RESUMEN
BACKGROUND: Age-related differences in the pharmacokinetics and pharmacodynamics of neuromuscular blocking agents (NMBAs) and the short duration of many surgical procedures put pediatric patients at risk of postoperative residual curarization (PORC). To date, the duration of neuromuscular blocking agent effect in children has not been analyzed in a quantitative review. The current meta-analysis aimed to compare spontaneous recovery following administration of various types and doses of neuromuscular blocking agents and to quantify the effect of prognostic variables associated with the recovery time in pediatric patients. METHOD: We searched for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared the time to 25% T1 (t25), from 25% to 75% T1 (RI25-75), and to ≥90% train-of-four (tTOF90) neuromuscular recovery between common neuromuscular blocking agent treatments administered as a single bolus to healthy pediatric participants. We compared spontaneous t25, RI25-75, and tTOF90 between (1) neuromuscular blocking agent treatments and (2) age groups receiving a given neuromuscular blocking agent intervention and anesthesia technique. Bayesian random-effects network and pairwise meta-analyses along with meta-regression were used to evaluate the results. RESULTS: We used data from 71 randomized controlled trials/controlled clinical trials including 4319 participants. Network meta-analysis allowed for the juxtaposition and ranking of spontaneous t25, RI25-75, and tTOF90 following common neuromuscular blocking agent interventions. For all neuromuscular blocking agents a log-linear relationship between dose and duration of action was found. With the neuromuscular blocking agent treatments studied, the average tTOF90 (mean[CrI95]) in children (>2-11 y) was 41.96 [14.35, 69.50] and 17.06 [5.99, 28.30] min shorter than in neonates (<28 d) and infants (28 d-12 M), respectively. We found a negative log-linear correlation between age and duration of neuromuscular blocking agent effect. The difference in the tTOF90 (mean[CrI95]) between children and other age groups increased by 21.66 [8.82, 34.53] min with the use of aminosteroid neuromuscular blocking agents and by 24.73 [7.92, 41.43] min with the addition of sevoflurane/isoflurane for anesthesia maintenance. CONCLUSIONS: The times to neuromuscular recovery are highly variable. These can decrease significantly with age and are prolonged when volatile anesthetics are administered. This variability, combined with the short duration of many pediatric surgical procedures, makes quantitative neuromuscular monitoring mandatory even after a single dose of neuromuscular blocking agent.
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Periodo de Recuperación de la Anestesia , Bloqueo Neuromuscular , Niño , Preescolar , Humanos , Lactante , Metaanálisis en Red , Bloqueo Neuromuscular/métodos , Bloqueantes Neuromusculares/administración & dosificación , Recién NacidoRESUMEN
Anesthetic agent consumption is often calculated as the product of fresh gas flow (FGF) and vaporizer dial setting (FVAP). Because FVAP of conventional vaporizers is not registered in automated anesthesia records, retrospective agent consumption studies are hampered. The current study examines how FVAP can be retrospectively calculated from the agent's inspired (FIN) and end-expired concentration (FET), FGF, and minute ventilation (MV). Theoretical analysis of agent mass balances in the circle breathing reveals FVAP = [FIN - (dead space fraction * FIN + (1 - dead space fraction) * FET) * (1 - FGF/MV)]/(1-(1 - FGF/MV)). FIN, FET, FGF and MV are routinely monitored, but dead space fraction is unknown. Dead space fraction for sevoflurane, desflurane, and isoflurane was therefore determined empirically from an unpublished data set of 161 patient containing FVAP, FIN, FET, MV and FGF ranging from 0.25 to 8 L/min delivered via an ADU® (GE, Madison, WI, USA). Dead space fraction for each agent was determined empirically by having Excel's solver function calculate the value of dead space fraction that minimized the sum of the squared differences between dialed FVAP and predicted FVAP. With dead space fraction known, the model was then prospectively tested for sevoflurane in O2/air using data collected over the course of two weeks with one FLOW-i (Getinge, Solna, Sweden) and one Zeus workstation (Dräger, Lübeck, Germany). Because both workstations use an electronically controlled vaporizer/injector, the dialed FVAP were available to allow the calculation of median performance error (MDPE) and median absolute performance error (MDAPE). MDPE and MDAP are reported as median and interquartiles. The empirical dead space fraction for isoflurane, sevoflurane, and desflurane were 0.59, 0.49, and 0.66, respectively. For prospective testing, a total of 149.4 h of useful data were collected from 78 patient with the Zeus and Flow-i combined, with FGF ranging from 0.18 to 8 L/min. The model predicted dialed FVAP well, with a MDPE of -1 (-11, 6) % and MDAPE of 8 (4, 17) %. FVAP can be retrospectively calculated from FIN, FET, FGF, and MV plus an agent specific dead space fraction factor with a degree of error that we believe suffices for retrospective sevoflurane consumption analyses. Performance with other agents and N2O awaits further validation.
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Anestésicos por Inhalación , Isoflurano , Éteres Metílicos , Humanos , Sevoflurano , Desflurano , Estudios Retrospectivos , Estudios Prospectivos , Anestesia por InhalaciónRESUMEN
Inhalational inductions with sevoflurane (up to 8% inspired concentration) have been the standard for inducing anesthesia in children for over three decades. However, when sevoflurane was first introduced, clinicians reported isolated cases of unexpected myoclonic jerking movements during the induction in children without epilepsy. These cases raised concerns regarding the widespread use of sevoflurane particularly after reports of seizures and epileptiform electroencephalographic (EEG) discharges surfaced. The latter reports prompted recommendations to reduce the concentration of sevoflurane during induction of anesthesia. More recently, a shift away from the use of nitrous oxide has prompted some to question whether sevoflurane has a role as an induction agent in children. The preponderance of evidence supports the practice of safely inducing anesthesia with 8% sevoflurane with or without nitrous oxide in children but recommended strategies to mitigate against epileptiform discharges may be more harmful than beneficial.
Asunto(s)
Anestésicos por Inhalación , Éteres Metílicos , Anestesia General , Anestesia por Inhalación , Anestésicos por Inhalación/efectos adversos , Niño , Conducta Exploratoria , Humanos , Óxido Nitroso , SevofluranoRESUMEN
BACKGROUND: We aimed to evaluate if two-handed mask airway is superior to one-handed mask airway during inhalational induction of anesthesia in children. METHODS: A randomized, two period, crossover study was performed on 60 children aged 1-8 years, with obstructive sleep apnea due to adenotonsillar hypertrophy, scheduled for adenotonsillectomy. Children were assigned to two study sequences and one control sequence of 20 subjects each. A control sequence was added to evaluate the effect of anesthetic depth. Sequence 1: One-handed followed by two-handed airway, 30 seconds each; Sequence 2: two-handed followed by one-handed airway, 30 seconds each and Sequence 3: two-handed airway, for 60 seconds. The work of breathing indices, phase angle, and labored breathing index were recorded using respiratory inductance plethysmography. Additional outcome measures were tidal volume, minute ventilation, and respiratory rate. A straight comparison and a crossover analysis was performed. RESULTS: The initial comparison revealed that one-handed airway had greater phase angle (mean diff. 17.4; 95% confidence interval [CI] 1.07-33.68; P = .034), greater labored breathing index (mean diff. 0.56; 95% CI 0.16-1.04; P = .004),lower minute ventilation (mean diff. -1567; 95% CI -2695 to -5.4; P = .004),and lower tidal volume (mean diff. -39; 95% CI -2.7 to -5.4; P = .02) than two-handed airway. On crossover analysis, within-subject difference in the phase angle was greater during one-handed than two-handed airway (34.3; 95% CI 8.46-60.14; P = .01) as was labored breathing index (mean diff. 1.2; 95% CI 0.39-2.00; P < .0046).Minute ventilation was lower during one-handed than two-handed airway (mean diff. -3359; 95% CI -4363 to -2355, P < 0.0001) as was tidal volume(mean diff. -78; 95% CI -110.4 to -45.8; P < .0001). CONCLUSION: In children with obstructive sleep apnea due to adenotonsillar hypertrophy, two-handed airway provides superior airway patency that was not influenced by the anesthetic depth.
