Pseudoaneurysm and Renal Artery Stenosis Post-renal Transplant: A Rare Presentation.

We report the case of a 51-year-old gentleman who underwent living renal transplantation in Pakistan for end-stage renal disease one and a half years ago. He presented to our hospital with renal artery stenosis and an extra-renal pseudoaneurysm at the anastomotic site of the transplanted kidney. This can cause graft dysfunction and hypertension due to impairment of arterial perfusion in the transplanted kidney. Treatment with percutaneous transluminal angioplasty and covered stenting of the pseudoaneurysm and stenosis improved kidney function and hypertension.

Endotracheal tube cuff position in relation to the cricoid in children: A retrospective computed tomography-based analysis.

BACKGROUND: The use of cuffed endotracheal tubes (ETT) has become the standard of care in pediatric practice. The rationale for the use of a cuffed ETT is to minimize pressure around the cricoid while providing an effective airway seal. However, safe care requires that the cuff lie distal to the cricoid ring following endotracheal intubation. The current study demonstrates the capability of computed tomography (CT) imaging in identifying the position of the cuff of the ETT in intubated patients. METHODS: In this retrospective study, the ETT cuff position was examined on the sagittal plane images of neck and chest CT scans of 44 children. The position of the proximal and the distal aspect of the ETT cuff inside the trachea was recorded in relation to the vertebral levels. The vertebral levels were used to estimate the location of the cricoid ring and its relationship to the cuff. RESULTS: The vertebrae were used as the primary landmarks to define the position of the cricoid and its relationship to the cuff of the ETT. Correlating vertebral levels with the cricoid for different age groups, the proximal (cephalad) edge of the ETT cuff was below the cricoid in 41 of 44 patients (93%). The ETT cuff was deep in 6 patients, below the 1st thoracic vertebra, with 2 ETTs in the right mainstem bronchus. CONCLUSION: This is the first study demonstrating that the cuff of the ETT and its position in the trachea can be identified on CT imaging in children. The ETT cuff was below the level of the cricoid in the majority of patients irrespective of the patient's age as well as the size, make, and type of ETT.

Point-of-care ultrasound to confirm endotracheal tube cuff position in relationship to the cricoid in the pediatric population.

BACKGROUND: Anatomically, the subglottic area and the cricoid ring are the narrowest portions of the larynx. To limit the potential for damage related to mucosal pressure injuries from the presence of an endotracheal tube, the cuff should be placed below the cricoid in children. Previously, no clinical or imaging method has been used in real time to determine the exact location of the endotracheal tube cuff after endotracheal intubation. Point-of-care ultrasound may provide an option as a safe and rapid means of visualizing the endotracheal tube cuff and its relationship to the cricoid ring thereby achieving ideal endotracheal tube cuff positioning-below the cricoid. METHODS: In this prospective, nonrandomized trial, point-of-care ultrasound was used following endotracheal intubation in children to evaluate the position of the endotracheal tube cuff in relationship to the cricoid and tracheal rings. After anesthesia was induced and the trachea was intubated, the endotracheal tube cuff and its position in relation to the cricoid and tracheal rings were identified in the longitudinal plane using point-of-care ultrasound. With the patient's neck in a neutral position, the level of the proximal (cephalad) margin of the saline-filled cuff of the endotracheal tube was identified and recorded in relationship to the cricoid and tracheal rings. The ideal position is defined as the cephalad margin of the endotracheal tube cuff below the level of the cricoid. RESULTS: The study cohort included 80 patients, ranging in age from 1 to 78 months. In all patients, the cuff of the ETT, cricoid, and tracheal rings were identified. The cephalad end of the endotracheal tube cuff was found at the level of the cricoid in 16.3% of patients, at the first tracheal ring in 27.5% of patients, at the second tracheal ring in 23.8% of patients, at the third tracheal ring in 17.5% of patients, and at below the fourth tracheal ring in 15% of patients. Initial endotracheal tube cuff position had no significant association with age, height, weight, endotracheal tube size, and endotracheal tube type. CONCLUSION: Point-of-care ultrasound provides a rapid and effective means of identifying the position of the endotracheal tube cuff in relationship to the cricoid ring. The technique may have applications in the perioperative arena, emergency departments, and intensive care units.

Mainstem Bronchial Diameters and Dimensions in Infants and Children: A Systematic Review of the Literature.

