2026 FSA Podium and Poster Abstracts

Background: Communications from the American Society of Anesthesiologists (ASA), Society for Pediatric Anesthesia (SPA), and Venezuelan Society of Anesthesiologists (VSA) have described severe postoperative neurologic injury and death in previously healthy children of Venezuelan maternal lineage following elective general anesthesia, raising concern for a maternally inherited mitochondrial DNA variant (MT-ND4) associated with complex I (CI) dysfunction[1]. These cases were characterized by routine anesthetic exposure, absence of clear intraoperative events, delayed emergence, and basal ganglia–predominant injury. Patients with maternal Venezuelan lineage (particularly from the Carabobo region) should be considered at risk. In these patients, regional or monitored anesthesia is preferred; if general anesthesia is required, experts advise avoidance of volatile agents, consideration of total intravenous anesthesia, processed EEG monitoring (BIS), and meticulous physiologic management. We present a previously healthy adult who developed catastrophic neurologic injury after elective surgery in 2021 and was found post-mortem to harbor a homoplasmic MT-ND4 variant now implicated in anesthetic-associated fatalities.

Case: A 22-year-old woman underwent elective septorhinoplasty and breast augmentation under general anesthesia using sevoflurane. Throughout the case, the blood pressure was supported with vasopressors and fluid administration. The blood pressures were maintained within a lower physiologic range to minimize surgical bleeding. Urine output remained adequate. BIS monitoring was applied but removed due to interference with the surgical field per surgeon’s request. The patient did not regain consciousness at the end of the procedure despite complete exhalation of sevoflurane, reversal of neuromuscular blockade, and administration of naloxone and flumazenil.

Neuroimaging demonstrated bilateral basal ganglia and cortical injury interpreted as global hypoxic-ischemic changes with hemorrhagic transformation. Laboratory findings indicated metabolic acidosis. Subsequent imaging was suspicious for toxic leukoencephalopathy with increasing intracranial pressure, culminating in global edema and early herniation. The patient was terminally extubated on postoperative day seven. Post-mortem mitochondrial genome sequencing identified a homoplasmic MT-ND4 variant (m.11232T>C; p.Leu158Pro), also present in her Venezuelan mother. Later, it was discovered that the patient’s brother previously had difficulty awakening from general anesthesia but did not suffer sequelae.

Discussion: MT-ND4 encodes a subunit of electron transport chain CI. Volatile anesthetics inhibit CI function, and patients with CI defects may exhibit heightened anesthetic sensitivity[2]. A published fatal pediatric case reported the identical MT-ND4 variant following anesthetic exposure with metabolic acidosis and basal ganglia–predominant injury[3]. The radiographic pattern in this adult case parallels findings described in emerging reports of anesthetic-associated mitochondrial vulnerability. The recent statement from the VSA described in-vitro data demonstrating marked suppression of oxygen consumption in cells carrying this variant when exposed to sevoflurane, supporting plausibility of CI-mediated susceptibility.

This case highlights the potential for occult mitochondrial disease to present perioperatively in previously healthy adults. Preoperative screening and use of anesthetic strategies that minimize CI stress may mitigate risk, but continued reporting and investigation are needed to clarify genotype–phenotype associations and anesthetic susceptibility.

Citations

• 1. www.asahq.org/advocating-for-you/guidance/asa-spa-neurological
• 2. PMID: 33591116
• 3. https://doi.org/10.21203/rs.3.rs-2539495/v1