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Máscaras Laríngeas , Respiración Artificial , Adenoidectomía , Anestesia General , Niño , Estudios Cruzados , Humanos , Volumen de Ventilación PulmonarRESUMEN
Anesthesia for pediatric airway procedures constitutes a true art form that requires training and experience. Communication between anesthetist and surgeon to establish procedure goals is essential in determining the most appropriate anesthetic management. But does the mode of anesthesia have an impact? Traditionally, inhalational anesthesia was the most common anesthesia technique used during airway surgery. Introduction of agents used for total intravenous anesthesia (TIVA) such as propofol, short-acting opioids, midazolam, and dexmedetomidine has driven change in practice. Ongoing debates abound as to the advantages and disadvantages of volatile-based anesthesia versus TIVA. This pro-con discussion examines both volatiles and TIVA, from the perspective of effectiveness, safety, cost, and environmental impact, in an endeavor to justify which technique is the best specifically for pediatric airway procedures.
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Anestesia por Inhalación/métodos , Anestesia por Inhalación/normas , Anestesia Intravenosa/métodos , Anestesia Intravenosa/normas , Sistema Respiratorio/cirugía , Nivel de Atención , Animales , Niño , Preescolar , HumanosRESUMEN
Reducing fresh gas flow during inhalational anaesthesia results in cost savings and decreases environmental impact. We are interested in the influence of fresh gas flow on the early (induction) phase of overall fresh gas flow and vapour consumption. This stage is often excluded in studies of fresh gas flow. Data were collected from 3199 sevoflurane anaesthetics over an 11-month period in four operating theatres. We determined fresh gas flow at different stages of anaesthesia, and developed an explanatory model for the influence of the 'induction' period. Following a three-month collection of baseline data we emphasised the importance of the early phase to our department repeatedly over a two-week period. We explored the relationship between fresh gas flow and total vapour usage, and used a simple mathematical model to explore the effect of changes in the fresh gas flow and duration of the 'induction' phase. Mean fresh gas flow was 1.15 l.min-1 in the baseline period and 0.91 l.min-1 in the two months following our educational effort (p = 0.0005). In the following six months, mean fresh gas flow was 1.17 l.min-1 (p = 0.7726 compared with baseline). These results were driven by changes in both fresh gas flow and duration of the initial high-flow period. We found some correlation (R2 = 0.85) between overall fresh gas flow and vapour consumption; a 1 l.min-1 increase in fresh gas flow consumes an additional 18 ml.hr-1 of liquid sevoflurane. This preliminary study demonstrates that an episode of high fresh gas flow at the start of anaesthesia has a large and modifiable effect on overall fresh gas flow and vapour consumption. We also confirmed the linear relationship between fresh gas flow and vapour usage.
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Anestesia por Inhalación/métodos , Anestesia por Inhalación/estadística & datos numéricos , Anestésicos por Inhalación/administración & dosificación , Mejoramiento de la Calidad , Sevoflurano/administración & dosificación , Humanos , Nueva ZelandaRESUMEN
This is an account of an interview with David John Hatch who was one of the first Professors of Pediatric Anesthesia in the world. He began his anesthesia career as a medical student administering chloroform and ended it 40 years later as a Consultant at Great Ormond Street Hospital where he developed and led a world renowned research team measuring and assessing lung function in infants and children. These productive years earned him his chair at the Institute of Child Health in London (part of University College London) funded by Portex (currently, a branch of Smiths Medical). His academic achievements include over 110 journal publications, two textbooks and having many honors and awards. Yet he does not think of himself as an academic. In his words "I wanted to be a hard working clinician with an interest in research, and not just academic".
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Anestesiología/historia , Docentes/historia , Anestesia/historia , Anestesiología/educación , Distinciones y Premios , Niño , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Lactante , Londres , Masculino , Pruebas de Función RespiratoriaRESUMEN
Inhaled anesthetics have been utilized mostly for general anesthesia in the operating room and oftentimes for sedation and for treatment of refractory status epilepticus and status asthmaticus in the intensive care unit. These contexts in the ICU setting are related to potential for prolonged administration wherein potential organ toxicity is a concern. Over the last decade, several clinical and animal studies of neurotoxicity attributable to inhaled anesthetics have been emerging, particularly in extremes of age. This review overviews potential for and potential mechanisms of neurotoxicity and systemic toxicity of prolonged inhaled anesthesia and clinical scenarios where inhaled anesthesia has been used in order to assess safety of possible prolonged use for sedation. High dose inhaled agents are associated with postoperative cognitive dysfunction (POCD) and other situations. However, thus far no strong indication of problematic neuro or organ toxicity has been demonstrated after prolonged use of low dose volatile anesthesia.