Anatomic measurements of the right (RMB) and left mainstem bronchi (LMB) in infants and children have been accomplished using various modalities. The objective of the present review was to determine whether enough data were available to provide standardized lower airway dimensions in the pediatric population. For the present study, 12 studies with data of the lower pediatric airway dimensions of 1,611 children published from 1923-2020 were reviewed and analyzed. The eligible criteria included studies measuring lower airway dimensions in the pediatric population. Various techniques were used for airway measurement, with computed tomography studies being most abundant. There was a progressive increase in the size of RMB and LMB with age, with a close approximation of the LMB-to-RMB ratio across all studies. In children younger than 1 year old, the RMB and LMB diameters were between 4 and 5 mm and 3 and 5 mm, respectively. Overall, there was significant variation in the methods and modality used to obtain measurements, and therefore it was difficult to establish standardized lower airway dimensions in the pediatric population. Additional homogeneous data with standardized measurement techniques and modalities across different pediatric age groups are needed to define these dimensions further. Such data may be helpful in designing airway equipment, lung isolation devices, and airway stents.

Comparison of the skin-to-epidural space distance at the thoracic and lumbar levels in children using magnetic resonance imaging.

BACKGROUND: Several studies have attempted to estimate the approximate distance from the skin-to-epidural space using different imaging modalities (computed tomography [CT], ultrasound, and magnetic resonance imaging [MRI]) and direct needle measurements. The objective of our study was to compare the distance from the skin to the epidural space (SED) at multiple levels, focusing on T6-7, T9-10, and L2-3 using MRI. METHODS: After institutional review board (IRB) approval, sagittal T2-weighted MRI images of the spine of 108 children in the age group ranging from 3 months to 8 years undergoing radiological evaluation in the supine position at our institution were analyzed. The SED at T6-7 and T9-10 levels (straight and inclined) and SED at L2-3 (straight) were determined and compared using repeated-measures ANOVA and paired t-tests with a Bonferroni correction for 10 pairwise comparisons (P < 0.005 was considered statistically significant). RESULTS: The average SED (measured straight and inclined) was 18.2 mm and 21.6 mm at T6-7; 18.3 mm and 20.5 mm at T9-10; and 21.8 mm (straight) at L2-3. The repeated-measures ANOVA F-test indicated significant variability in SED (P < 0.001) among the 5 measurements obtained. At the P < 0.005 significance level, corrected for multiple comparisons, the SED (straight) at T9-10 straight was shorter than the other measured distances. CONCLUSION: The distance from the skin to the epidural space is not constant at various vertebral levels. At the levels measured, it was greatest at the lumbar level and at least at the thoracic level of T9-10. A single predictive formula was not applicable for calculating the approximate SED at all vertebral levels.

The pediatric airway: Historical concepts, new findings, and what matters.

New observations from novel imaging techniques regarding the anatomy, dimensions, and shape of the pediatric airway have emerged and provide insight for potential changes in the clinical management of the airway in infants and children. These new findings are challenging the historical concepts of a funnel-shaped upper airway with the cricoid ring as the narrowest dimension. Although these tenets have been accepted and used to guide clinical practice in airway management, there are limited clinical investigations in children to support the validity of these concepts. Imaging modalities such as magnetic resonance imaging, computed tomography (CT) scanning, multi-detector CT imaging, and videobronchoscopy suggest the need to revisit the historical view of the pediatric airway. This manuscript reviews the historical evolution of pediatric airway studies, summarizes important scientific observations from recent investigations relevant to our clinical understanding of pediatric airway anatomy, and discusses the importance of these findings for pediatric airway management.

Risk factors for post-induction hypotension in children presenting for surgery.

