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Hellblom A, Miller WP, Soller M, Samuelsson C. Malignant hyperthermia safety - A nationwide survey of publicly funded Swedish healthcare. Acta Anaesthesiol Scand 2024; 68:788-793. [PMID: 38566397 DOI: 10.1111/aas.14417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 03/11/2024] [Accepted: 03/16/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Malignant hyperthermia (MH) is a rare pharmacogenetic disorder that can lead to a life-threatening reaction during general anaesthesia with triggering agents. Prompt life-saving treatment includes the immediate administration of the antidote dantrolene. This study investigated Swedish healthcare providers' awareness and adherence to guidelines and recommendations with respect to MH and whether adherence to safe MH-praxis varies with hospital care-complexity level and private versus public management form. METHOD Agreements and procurement specifications between all 21 Swedish County Councils and privately run surgical care providers were reviewed alongside with questionnaire-aided collection of information from 62 publicly funded health care providers (both privately and publicly run). RESULTS No procurement requirement specification or contract contained requirements on anaesthesia or aspects of MH. All publicly run hospitals stocked dantrolene and 28 out of 52 (54%) stocked the recommended amount. Seven out of nine (78%) of the privately run institutions stocked dantrolene, and one stocked the recommended amount. Publicly run hospitals adhered to recommendations to a greater extent than privately run institutions, both with respect to stocking of dantrolene (p = .02) and to stocking the recommended amount (p = .03). CONCLUSIONS Contracts between Swedish county councils and private surgical care subcontractors rarely outline expectations of standards for the safe practice of anaesthesia such as preparedness to handle a life-threatening MH reaction. Among Swedish publicly funded anaesthesia providers there is room for improvement in adherence to the EMHG guideline on dantrolene availability. Publicly run hospitals seem to have better compliance with these recommendations than privately run institutions. Raising awareness about current guidelines is important to improve safety for known and unknown MH-susceptible individuals.
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Affiliation(s)
- Anna Hellblom
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
- Department of Laboratory Medicine, Clinical Genetics, Lund University, Lund, Sweden
| | | | - Maria Soller
- Department of Laboratory Medicine, Clinical Genetics, Lund University, Lund, Sweden
- Department of Clinical Genetics and Genomics, Karolinska University Hospital, Stockholm, Sweden
| | - Carolina Samuelsson
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden
- Halland Hospitals, Region Halland, Halland, Sweden
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Ng Kwet Shing RH, Clayton LB, Smith SL, Watson MJ, McKenzie LM, Chalmers DP, Whitaker G, Bilmen JG. The novel rapid formulation of intravenous dantrolene (NPJ5008) versus standard dantrolene (Dantrium®): A clinical part-randomised phase 1 study in healthy volunteers. Eur J Anaesthesiol 2024; 41:381-390. [PMID: 38445365 PMCID: PMC10990017 DOI: 10.1097/eja.0000000000001966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
BACKGROUND Delays in treating anaesthesia-induced malignant hyperthermia increase risks of complications and death. NPJ5008 is a novel formulation of the indicated treatment, dantrolene sodium, developed to shorten preparation and administration times compared with the reference formulation Dantrium®. The two formulations have been compared preclinically. OBJECTIVES Assess bioequivalence of overall dantrolene (free acid) exposure of NPJ5008 versus Dantrium® and ascertain similarities in their pharmacokinetics and safety/tolerability profiles. Evaluate preparation/administration time savings for the new formulation. DESIGN Part 1 of this open-label trial in humans was a 1 : 1 randomised crossover study; part 2 was a single-arm study. Trial pharmacy data and laboratory simulations assessed preparation/administration step timings. SETTING Single clinical centre in the UK, April to July 2021. PARTICIPANTS Twenty-one healthy male and female individuals. INTERVENTIONS Part 1: single intravenous 60 mg dose of NPJ5008 or Dantrium®, sequentially. Part 2: single intravenous 120 mg dose of NPJ5008. Simulation: five vials per formulation using paediatric and adult cannulas. MAIN OUTCOME MEASURES Overall drug exposure to last measurable concentration (AUC 0 to last ) and extrapolated to infinity (AUC 0 to ∞ ) were primary endpoints. Other pharmacokinetic, clinical and muscle-function parameters, and adverse events, were monitored. RESULTS Adjusted geometric mean ratios of NPJ5008 versus Dantrium® were 90.24 and 90.44% for AUC 0 to last and AUC 0 to ∞ , respectively, with the 90% confidence intervals (CI) within the 80 to 125% acceptance interval, establishing bioequivalence. No new safety issues emerged: any adverse events were of a similar magnitude across treatments and related to pharmacological properties of dantrolene. Pharmacy and simulation data revealed that every step in preparation and administration was 26 to 69% faster for NPJ5008 than Dantrium®. CONCLUSION NPJ5008 showed comparable pharmacokinetic and safety profiles to Dantrium®, while reducing dantrolene dose preparation/administration times, potentially reducing patient complications/healthcare resourcing in malignant hyperthermia. TRIAL REGISTRATION EudraCT Number: 2020-005719-35, MHRA approval.