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Anestesia por Inhalación/efectos adversos , Anestésicos por Inhalación/administración & dosificación , Anestésicos por Inhalación/toxicidad , Animales , Sistema Nervioso Central/efectos de los fármacos , Disfunción Cognitiva/inducido químicamente , Cuidados Críticos , Sedación Profunda/efectos adversos , Humanos , Inflamación/inducido químicamente , Unidades de Cuidados Intensivos , Síndromes de Neurotoxicidad/etiología , Complicaciones Posoperatorias/inducido químicamente , Estado Asmático/terapia , Estado Epiléptico/terapiaRESUMEN
Introducción. La inducción anestésica con sevofluorano se asocia con agitación postanestésica (APA) en niños. Concentraciones de sevofluorano mayores a 6% producen actividad cerebral epileptiforme, la que podría estar relacionada a APA. El propósito de este estudio fue comparar el efecto de dos diferentes concentraciones de inducción anestésica con sevofluorano sobre la incidencia de APA, en niños sometidos a cirugía infraumbilical. Método. Estudio prospectivo y doble ciego, en pacientes de 2 a 7 años, operados de fimosis o hernia inguinal con anestesia general y bloqueo epidural caudal. Los pacientes fueron aleatorizados para recibir sevofluorano 5 por ciento (grupo S5) o sevofluorano 8 por ciento (grupo S8). Se registraron variables demográficas, signos vitales, profundidad anestésica utilizando índice biespectral (BIS) y respuesta motora durante distintos momentos de la anestesia. Se evaluó la presencia de agitación en pabellón y recuperación utilizando la escala de APA pediátrica (PAED). Análisis estadístico: t-test o Mann-Whitney y test Chi-cuadrado o Fisher, p < 0,05 considerada significativa. Resultados. Se reclutaron 33 pacientes, 16 en el grupo S5 y 17 en el grupo S8. Ambos grupos fueron comparables en cuanto a variables demográficas, signos vitales, respuesta motora y valores de BIS. No hubo diferencias significativas en la incidencia de APA en pabellón (S5: 31,3 por ciento y S8: 35,3 por ciento) y en recuperación (S5: 43,8 por ciento y S8: 41,2 por ciento), entre los grupos. Conclusión. No habría relación entre la concentración de inducción anestésica de sevofluorano y la incidencia de APA en niños sometidos a cirugía infraumbilical con anestesia general y bloqueo caudal. (AU)
Introduction. Induction of anesthesia with sevoflurane is associated with post-anesthetic agitation (PAA) in children. Sevoflurane concentration greater than 6% produces epileptiform brain activity, which could be related to PAA. The aim of this study was to compare the effect of two different sevoflurane concentrations for anesthesia induction on the incidence of PAA in children undergoing infraumbilical surgery. Method. Prospective, double blind study, performed in patients 2 to 7 years of age, undergoing circumcision or inguinal hernia repair under general anesthesia and epidural caudal block. Patients were randomized to receive sevoflurane 5 percent (S5 group) or sevoflurane 8 percent (S8 group), during anesthesia induction. Demographic variables, vital parameters, anesthesia depth using bispectral index (BIS) and motor responses during different moments of anesthesia were recorded. The presence of agitation in the operating room and recovery room were determined using the pediatric PAA scale (PAED). Statistical analysis: t-test or Mann-Whitney, and Chi-square or Fisher test, p < 0.05 considered significant. Results. Thirty-three patients were enrolled, 16 in the S5 group and 17 in the S8 group. Demographic variables, vital parameters, motor responses and BIS values were comparable between both groups. There were no significant differences in the incidence of PAA in the operating room (S5: 31.3 percent percent and S8: 35.3 percent) or in the recovery room (S5: 43,8 percent and S8: 41.2 percent), between both groups. Conclusion. Sevoflurane concentration used for induction of anesthesia would not be related to the incidence of PAA in children undergoing infraumbilical surgery under general anesthesia and epidural caudal block. (AU)
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Humanos , Masculino , Femenino , Niño , Sedación Profunda , Delirio del Despertar , Niño , Anestesia por InhalaciónRESUMEN