BACKGROUND: Preoperative factors have been correlated with pre-incision hypotension (PIH) in children undergoing surgery, suggesting that PIH can be predicted through preoperative screening. We studied blood pressure (BP) changes in the 12 min following the induction of anesthesia to study the incidence of post-induction hypotension and to assess the feasibility of predicting PIH in low-risk children without preoperative hypotension or comorbid features. METHODS: We retrospectively evaluated 200 patients ranging in age from 2 to 8 years with American Society of Anesthesiologists' (ASA) physical status I or II, undergoing non-cardiac surgery. Patients were excluded if they had preoperative (baseline) hypotension (systolic blood pressure (SBP) < 5th percentile for age). BP and heart rate (HR) were recorded at 3 min intervals for 12 min after the induction of anesthesia. Pre-incision hypotension (PIH) was initially defined as SBP < 5th percentile for age: (1) at any timepoint within 12 min of induction; (2) for the median SBP obtained during the 12 min study period; or (3) at 2 or more timepoints including the final point at 12 min after the induction of anesthesia (sustained hypotension). In addition, we examined PIH defined as > 20% decrease in SBP from baseline: (4) at any timepoint within 12 min of the induction of anesthesia; (5) for the median SBP obtained during the 12 min study period; or (6) at two or more timepoints including the final point at 12 min after the induction of anesthesia. Agreement among the six definitions was analyzed, in addition to the effects of age, gender, type of anesthetic induction, use of premedication, preoperative BP, preoperative HR, and body mass index on the incidence of PIH according to each definition. RESULTS: Five patients were excluded due to baseline hypotension and six were excluded for missing data. In the remaining cohort, estimated PIH prevalence ranged from 4% [definition (Stewart et al., in Paediatr Anaesth 26:844-851, 2016), sustained PIH according to SBP percentile-for-age] to 57% [definition (Task Force on Blood Pressure Control in Children, in Pediatrics 79:1-25, 1987), at least one timepoint where SBP was > 20% lower than baseline]. Pairwise agreement among the six definitions ranged from 49 to 91% agreement. No sequelae of PIH were noted during subsequent anesthetic or postoperative care. On multivariable analysis, no covariates were consistently associated with PIH risk across all six definitions of PIH. CONCLUSION: The present study describes the incidence and prediction of PIH in a cohort of relatively healthy children. In this setting, accurate prediction of PIH appears to be hampered by lack of agreement between definitions of PIH. Overall, there was a low PIH incidence when the threshold of SBP < 5th percentile for age was used. LEVEL OF EVIDENCE: II.

Tracheobronchial angles in children: Three-dimensional computed tomography-based measurements.

BACKGROUND: Studies have shown significant variation in the tracheobronchial angles in pediatric-aged patients. The current study revisits tracheobronchial angle measurements in children using accurate computed tomography-based 3-dimensional images to add clarity to the understanding of tracheobronchial angles. The primary objective of the current study was to measure the right and left bronchial angle take off from the trachea using 3-dimensional computed tomography-based images of the air column in the tracheobronchial tree. METHODS: Computed tomography-based images of 45 children younger than 8 years were reviewed. The children were evaluated during spontaneous ventilation either during natural sleep or with sedation. The right and left bronchial angles were computed between the central axes of the respective main bronchi and a vertical line passing through the central axis of the longitudinal tracheal air column. The right and left bronchial angles were compared using paired t tests, and the age dependence of the right bronchial angle and left bronchial angle difference was evaluated using Pearson's correlation coefficient. RESULTS: The study cohort included 18 males and 27 females with an average age of 49 ± 25 months. The right bronchial angle ranged from 23° to 56° (mean 42 ± 7°), whereas left bronchial angle varied between 25° and 68° (mean 43 ± 9°). The difference in means of 1 degree was not statistically significant (95% confidence interval of difference: -1°, 4°; P = .282). No association was found between left and right bronchial angle difference and patient age (r = -.019). CONCLUSION: According to computed tomography-based 3-dimensional imaging, right and left bronchial angles are virtually identical in children up to 8 years of age, and the difference between right and left bronchial angles does not vary with age in this population.

Volume relationships between cricoid and main stem bronchi in children using three-dimensional computed tomography imaging.

BACKGROUND: There are limited data to guide the selection of the appropriate sized endobronchial tube for main stem intubation to provide one-lung ventilation in children. The relationship between the cricoid and the main bronchi (right and left) has been previously evaluated using two-dimensional computed tomography (CT) imaging and video-bronchoscopic images. The present study defines the three-dimensional, CT-derived volume-based relationships between the right main-stem bronchus (RMB), left main-stem bronchus (LMB), and the cricoid ring. METHODS: The three-dimensional CT images of 35 children, less than 8 years of age, undergoing radiological evaluation unrelated to airway or mediastinal symptomatology were examined. The images of the airway column were evaluated at the level of the cricoid and main stem bronchi (right and left). Volumes were calculated and comparisons made between these levels. RESULTS: There was no statistically significant difference based on gender for the cricoid and main stem bronchi volumes. A statistically significant difference was observed between the cricoid and left main stem bronchi volumes as well as between the right and left main stem bronchi. CONCLUSION: The relationship (ratio) between the volumes of the cricoid and main stem bronchi remains constant by age. The cricoid dimensions can be used to predict the main stem bronchi dimensions.

