinal studies now indicate that cognitive dysfunction following coronary artery bypass surgery (CABG) is both common and persistent. This dysfunction is due in part to the inflammatory response and cerebral ischaemia-reperfusion, with nitric oxide (NO) as an important mediator of both. We hypothesized that a clinically significant association exists between plasma concentrations of nitrate/nitrite (NO3-/NO2-) and cognitive dysfunction after CABG.

METHODS

Cognitive assessment was performed on 36 adult patients the day before CABG, on the fourth postoperative day and 3 months postoperatively. Patient spouses (n = 10) were also studied.

RESULTS

A new cognitive deficit was present in 22/36 (62%) 4 days postoperatively and in 16/35 (49%) of patients, 3 months postoperatively. Patients who had cognitive dysfunction 3 months postoperatively were more likely to have cognitive dysfunction and increased plasma NO3-/NO2- concentrations compared to the non-deficit group preoperatively (22.6 (9.2) vs. 27.6 (8.4)) (P = 0.002). Plasma NOx (NO3- plus NO2-) concentrations were greater in patients with cognitive dysfunction 3 months postoperatively, 2 h (24.2 (6.3) vs. 19.1 (5.2)) (P = 0.002), and 12 h postoperatively (24.8 (7.6) vs. 18.8 (5.6)) (P = 0.001). There was, however, a time course similarity in NOx elevations for both deficit and non-deficit groups.

CONCLUSIONS

Perioperative plasma NOx concentrations do not serve as an effective biomarker of cognitive deficit after CABG.

Nebulised ipratropium causing a unilateral fixed dilated pupil in the critically ill patient: a report of two cases

We describe two cases of a unilateral fixed dilated pupil secondary to the ocular instillation of nebulised ipratropium bromide. In one patient there was no other neurological abnormality. The second patient was unconscious following a cardiac arrest. While a fixed dilated pupil is an alarming sign, if it is caused by ocular instillation of ipratropium bromide the condition will resolve, although it may take up to 24 hours. The differential diagnosis of a unilateral dilated pupil includes partial third nerve palsy, tonic pupil, direct trauma to the eye and pharmacological mydriasis. The diagnosis can often be determined using pilocarpine eye drops.

The management of dural puncture in obstetrics and the efficacy of epidural blood patches

Epidural blood patch is the definitive treatment for post dural puncture headaches (PDH), providing acceptable short-term relief. Disappointingly however debate exists as to their long-term success. To investigate their efficacy in our practice, a retrospective audit of all epidural blood patches performed over a four year period was performed. Patients were subsequently followed up using a postal questionnaire and persistent symptom relief and patient satisfaction was measured. During the study period 87 patients required an epidural blood patch, 11 required repeat patches. 71.26% of patients had complete symptom resolution on discharge. The response rate to follow up survey was 73.26% with the majority, 57.44%, replying that their symptoms returned following their discharge home. Only 25.53% said they would have an epidural or spinal anaesthetic for future deliveries. Epidural blood patches provide excellent short-term relief but long-term results are disappointing. Patients receiving epidural blood patches need improved long-term follow up.

Long-term headache following epidural analgesia

Epidural analgesia is widely used in modern obstetric practice. Complications are uncommon but if they occur may result in significant morbidity. Post dural puncture headache (PDPH), in particular, may be particularly incapacitating especially if left untreated. In this report we describe the management of a case of unrecognised and undiagnosed PDPH.