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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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Peixoto C, Dourado C, Santos H, Roberto P. Perioperative anesthetic management of very long-chain acyl-coenzyme a dehydrogenase deficiency. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:231-234. [PMID: 36842679 DOI: 10.1016/j.redare.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 12/13/2021] [Indexed: 02/26/2023]
Abstract
Very long-chain acyl-coenzyme A dehydrogenase deficiency is a rare disorder of β-oxidation fatty acid metabolism that results in susceptibility to hypoglycemia, liver failure, cardiomyopathy and rhabdomyolysis during catabolic situations. We report the case of a 10-year-old male undergoing a totally implanted central venous catheter placement during hospitalisation for rhabdomyolysis, who was successfully managed with general anesthesia with nitrous oxide, sevoflurane and remifentanil. No hypoglycemia occurred and creatine kinase levels did not increase in the perioperative period. We describe the challenges encountered and the strategies used to avoid further decompensation of the disease due to surgical stress.
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Affiliation(s)
- C Peixoto
- Medical Degree, Department of Anesthesiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.
| | - C Dourado
- Medical Degree, Department of Anesthesiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - H Santos
- Medical Degree, Department of Pediatrics, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - P Roberto
- Medical Degree, Department of Anesthesiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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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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Owaki-Nakano R, Higashi M, Iwashita K, Shigematsu K, Toyama E, Yamaura K. Anesthetic management of multiple acyl-coenzyme A dehydrogenase deficiency in a series of surgeries under general anesthesia: a case report. JA Clin Rep 2021; 7:54. [PMID: 34245397 PMCID: PMC8272790 DOI: 10.1186/s40981-021-00459-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/28/2021] [Accepted: 07/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Glutaric acidemia is a type of multiple acyl-coenzyme A dehydrogenase deficiency, an inborn error in fatty acid metabolism. In patients with glutaric acidemia, during the perioperative period, prolonged fasting, stress, and pain have been identified as risk factors for the induction of metabolic derangement. This report describes the surgical and anesthetic management of a patient with glutaric acidemia. CASE PRESENTATION A 56-year-old male patient with glutaric acidemia type 2 underwent a series of surgeries. During the initial off-pump coronary artery bypass surgery, the patient developed renal failure due to rhabdomyolysis upon receiving glucose at 2 mg/kg/min. However, in the second laparoscopic cholecystectomy, rhabdomyolysis was avoided by administering glucose at 4 mg/kg/min. CONCLUSIONS To avoid catabolism in patients with glutaric acidemia, appropriate glucose administration is important, depending on the surgical risk.
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Affiliation(s)
- Ryoko Owaki-Nakano
- Department of Anesthesiology, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Midoriko Higashi
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Kohei Iwashita
- Department of Anesthesiology, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Kenji Shigematsu
- Department of Anesthesiology, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Emiko Toyama
- Department of Anesthesiology, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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The perioperative transition of serum biomarkers of a 1.5-year-old boy with very-long-chain acyl-CoA dehydrogenase deficiency. Mol Genet Metab Rep 2021; 27:100760. [PMID: 33996489 PMCID: PMC8086129 DOI: 10.1016/j.ymgmr.2021.100760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/14/2021] [Accepted: 04/14/2021] [Indexed: 12/31/2022] Open
Abstract
Very long-chain acyl-coenzyme A dehydrogenase deficiency (VLCADD, OMIM 201475) is a congenital fatty acid oxidation disorder. Individuals with VLCADD should avoid catabolic states, including strenuous exercise and long-term fasting; however, such conditions are required when undergoing surgery. The perioperative management of VLCADD in infants has rarely been reported and details regarding the transition of serum biomarkers reflecting catabolic status have not been disclosed. Herein, we present the perioperative clinical and biological data of cryptorchidism in a 1.5-year-old boy with VLCADD. The patient was diagnosed through newborn screening and his clinical course was very stable. Genetic testing of ACADVL revealed compound heterozygous variants c.506 T > C (p.Met169Thr) and c.606-609delC (p.L216*). The enzyme activity of the patient with VLCAD was only 20% compared to that of healthy control. Left orchiopexy for the pediatric cryptorchidism was planned and performed at 1 and a half year of age. Induction anesthesia involved thiopental, fentanyl and rocuronium. The glucose infusion rate was maintained above 6.6 mg/kg/min starting the day before surgery until the operation was completed. Anesthesia was maintained with sevoflurane at approximately 2%. The serum concentration of tetradecenoylcarnitine were stable during the operation, ranging between 0.08 and 0.19 μM (cutoff <0.2 μM), and never deviated from the reference range. Concentration of other serum biomarkers including free fatty acid, 3-OH-butyrate, and creatine kinase, remained similarly unchanged. In this report, we describe the uneventful perioperative management of unilateral orchiopexy for left cryptorchidism in a 1.5-year-old boy with VLCADD using sufficient glucose infusion and volatile anesthesia.