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Affiliation(s)
- Richard H Ng Kwet Shing
- From the Norgine, Harefield (RHNKS, LBC, SLS, MJW), Quotient Sciences, Ruddington (LMM, DPC, GW) and University of Leeds, Leeds, UK (JGB)
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Cong Z, Wan T, Wang J, Feng L, Cao C, Li Z, Wang X, Han Y, Zhou Y, Gao Y, Zhang J, Qu Y, Guo X. Epidemiological and clinical features of malignant hyperthermia: A scoping review. Clin Genet 2024; 105:233-242. [PMID: 38148504 DOI: 10.1111/cge.14475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/22/2023] [Accepted: 12/07/2023] [Indexed: 12/28/2023]
Abstract
Malignant hyperthermia (MH) is a potentially fatal inherited pharmacogenetic disorder related to pathogenic variants in the RYR1, CACNA1S, or STAC3 genes. Early recognition of the occurrence of MH and prompt medical treatment are indispensable to ensure a positive outcome. The purpose of this study was to provide valuable information for the early identification of MH by summarizing epidemiological and clinical features of MH. This scoping review followed the methodological framework recommended by Arksey and O'Malley. PubMed, Embase, and Web of science databases were searched for studies that evaluated the epidemical and clinical characteristics of MH. A total of 37 studies were included in this review, of which 26 were related to epidemiology and 24 were associated with clinical characteristics. The morbidity of MH varied from 0.18 per 100 000 to 3.9 per 100 000. The mortality was within the range of 0%-18.2%. Identified risk factors included sex, age, disorders associated with MH, and others. The most frequent initial clinical signs included hyperthermia, sinus tachycardia, and hypercarbia. The occurrence of certain signs, such as hypercapnia, delayed first temperature measurement, and peak temperature were associated with poor outcomes. The epidemiological and clinical features of MH varied considerably and some risk factors and typical clinical signs were identified. The main limitation of this review is that the treatment and management strategies were not assessed sufficiently due to limited information.
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Affiliation(s)
- Zhukai Cong
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Tingting Wan
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Jiechu Wang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Luyang Feng
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Cathy Cao
- Department of Anesthesiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Xiaoxiao Wang
- Research Center for Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Yongzheng Han
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Yang Zhou
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Ya Gao
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Jing Zhang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Yinyin Qu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
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Yu KD, Betts MN, Urban GM, Schwartz MLB, Robinson TO, Moyer RJ, Taddonio SW, Vasudevan A, Johns A, Sturm AC, Kelly MA, Williams MS, Poler SM, Buchanan AH. Evaluation of Malignant Hyperthermia Features in Patients with Pathogenic or Likely Pathogenic RYR1 Variants Disclosed through a Population Genomic Screening Program. Anesthesiology 2024; 140:52-61. [PMID: 37787745 DOI: 10.1097/aln.0000000000004786] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
BACKGROUND Malignant hyperthermia (MH) susceptibility is a heritable musculoskeletal disorder that can present as a potentially fatal hypermetabolic response to triggering anesthesia agents. Genomic screening for variants in MH-associated genes RYR1 and CACNA1S provides an opportunity to prevent morbidity and mortality. There are limited outcomes data from disclosing variants in RYR1, the most common MH susceptibility gene, in unselected populations. The authors sought to identify the rate of MH features or fulminant episodes after triggering agent exposure in an unselected population undergoing genomic screening including actionable RYR1 variants. METHODS The MyCode Community Health Initiative by Geisinger (USA) is an electronic health record-linked biobank that discloses pathogenic and likely pathogenic variants in clinically actionable genes to patient-participants. Available electronic anesthesia and ambulatory records for participants with actionable RYR1 results returned through December 2020 were evaluated for pertinent findings via double-coded chart reviews and reconciliation. Descriptive statistics for observed phenotypes were calculated. RESULTS One hundred fifty-two participants had an actionable RYR1 variant disclosed during the study period. None had previous documented genetic testing for MH susceptibility; one had previous contracture testing diagnosing MH susceptibility. Sixty-eight participants (44.7%) had anesthesia records documenting triggering agent exposure during at least one procedure. None received dantrolene treatment or had documented muscle rigidity, myoglobinuria, hyperkalemia, elevated creatine kinase, severe myalgia, or tea-colored urine. Of 120 possibly MH-related findings (postoperative intensive care unit admissions, hyperthermia, arterial blood gas evaluation, hypercapnia, or tachycardia), 112 (93.3%) were deemed unlikely to be MH events; 8 (6.7%) had insufficient records to determine etiology. CONCLUSIONS Results demonstrate a low frequency of classic intraanesthetic hypermetabolic phenotypes in an unselected population with actionable RYR1 variants. Further research on the actionability of screening for MH susceptibility in unselected populations, including economic impact, predictors of MH episodes, and expanded clinical phenotypes, is necessary. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Kristen D Yu
- