Malignant Hyperthermia: A Clinical Review

Current Practices in Pharmacogenomics

Pharmacogenomics, where genomic information is used to tailor medication management, is a strategy to maximize drug efficacy and minimize toxicity. Although pediatric evidence is less robust than for adults, medications influenced by pharmacogenomics are prescribed to children and adolescents. Evidence-based guidelines and drug label annotations are available from the Clinical Pharmacogenetics Implementation Consortium (CPIC) and the Pharmacogenomics Knowledgebase (PharmGKB). Some pediatric health care facilities use pharmacogenomics to provide dosing recommendations to pediatricians. Herein, we use a case-based approach to illustrate the use of pharmacogenomic data in pediatric clinical care and provide resources for finding and using pharmacogenomic guidelines.

Feasibility pilot trial for the Trajectories of Recovery after Intravenous propofol versus inhaled VolatilE anesthesia (THRIVE) pragmatic randomised controlled trial

INTRODUCTION

Millions of patients receive general anaesthesia for surgery annually. Crucial gaps in evidence exist regarding which technique, propofol total intravenous anaesthesia (TIVA) or inhaled volatile anaesthesia (INVA), yields superior patient experience, safety and outcomes. The aim of this pilot study is to assess the feasibility of conducting a large comparative effectiveness trial assessing patient experiences and outcomes after receiving propofol TIVA or INVA.

METHODS AND ANALYSIS

This protocol was cocreated by a diverse team, including patient partners with personal experience of TIVA or INVA. The design is a 300-patient, two-centre, randomised, feasibility pilot trial. Patients 18 years of age or older, undergoing elective non-cardiac surgery requiring general anaesthesia with a tracheal tube or laryngeal mask airway will be eligible. Patients will be randomised 1:1 to propofol TIVA or INVA, stratified by centre and procedural complexity. The feasibility endpoints include: (1) proportion of patients approached who agree to participate; (2) proportion of patients who receive their assigned randomised treatment; (3) completeness of outcomes data collection and (4) feasibility of data management procedures. Proportions and 95% CIs will be calculated to assess whether prespecified thresholds are met for the feasibility parameters. If the lower bounds of the 95% CI are above the thresholds of 10% for the proportion of patients agreeing to participate among those approached and 80% for compliance with treatment allocation for each randomised treatment group, this will suggest that our planned pragmatic 12 500-patient comparative effectiveness trial can likely be conducted successfully. Other feasibility outcomes and adverse events will be described.

ETHICS AND DISSEMINATION

This study is approved by the ethics board at Washington University (IRB# 202205053), serving as the single Institutional Review Board for both participating sites. Recruitment began in September 2022. Dissemination plans include presentations at scientific conferences, scientific publications, internet-based educational materials and mass media.

TRIAL REGISTRATION NUMBER

NCT05346588.

Lysosomal Ca2+ as a mediator of palmitate-induced lipotoxicity

While the mechanism of lipotoxicity by palmitic acid (PA), an effector of metabolic stress in vitro and in vivo, has been extensively investigated, molecular details of lipotoxicity are still not fully characterized. Since recent studies reported that PA can exert lysosomal stress in addition to well-known ER and mitochondrial stress, we studied the role of lysosomal events in lipotoxicity by PA, focusing on lysosomal Ca²⁺. We found that PA induced accumulation of mitochondrial ROS and that mitochondrial ROS induced release of lysosomal Ca²⁺ due to lysosomal Ca²⁺ exit channel activation. Lysosomal Ca²⁺ release led to increased cytosolic Ca²⁺ which induced mitochondrial permeability transition (mPT). Chelation of cytoplasmic Ca²⁺ or blockade of mPT with olesoxime or decylubiquinone (DUB) suppressed lipotoxicity. Lysosomal Ca²⁺ release led to reduced lysosomal Ca²⁺ content which was replenished by ER Ca²⁺, the largest intracellular Ca²⁺ reservoir (ER → lysosome Ca²⁺ refilling), which in turn activated store-operated Ca²⁺ entry (SOCE). Inhibition of ER → lysosome Ca²⁺ refilling by blockade of ER Ca²⁺ exit channel using dantrolene or inhibition of SOCE using BTP2 inhibited lipotoxicity in vitro. Dantrolene or DUB also inhibited lipotoxic death of hepatocytes in vivo induced by administration of ethyl palmitate together with LPS. These results suggest a novel pathway of lipotoxicity characterized by mPT due to lysosomal Ca²⁺ release which was supplemented by ER → lysosome Ca²⁺ refilling and subsequent SOCE, and also suggest the potential role of modulation of ER → lysosome Ca²⁺ refilling by dantrolene or other blockers of ER Ca²⁺ exit channels in disease conditions characterized by lipotoxicity such as metabolic syndrome, diabetes, cardiomyopathy or nonalcoholic steatohepatitis.