Cricoid ring: Shape, size, and variability in infants and children.

BACKGROUND: Knowledge regarding the shape, size, and variability of the cricoid ring is important to properly choose the correct endotracheal tube (ETT) in the pediatric patient. Studies have measured the size of the cricoid ring using methodologies such as moulages, magnetic resonance imaging, and video-bronchoscopy. In the present study, computed tomography (CT) -based images were used to determine the shape, size, and configuration of the cricoid ring in the pediatric population taking into considerations growth and development. METHODS: This is a retrospective review using 130 CT images of children ranging in age from 1 month to 10 years undergoing radiological evaluation unrelated to airway symptomatology. The CT scans were obtained in spontaneously breathing patients during either natural sleep or procedural sedation. Anteroposterior (AP) and transverse (T) diameters were measured at the cricoid ring using these images. RESULTS: The cricoid ring is generally round in children older than 1 year with a T/AP ratio ranging between 0.98 and 1.01. However, in infants (1-12 months of age), the cricoid ring is elliptical with the AP dimension an average of 0.31 mm larger than the T dimension with a T/AP ratio of 0.95. A statistically significant difference between the T and AP dimensions was only observed in infancy (P < 0.05). CONCLUSION: The cricoid ring is round in children older than 1 year of age. In infants, the cricoid shape presents a more elliptical configuration because the T-axis is narrower than the AP dimension. CT is recognized as the most accurate technique to study cricoid ring configuration, and the present data may help clinicians determine the appropriate type, size, and shape of ETTs, particularly in infants.

Estimation of the depth of the thoracic epidural space in children using magnetic resonance imaging.

BACKGROUND: The estimation of the distance from the skin to the thoracic epidural space or skin to epidural depth (SED) may increase the success rate and decrease the incidence of complications during placement of a thoracic epidural catheter. Magnetic resonance imaging (MRI) is the most comprehensive imaging modality of the spine, allowing for the accurate determination of tissue spaces and distances. The present study uses MRI-derived measurements to measure the SED and define the ratio between the straight and inclined SEDs at two thoracic levels (T6-7 and T9-10) in children. METHODS: The T2-weighed sagittal MRI images of 109 children, ranging in age from 1 month to 8 years, undergoing radiological evaluation unrelated to spine pathology were assessed. The SEDs (inclined and straight) were determined, and a comparison between the SEDs at two thoracic levels (T6-7 and T9-10) was made. Univariate and multivariate linear regression models were used to assess the relationship of the inclined thoracic T6-7 and T9-10 SED measurements with age, height, and weight. RESULTS: Body weight demonstrated a stronger association with the SED than did the age or height with R2 values of 0.6 for T6-7 and 0.5 for T9-10. The formulae describing the relationship between the weight and the inclined SED were T6-7 inclined (mm) = 7 + 0.9 × kg and T9-10 inclined (mm) = 7 + 0.8 × kg. CONCLUSION: The depth of the pediatric thoracic epidural space shows a stronger correlation with weight than with age or height. Based on the MRI data, the predictive weight-based formulas can serve as guide to clinicians for placement of thoracic epidural catheters.

Upper airway in infants-a computed tomography-based analysis.