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Yuasa H, Onoda Y, Kitaura A, Mino T, Tsukimoto S, Nakao S. Anesthesia management in a patient with very long-chain acyl-Coenzyme A dehydrogenase deficiency. JA Clin Rep 2020; 6:72. [PMID: 32939699 PMCID: PMC7494713 DOI: 10.1186/s40981-020-00379-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/09/2020] [Indexed: 12/31/2022] Open
Abstract
Background In a patient with very long-chain acyl-Coenzyme A dehydrogenase (VLCAD) deficiency, metabolism of fatty acids is impaired and a supply of alternative energy is limited when glucose level is insufficient on starvation. Case presentation A 37-year-old woman with VLCAD deficiency was diagnosed with an ovarian cyst and was scheduled for laparoscopic ovarian cystectomy. Glucose was administered intravenously with the start of fasting. Anesthesia was induced with remifentanil, midazolam, and thiamylal, maintained with desflurane and remifentanil. Body temperature was maintained at 36.2–36.7 °C. During anesthesia, hypoglycemia did not occur, creatine kinase levels were in the normal range, and myoglobinuria was not detected. No shivering was observed after extubation. Conclusions Glucose was administered to avoid perioperative hypoglycemia. Body temperature was controlled to avoid shivering, which would otherwise increase skeletal muscle energy needs. Blood creatine kinase did not increase, and myoglobinuria was not detected; thus, rhabdomyolysis was unlikely to develop.
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Affiliation(s)
- Haruyuki Yuasa
- Department of Anesthesiology, Faculty of Medicine, Kindai University, 377-2 Ohonohigashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Yukio Onoda
- Onoda Clinic, 1917-1 Yuasa Yuasa-cho Arita-gun, Wakayama, 643-0004, Japan
| | - Atsuhiro Kitaura
- Department of Anesthesiology, Faculty of Medicine, Kindai University, 377-2 Ohonohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Takashi Mino
- Department of Anesthesiology, Faculty of Medicine, Kindai University, 377-2 Ohonohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Shota Tsukimoto
- Department of Anesthesiology, Faculty of Medicine, Kindai University, 377-2 Ohonohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Shinichi Nakao
- Department of Anesthesiology, Faculty of Medicine, Kindai University, 377-2 Ohonohigashi, Osakasayama, Osaka, 589-8511, Japan
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Van Calcar SC, Sowa M, Rohr F, Beazer J, Setlock T, Weihe TU, Pendyal S, Wallace LS, Hansen JG, Stembridge A, Splett P, Singh RH. Nutrition management guideline for very-long chain acyl-CoA dehydrogenase deficiency (VLCAD): An evidence- and consensus-based approach. Mol Genet Metab 2020; 131:23-37. [PMID: 33093005 DOI: 10.1016/j.ymgme.2020.10.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/31/2020] [Accepted: 10/02/2020] [Indexed: 12/18/2022]
Abstract
The nutrition management guideline for very-long chain acyl-CoA dehydrogenase deficiency (VLCAD) is the fourth in a series of web-based guidelines focusing on the diet treatment for inherited metabolic disorders and follows previous publication of guidelines for maple syrup urine disease (2014), phenylketonuria (2016) and propionic acidemia (2019). The purpose of this guideline is to establish harmonization in the treatment and monitoring of individuals with VLCAD of all ages in order to improve clinical outcomes. Six research questions were identified to support guideline development on: nutrition recommendations for the healthy individual, illness management, supplementation, monitoring, physical activity and management during pregnancy. This report describes the methodology used in its development including review, critical appraisal and abstraction of peer-reviewed studies and unpublished practice literature; expert input through two Delphi surveys and a nominal group process; and external review from metabolic physicians and dietitians. It includes the summary statements of the nutrition management recommendations for each research question, followed by a standardized rating based on the strength of the evidence. Online, open access of the full published guideline allows utilization by health care providers, researchers and collaborators who advise, advocate and care for individuals with VLCAD and their families and can be accessed from the Genetic Metabolic Dietitians International (https://GMDI.org) and Southeast Regional Genetics Network (https://southeastgenetics.org/ngp) websites.