AIM: Examination of dynamic airway collapse in patients with obstructive sleep apnea (OSA) during drug-induced sleep endoscopy (DISE) can help identify the anatomic causes of airway obstruction. We hypothesized that a combination of dexmedetomidine and ketamine (Group DK) would result in fewer oxygen desaturations and a higher successful completion rate during DISE in children with OSA when compared to propofol (Group P) or sevoflurane/propofol (Group SP). METHODS: In this retrospective study, we reviewed the records of 59 children who presented for DISE between October 2013 and March 2015. Data analyzed included demographics, OSA severity, and hemodynamics (heart rate and blood pressure). The primary outcomes were airway desaturation during DISE to <85% and successful completion of DISE; these were compared between the three groups: DK, P, and SP. RESULTS: Preoperative polysomnography was available for 49 patients. There were significantly more patients with severe OSA in Group P as compared to the other two groups. The mean (±sd) bolus dose for ketamine, dexmedetomidine, and propofol were 2.0 ± 0.6 mg·kg(-1) , 1.9 ± 0.9 mcg·kg(-1) , and 1.8 ± 1.1 mg·kg(-1) , respectively. The mean (±sd) infusion rate for dexmedetomidine was 1.6 ± 0.7 mcg·kg(-1) ·h(-1) and for propofol was 248 ± 68 mcg·kg(-1) ·min(-1) in Group P and 192 ± 48 mcg·kg(-1) ·min(-1) in Group SP. Patients in Group DK had significantly fewer desaturations to <85% during DISE compared to Group P. Patients in Group DK had significantly more successful completion of DISE (100% Group DK, 92% Group P, and 79% Group SP) as compared to Group SP. CONCLUSIONS: These results suggest that the described dose regimen of propofol used alone or in combination with sevoflurane appears to be associated with more oxygen desaturations and a lower rate of successful completion than a combination of dexmedetomidine and ketamine during DISE in children with OSA.
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Obstrucción de las Vías Aéreas/epidemiología , Dexmedetomidina , Endoscopía , Ketamina , Éteres Metílicos , Propofol , Apnea Obstructiva del Sueño/epidemiología , Analgésicos , Anestésicos por Inhalación , Anestésicos Intravenosos , Causalidad , Niño , Quimioterapia Combinada , Femenino , Humanos , Hipnóticos y Sedantes , Masculino , Estudios Retrospectivos , Sevoflurano , Sueño/efectos de los fármacosRESUMEN
BACKGROUND: We conducted a prospective, randomized, double-blind, placebo-controlled study to verify the hypothesis that intranasal dexmedetomidine premedication can reduce the minimum alveolar concentration of sevoflurane for laryngeal mask airway insertion in children. METHODS: Ninety American Society of Anesthesiologists (ASA) physical status I subjects, aged 3-7 years, were randomized to three equal groups to receive saline (Group S), dexmedetomidine 1 µg · kg(-1) (Group D1 ), or dexmedetomidine 2 µg · kg(-1) (Group D2 ) approximately 45 min before anesthesia. The minimum alveolar concentration for laryngeal mask airway insertion of sevoflurane was determined according to the Dixon's up-and-down method. Emergence delirium was evaluated using the Pediatric Anesthesia Emergence Delirium (PAED) scale in the postanesthesia care unit (PACU). RESULTS: Dexmedetomidine premedication of 1 and 2 µg · kg(-1) was associated with reduction in sevoflurane from 1.92% to 1.53% and 1.23%, corresponding to decrease of 20% and 36%, respectively. The peak PAED scores (median [IQR]) were 9 [8-11.5], 5 [3-5.3], and 3 [2-4] in Group S, Group D1, and Group D2 , respectively. The incidence of emergence delirium (defined as peak PAED score ≥ 10) was significantly lower in Groups D1 and D2 than in Group S (P < 0.001). Simultaneously, the induction qualities and the parent's satisfaction scores were significantly higher in Groups D1 and D2 than in Group S (P < 0.001). CONCLUSION: Intranasal dexmedetomidine premedication produces a dose-dependent decrease in the minimum alveolar concentration for laryngeal mask airway insertion of sevoflurane and emergence delirium in the PACU.