BACKGROUND: Recent studies suggest that the pediatric airway is elliptical with the subglottis rather than the cricoid as the narrowest part contrary to the old belief of a funnel-shaped airway. The shape of the airway in neonates and infants has not been studied separately. This study seeks to define the shape of the upper airway in neonates and infants, and determine if there are differences in airway shape between infants and older children. METHODS: We studied 40 computed tomographic scans of children from birth to 12 months of age undergoing radiological evaluation unrelated to airway symptomatology. The computed tomographic scans were obtained during either natural sleep or with sedation and spontaneous ventilation without airway devices in place. Transverse and anteroposterior diameters were measured at the subglottic level and at the cricoid ring. RESULTS: The mean age was 5.9 ± 3.4 months. The mean transverse and anteroposterior diameters were 5.3 ± 0.83 mm and 7.2 ± 0.89 mm at the subglottic region and 6.1 ± 0.86 mm and 6.7 ± 0.79 mm at the cricoid level. An increase in the transverse dimension of the airway was observed from the subglottic region to the cricoid ring. Although the anteroposterior dimension decreased from the subglottis to the cricoid ring, the airway remained wider in the anteroposterior dimension compared to the transverse dimension from the subglottis to the cricoid ring. CONCLUSION: The present study demonstrates that the airway in neonates and infants between the subglottic area and the cricoid remains elliptical. The cricoid is not round as has been observed in older children. The airway is wider anteroposteriorly and narrows in the transverse dimension from the subglottis to the cricoid in infants.

Pediatric upper airway dimensions using three-dimensional computed tomography imaging.

INTRODUCTION: Computed tomography- (CT) and magnetic resonance imaging (MRI)-based measurements have recently suggested that the narrowest dimension of the pediatric airway is the subglottic region. These data are contrary to the previously held tenets of a funnel- or conical-shaped airway. The current study evaluates airway volumes and shapes using three-dimensional CT images of the air way column in spontaneously breathing children. METHODS: The study included CT-based radiological images of the neck in children who required imaging unrelated to airway symptomatology. The children were evaluated during spontaneous ventilation during natural sleep or with sedation without airway devices in place. The three-dimensional images of the airway column were evaluated, volumes calculated, and comparisons made between the subglottic, cricoid, and tracheal volumes and shapes. RESULTS: The study cohort included 54 children, ranging in age from 2 months to 8 years. An increase in the airway volumes was observed from the subglottic (0.17 ± 0.06 mm3 ) to the cricoid (0.19 ± 0.06 mm3 ) to the tracheal regions (0.22 ± 0.07 mm3 ). The volumes of the subglottic, cricoid, and tracheal regions demonstrated a linear relationship with age. CONCLUSION: This study confirms recent studies demonstrating that the subglottic region not the cricoid is the narrowest part of the airway.

Endotracheal tubes and the cricoid: Is there a good fit?

BACKGROUND: Choosing an appropriately sized endotracheal tube (ETT) is important in pediatric patients as an inappropriately sized ETT may result in multiple endotracheal intubation attempts or excessive pressure on the tracheal mucosa with the potential for airway damage. Although age-based formulas are generally used with choice of an ETT based on the internal diameter (ID), measurements of the outer diameter (OD) of the ETT would seem to be a more scientific approach to determine the proper size of an ETT. However, the variable OD of the ETT despite the same ID makes the selection of a proper sized ETT more difficult. The current study compares airway dimensions measured using computed tomography (CT) with the OD of ETTs from various manufacturers. METHODS: The outer diameter of commonly used ETTs (12 cuffed and 5 uncuffed) were measured and compared with CT-based cricoid measurements obtained from a previous study involving 130 pediatric patients, ranging in age from 1 month to 10 years. These data were used to determine the likelihood of a clinically acceptable match. RESULTS: The differences of the cricoid dimensions between the 5th and the 95th percentile in each group ranged from a minimum of 2.23mm to a maximum of 6.51mm. Depending on the manufacturer, there was significant variation in the OD of the ETTs with the same ID. These discrepancies, which varied according to manufacturer and were greater with uncuffed as compared to cuffed ETTs, impacted the chances of an acceptable fit with the cricoid diameters. CONCLUSION: When choosing an ETT, age-based formulas which use the ID may not be uniformly accurate in ensuring the appropriately-sized ETT given the variation in the OD despite the same ID. These issues further support the use of cuffed ETTs as the variation in fit can be adjusted by inflation of the cuff to provide an adequate tracheal seal.

Cricoid and left bronchial diameter in the pediatric population.