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Affiliation(s)
| | - M Sowa
- CHOC Children's, Orange, CA, USA
| | - F Rohr
- Met Ed Co, Boulder, CO, USA; Children's Hospital of Boston, Boston, MA, USA
| | - J Beazer
- National PKU News, How Much Phe, LLC, Helena, MT, USA
| | - T Setlock
- Shodair Children's Hospital, Helena, MT, USA
| | - T U Weihe
- Children's Mercy, Kansas City, MO, USA
| | - S Pendyal
- Duke University Health System, Durham, NC, USA
| | - L S Wallace
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - J G Hansen
- Oregon Health & Science University, Portland, OR, USA
| | | | - P Splett
- University of Minnesota, St. Paul, MN, USA
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Yamada K, Matsubara K, Matsubara Y, Watanabe A, Kawakami S, Ochi F, Kuwabara K, Mushimoto Y, Kobayashi H, Hasegawa Y, Fukuda S, Yamaguchi S, Taketani T. Clinical course in a patient with myopathic VLCAD deficiency during pregnancy with an affected baby. JIMD Rep 2019; 49:17-20. [PMID: 31497477 PMCID: PMC6718132 DOI: 10.1002/jmd2.12061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 11/08/2022] Open
Abstract
Very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency is an autosomal recessive mitochondrial fatty acid oxidation disorder that manifests in three clinical forms: (a) severe, (b) milder, and (c) myopathic. Patients with the myopathic form present intermittent muscular symptoms such as myalgia, muscle weakness, and rhabdomyolysis during adolescence or adulthood. Here, the clinical symptoms and serum creatine kinase (CK) levels of a pregnant 31-year-old woman with the myopathic form of VLCAD deficiency were reduced during pregnancy. Clinical symptoms rarely appeared during pregnancy, although she had sometimes suffered from muscular symptoms before pregnancy. When ritodrine was administered for threatened premature labor at 35 weeks of gestation, her CK level was elevated to over 3900 IU/L. She delivered a full-term baby via cesarean section but suffered from muscle weakness with elevated CK levels soon after delivery. It has been reported that an unaffected placenta and fetus can improve maternal β-oxidation during pregnancy. However, in our case, the baby was also affected by VLCAD deficiency. These suggest that the clinical symptoms of a woman with VLCAD deficiency might be reduced during pregnancy even if the fetus is affected with VLCAD deficiency.
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Affiliation(s)
- Kenji Yamada
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
| | - Keiichi Matsubara
- Department of Obstetrics and GynecologyEhime University School of MedicineToonEhimeJapan
| | - Yuko Matsubara
- Department of Obstetrics and GynecologyEhime University School of MedicineToonEhimeJapan
| | - Asami Watanabe
- Department of PediatricsYawatahama City General HospitalYawatahamaEhimeJapan
- Department of PediatricsEhime University Graduate School of MedicineToonEhimeJapan
| | - Sanae Kawakami
- Department of PediatricsYawatahama City General HospitalYawatahamaEhimeJapan
| | - Fumihiro Ochi
- Department of PediatricsYawatahama City General HospitalYawatahamaEhimeJapan
- Department of PediatricsEhime University Graduate School of MedicineToonEhimeJapan
| | - Kozue Kuwabara
- Department of PediatricsEhime University Graduate School of MedicineToonEhimeJapan
| | - Yuichi Mushimoto
- Department of Pediatrics, Graduate School of Medical SciencesKyushu UniversityHigashi‐kuFukuokaJapan
| | - Hironori Kobayashi
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
| | - Yuki Hasegawa
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
| | - Seiji Fukuda
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
| | - Seiji Yamaguchi
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
| | - Takeshi Taketani
- Department of PediatricsShimane University Faculty of MedicineIzumoShimaneJapan
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