P064: ANESTHETIC MANAGEMENT IN A PATIENT WITH PRESUMED HISTORY OF PORPHYRIA
Valentina Rojas, MD1; Omar Chahine1; Hunter Sciscente1; Lucas Nieto1; Nicholas Nedeff1; Jonathan Nieves2
1HCA Florida Kendall Hospital; 2University of South Florida
A 40-year-old male with a past medical history of presumed porphyria, encephalitis, multiple DVTs with Xarelto, PE s/p IVC filter placement in 2013, bipolar disorder, and seizure disorder with Depakote. The patient presented after a mechanical fall and was found to have a bimalleolar fracture of the left ankle. Laboratory tests were unremarkable with no signs of renal dysfunction or liver function abnormalities.
The patient had no signs of acute exacerbation of porphyria. There was no associated acute neuropsychiatric decompensation, abdominal pain, rashes, new vascular events, or acute bleeding.
The patient does not know the type of porphyria but reported having encephalitis with a previous episode of porphyria 20 years ago. He further reports that his grandfather was diagnosed with porphyria.
After reviewing the implications of anesthesia in patients with porphyria and the potential for triggering an acute attack with medications that induce or maintain anesthesia, the anesthetic plan was to perform a saphenous and popliteal nerve block for effective pain control in medial and lateral malleolar fractures and Mac, and to be prepared to convert to general anesthesia if the patient did not tolerate.
Porphyrias are rare diseases, so diagnosis can be difficult and may take time, which is concerning for being involved in the care of an undiagnosed patient who developed their first attack under anesthesia. Any patient suspected of developing a porphyria attack should be screened cautiously and well-prepared before coming to surgery.
Porphyria should be considered in patients who present with an atypical medical, psychiatric, or surgical history. Acute attacks are associated with substantial morbidity and mortality.
Stress, fasting, dehydration, infection, hormonal disorders, and the administration of many medications can trigger acute attacks; therefore, medication safety should be checked.
The main objective of this case report will be to extensibly review all the medications that are contraindicated and the different anesthetic plans that are safe depending on whether the disease is in remission or under acute attack.