BACKGROUND: Lung isolation in the pediatric population can be problematic. The diameter and length of the right and left mainstem bronchi are not well described in young children. Information regarding these measurements may help determine the appropriate size of endotracheal tubes for endobronchial intubation as well as the development of lung isolation devices for the pediatric population. The present study is based on computed tomography (CT) measurements to evaluate airway dimensions. The goal of this study was to define the relationship between the diameters of the left mainstem bronchus (LMSB) and the cricoid ring, and to study the effect of age, weight, and height on these dimensions. METHODS: The two-dimensional CT images of 102 children, ranging in age from 1 month to 10 years, undergoing radiological evaluation unrelated to airway symptomatology were examined. The cricoid dimensions (anteroposterior and transverse diameters) were measured using transverse plane images. The LMSB diameter was measured below the carina along the long axis of left main bronchus. Univariate regression analysis was used to determine whether one or more of the variables (age, gender, height, weight) had a predictable relationship with the cricoid and the LMSB diameters. RESULTS: The cricoid as well as the LMSB diameters increase with age, height, and weight. The relationship between the cricoid diameter and the LMSB diameter remains constant across all ages with a ratio of 0.78 ± 0.14. This ratio was slightly larger for girls than boys (0.81 ± 0.16 vs 0.77 ± 0.13). CONCLUSION: The cricoid to LMSB ratio (relationship) remains constant with respect to age, height, and weight.

Age-based analysis of pediatric upper airway dimensions using computed tomography imaging.

BACKGROUND: Recent studies have challenged the historically accepted fact that the larynx is cone-shaped in infants and children. The present study used computed tomography (CT)-based measurements to evaluate airway dimensions. The purpose of this investigation was to determine the dimensional transition between the subglottic area and the cricoid ring in children. METHODS: This is a retrospective review of 220 CT scans of children aged 1 month to 10 years undergoing radiological evaluation unrelated to airways symptomatology. The CT scans were evaluated in children either sleeping naturally or sedated throughout the study period. Anteroposterior (AP) and Transverse (T) diameters were measured at the subglottic level and at the cricoid ring. RESULTS: The mean (±SD) age was 47.4 ± 33.1 months. The mean AP and transverse diameters were 9.2 ± 1.9 and 7.5 ± 1.6 mm at the subglottic area and 8.5 ± 1.7 and 8.3 ± 1.5 mm at the cricoid. AP dimension showed a decrease from the subglottis to the cricoid ring. A more rapid enlargement of the airway from the subglottis to cricoid ring is observed in the transverse dimension (P < 0.05). A linear progression in the size of airway dimensions between both levels was observed with age (r > 0.7). CONCLUSION: The narrower transverse dimension compared to the AP diameter suggests that the airway is elliptical immediately below the vocal cords. The present study demonstrates that the airway characteristics in children between the subglottic area and the cricoid change from an elliptical to a round (circular) shape. The cone-shaped airway characteristic, which has been historically proposed, was not observed. Given that subglottic transverse diameter is the smallest area dimension, one must assume this is the most likely area of resistance to the passage of an endotracheal tube rather than only the cricoid.

Is the World Health Organization-recommended dose of pralidoxime effective in the treatment of organophosphorus poisoning? A randomized, double-blinded and placebo-controlled trial.

BACKGROUND: Organophosphorus poisoning (OPP) is a major global public health problem. Pralidoxime has been used in a complimentary role to atropine for the management of OPP. World Health Organization (WHO) recommends use of pralidoxime but studies regarding its role have been inconclusive, ranging from being ineffective to harmful or beneficial. MATERIALS AND METHODS: The present study was undertaken to evaluate the effectiveness of pralidoxime. Eddleston's study was the most compelling factor for our study, as he showed worst outcomes using pralidoxime. Our practice of continuous use of pralidoxime was based on the WHO guidelines and the study by Pawar (2006), which showed better outcome with higher doses of pralidoxime. These conflicting results suggested that a re-evaluation of its use in our clinical practice was indicated. RESULTS: There was no difference in mortality rates, hemodynamic parameters and atropine requirements between the AP and A groups. Mean duration of ventilation (3.6 ± 4.6 in AP group vs. 3.6 ± 4.4 in A group) and Intensive Care Unit stay (7.1 ± 5.4 in AP group vs. 6.8 ± 4.7 in A group) was comparable. Serum sodium concentrations showed a correlation with mortality, with lower concentrations associated with better outcomes. CONCLUSION: The study suggests that add-on WHO-recommended pralidoxime therapy does not provide any benefit over atropine monotherapy. Adding pralidoxime does not seem to be beneficial and at the same time does not result in increased mortality rates. Our practice changed after completion of this study, and it has proven to be of significant benefit to patients who had to bear the expense of treatment.

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.