Anesthesia for a child with Leigh's syndrome

Anaesthetic management of a patient with Leigh's syndrome with central hypoventilation and obstructive sleep apnoea

Leigh's syndrome, which is characterised by progressive neurodegeneration involving the brainstem and basal ganglia, belongs to a family of disorders classified as mitochondrial myopathies. It is most commonly transmitted by an autosomal recessive mode of inheritance, but can sometimes occur in a mitochondrial pattern. It typically presents during infancy with developmental delay and deterioration of brainstem function. Respiratory failure is the common cause of death and postoperative morbidity in patients with Leigh's disease. Herein, we report the case of a 17-year-old female patient with Leigh's syndrome who underwent general anaesthesia for a tracheostomy, which was performed in view of the patient's requirement for long-term ventilation and frequent toileting for secretions. Her respiratory complications included central hypoventilation secondary to brainstem involvement, and obstructive sleep apnoea due to obesity and muscle dystonia. She was hospitalised for acute respiratory decompensation secondary to hospital-acquired pneumonia. We review the anaesthetic implications of this disease and discuss its impact on preoperative, intraoperative and postoperative management.

Anesthetic considerations in Leigh disease: Case report and literature review

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.

Anesthesia for corrective spinal surgery in a patient with Leigh's disease

We report a case of anesthesia for posterior spinal fusion in a woman with Leigh's disease. This is a syndrome with a heterogeneous phenotype including ocular signs, motor signs, and respiratory disorder. It is associated with defects in the enzymes of the mitochondrial respiratory chain and central neural degeneration. Anesthesia is associated with worsening of the respiratory symptoms. Our patient underwent major spinal surgery as a palliative procedure. Her postoperative course was complicated by acute lung injury and sepsis. She ultimately failed a prolonged respiratory wean. Serial magnetic resonance imaging revealed a rapidly progressive necrosis of her brain stem and cervical spinal cord consistent with activation of her underlying Leigh's disease. This is the first report of spinal surgery in this patient group. It is also the first radiological demonstration of Leigh's disease reactivation in the postoperative period. Anesthesia and surgery are hazardous in this patient population, and respiratory symptoms make this a high-risk group. Surgery should only be undertaken with caution and after frank consent. Early postoperative imaging is recommended if there are respiratory complications. No drug prophylaxis has been shown to alter disease activation.

IMPLICATIONS

Patients suffering from Leigh's disease are at high risk of serious postoperative respiratory morbidity. We present a case that demonstrates delayed respiratory complications and link this postoperative adverse outcome to aggressive reactivation of the underlying neurodegenerative condition.

Anaesthetic management of a patient with Leigh's syndrome

PURPOSE

Leigh's syndrome, a progressive neurodegenerative disorder of infancy and childhood, is clinically characterized mainly by developmental delay, nervous system dysfunction and respiratory abnormalities such as aspiration, wheezing, breathing difficulties, gasping, hypoventilation and apnoea. Acute exacerbation and respiratory failure may follow surgery, general anaesthesia or intercurrent illnesses. Hyperlecithinemia is variably present. Histopathological findings include necrosis, vascular proliferation, astrocytosis and demyelination of several brain areas. We present a 30-month-old patient with Leigh's syndrome anaesthetized for extracorporeal shockwave lithotripsy, and describe the anaesthetic considerations.

CLINICAL FEATURES

Leigh's syndrome was diagnosed at five months of age based on failure to thrive, lethargy, hypotonicity, choreo-athetosis and lactic acidaemia, with basal ganglia hypodense areas demonstrated by brain computerized tomographic scan. Muscle pyruvate dehydrogenase complex and NADH coenzyme Q oxidoreductase activity were 25% and 13% of control. No preoperative respiratory symptoms or signs were present. Preoperative fasting lasted two hours and gastric aspiration was negative. Anaesthesia was induced with ketamine and midazolam im, and N2O in oxygen, and maintained with propotol and N2O. No volatile anaesthetics were used. Intravenous fluids given were 1/2 normal saline and glucose 5% administered. Besides laryngospasm during anaesthetic induction, relieved by sublingual succinylcholine injection, the perianaesthetic course was uneventful. The lungs were mechanically ventilated and lithotripsy was performed. No adverse sequelae have occurred, and the patient was discharged one day later.

CONCLUSION

Perioperative management of patients with Leigh's syndrome requires cautious attention to the metabolic, neurological and respiratory aspects of the disease, and appropriate selection of anaesthetic drugs.

Acute respiratory failure precipitated by general anesthesia in Leigh's syndrome

Three patients with Leigh's syndrome developed respiratory failure following general anesthesia. Although all three had respiratory symptoms prior to the anesthetic, the diagnosis was not suspected at the time of the procedure in two of the children. We reviewed the case notes of 16 other patients with Leigh's syndrome. Eight had received anesthetic agents without incident. Although the majority subsequently developed respiratory abnormalities and died with respiratory failure, this problem was not evident at the time of anesthesia. In the presence of respiratory abnormalities, general anesthesia carries significant risks in Leigh's syndrome.

Anaesthesia and pyruvate dehydrogenase deficiency

A ten-month-old infant with pyruvate dehydrogenase deficiency received anaesthesia on two occasions, once for a laparotomy and once for a tracheostomy. During both anaesthetics (different techniques) she developed an increase in arterial lactate levels and a metabolic acidosis. Pyruvate dehydrogenase deficiency results in the inability to metabolize pyruvate with resultant accumulation of pyruvate and lactate. Inhibition of gluconeogenesis, which may be produced by halothane and thiopentone, will also increase lactate levels. Other causes of increased lactate levels are hypocarbia and high carbohydrate intake. In this patient hypocarbia may have produced increased lactate levels and increased the metabolic acidosis. Recommendations include avoidance of halogenated anaesthetics, avoidance of lactate containing solutions, maintenance of normocarbia, and stress-free anaesthesia.