Anesthesia and organic aciduria: is the use of lactated Ringer's solution absolutely contraindicated?
BACKGROUND
Organic acidurias (OAs) are rare inborn errors of metabolism that can present with various neurologic manifestations, propensity for acute metabolic decompensation with anion-gap metabolic acidosis, developmental delay, poor feeding, and failure to thrive.


OBJECTIVE
In this case series, we outline the anesthetic management and perioperative outcomes of OA patients.


METHODS
We reviewed demographic characteristics, comorbidities, and perioperative course of patients with four different OAs who underwent anesthetic care at our institution between January 1, 2000, and December 31, 2013.


RESULTS
Eleven patients with OA underwent 19 anesthetic procedures, of which 13 were <2 h in duration and seven were outpatient procedures. One patient with methylmalonic acidemia developed metabolic acidosis during a 10-h procedure with substantial blood loss but lacked evidence that this acidosis could be attributed to his underlying metabolic disease. The patients who received hydration with lactated Ringer's solution and/or nitrous oxide anesthetic had a perioperative course free of metabolic complication. Two patients died within 30 days of surgery from causes likely to be unrelated to anesthetic exposure.


CONCLUSIONS
Our patients with various forms of metabolically compensated OAs tolerated anesthetics for surgical procedures without metabolic decompensation, even when lactated Ringer's solution was used for hydration. Measures to prevent protein catabolism and intraoperative events that may precipitate metabolic acidosis, in addition to close monitoring of acid-base status during more extensive procedures, must be part of perioperative treatment of these patients.
Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.|Department of Anesthesia and Intensive Care, University Children's Hospital, Brno, Czech Republic.
Katerina
K
Ruzkova
Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.
Toby N
TN
Weingarten
Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.
Kelly J
KJ
Larson
Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.
Robert J
RJ
Friedhoff
Division of Laboratory Genetics and Department of Medical Genetics, Mayo Clinic, Rochester, MN, USA.
Dimitar K
DK
Gavrilov
Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.
Juraj
J
Sprung
D000138:Acidosis / Q000150:complications*; D000293:Adolescent; D000328:Adult; D000592:Amino Acid Metabolism, Inborn Errors / Q000150:complications* / Q000601:surgery; D000758:Anesthesia / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007552:Isotonic Solutions / Q000008:administration & dosage*; D008297:Male; D000077325:Ringer's Lactate; D055815:Young Adult
D007552:Isotonic Solutions; D000077325:Ringer's Lactate
3-methylglutaconic aciduria; acidosis, metabolic; anesthesia, general; isovaleric aciduria; methylmalonic aciduria; propionic aciduria