Malignant Hyperthermia in Bariatric Surgery: A Case Study With Clinical, Pathophysiological, Biochemical and Biophysical Correlations

Malignant hyperthermia (MH) is an acute pharmacogenetic disorder, which while uncommon is potentially fatal. MH is a calcium channelopathy of skeletal muscle in which a constant increase of intracytoplasmic Ca2+ concentration occurs causing a change in cellular metabolism. A hypermetabolic state develops when susceptible patients are exposed to halogenated volatile inhalational anesthetic agents and depolarizing muscle relaxants and/or extreme physical activity in hot environments. MH presents variable clinical expression. During an episode of MH, the patient may present clinical signs and laboratory findings including masseter muscle spasm, tachycardia, rise in end-tidal CO2 (EtCO2), tachypnea, hyperthermia, cyanosis, metabolic acidosis, rhabdomyolysis, hyperkalemia, myoglobinuria, hyperlactacidemia, and acute renal failure. The aim of this case report is to describe an episode of MH associated with the use of halogenated anesthetic during bariatric surgery. A 29-year-old Brazilian man was admitted to the hospital to undergo a bariatric surgery. The patient's relevant medical history included morbid obesity grade III, allergy to sulfa-based drugs and severe obstructive sleep apnea. Preoperative evaluations with cardiopulmonary exercise testing, echocardiogram and electrocardiogram showed no anatomical and functional changes of the patient's heart. Surgical procedures lasted for 4 h, without complications, but the evolution of the patient's condition indicated oliguria and acute breathing insufficiency. Five hours after the patient was placed under mechanical ventilation in the intensive care unit, he started to present clinical signs of hypermetabolic state, with tremors, excessive sweating, and rapid body temperature increases. In the postoperative period, the patient had hyperglycemia, hypocalcemia, hypernatremia, hyperkalemia, changes in creatine phosphokinase (CPK), aspartate transaminase (AST), alanine aminotransferase (ALT), urea and creatine concentrations, and metabolic and respiratory acidosis. Urinalysis showed traces of proteinuria, presence of ketones, leukocytes, red blood cells, and urobilinogen. In our case report, MH crisis was diagnosed late; the dantrolene was not administrated because it was not available and the patient died. This detailed case report of MH episode triggered by isoflurane anesthetic during bariatric surgery allowed us to describe the severity and lethality of this hypermetabolic syndrome. Dantrolene should be mandatory in all operating rooms. Knowledge of the symptoms, an early diagnosis and an adequate treatment can prevent the death of patients in MH crisis.

Nursing Interventions of Intraoperative Malignant Hyperthermia in Patients With Scoliosis: A Report of 3 Cases

INTRODUCTION

The report summarizes the intraoperative rescue and nursing intervention of malignant hyperthermia (MH) in the correction surgery for 3 patients with spinal deformity. Although rare, MH may occur in up to 1 of 5000 cases.

INTERVENTION

The key points of nursing care include preoperative MH risk assessment, MH early warning, cessation of anesthetic, use of a validated scoring system, and initiation of cooling measures.

CONCLUSION

Prompt nursing recognition and team-fcoused interventions provided successful rescue of 3 patients with MH.