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Periodo de Recuperación de la Anestesia , Delirio/prevención & control , Dexmedetomidina/farmacología , Máscaras Laríngeas , Éteres Metílicos/farmacocinética , Premedicación/métodos , Administración Intranasal , Anestésicos por Inhalación/farmacocinética , Niño , Preescolar , Dexmedetomidina/administración & dosificación , Método Doble Ciego , Sinergismo Farmacológico , Femenino , Humanos , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/farmacología , Masculino , Estudios Prospectivos , Sevoflurano , Resultado del TratamientoRESUMEN
BACKGROUND: Adverse neurodevelopmental outcomes are observed in up to 50% of infants after complex cardiac surgery. We sought to determine the association of perioperative anesthetic exposure with neurodevelopmental outcomes at age 12 months in neonates undergoing complex cardiac surgery and to determine the effect of brain injury determined by magnetic resonance imaging (MRI). METHODS: Retrospective cohort study of neonates undergoing complex cardiac surgery who had preoperative and 7-day postoperative brain MRI and 12-month neurodevelopmental testing with Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Doses of volatile anesthetics (VAA), benzodiazepines, and opioids were determined during the first 12 months of life. RESULTS: From a database of 97 infants, 59 met inclusion criteria. Mean ± sd composite standard scores were as follows: cognitive = 102.1 ± 13.3, language = 87.8 ± 12.5, and motor = 89.6 ± 14.1. After forward stepwise multivariable analysis, new postoperative MRI injury (P = 0.039) and higher VAA exposure (P = 0.028) were associated with lower cognitive scores. ICU length of stay (independent of brain injury) was associated with lower performance on all categories of the Bayley-III (P < 0.02). CONCLUSIONS: After adjustment for multiple relevant covariates, we demonstrated an association between VAA exposure, brain injury, ICU length of stay, and lower neurodevelopmental outcome scores at 12 months of age. These findings support the need for further studies to identify potential modifiable factors in the perioperative care of neonates with CHD to improve neurodevelopmental outcomes.
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Anestésicos/efectos adversos , Encefalopatías/inducido químicamente , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Discapacidades del Desarrollo/inducido químicamente , Sistema Nervioso/crecimiento & desarrollo , Anestésicos/administración & dosificación , Encéfalo/patología , Encefalopatías/patología , Encefalopatías/psicología , Puente Cardiopulmonar , Estudios de Cohortes , Discapacidades del Desarrollo/epidemiología , Discapacidades del Desarrollo/fisiopatología , Femenino , Cardiopatías Congénitas/psicología , Humanos , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/efectos adversos , Lactante , Recién Nacido , Trastornos del Desarrollo del Lenguaje/inducido químicamente , Trastornos del Desarrollo del Lenguaje/epidemiología , Imagen por Resonancia Magnética , Masculino , Sistema Nervioso/efectos de los fármacos , Pruebas Neuropsicológicas , Periodo Perioperatorio , Estudios RetrospectivosRESUMEN
Mitochondrial disease, once thought to be a rare clinical entity, is now recognized as an important cause of a wide range of neurologic, cardiac, muscle, and endocrine disorders . The incidence of disorders of the respiratory chain alone is estimated to be about 1 per 4-5000 live births, similar to that of more well-known neurologic diseases . High-energy requiring tissues are uniquely dependent on the energy delivered by mitochondria and therefore have the lowest threshold for displaying symptoms of mitochondrial disease. Thus, mitochondrial dysfunction most commonly affects function of the central nervous system, the heart and the muscular system . Mutations in mitochondrial proteins cause striking clinical features in those tissues types, including encephalopathies, seizures, cerebellar ataxias, cardiomyopathies, myopathies, as well as gastrointestinal and hepatic disease. Our knowledge of the contribution of mitochondria in causing disease or influencing aging is expanding rapidly . As diagnosis and treatment improve for children with mitochondrial diseases, it has become increasingly common for them to undergo surgeries for their long-term care. In addition, often a muscle biopsy or other tests needing anesthesia are required for diagnosis. Mitochondrial disease represents probably hundreds of different defects, both genetic and environmental in origin, and is thus difficult to characterize. The specter of possible delayed complications in patients caused by inhibition of metabolism by anesthetics, by remaining in a biochemically stressed state such as fasting/catabolism, or by prolonged exposure to pain is a constant worry to physicians caring for these patients. Here, we review the considerations when caring for a patient with mitochondrial disease.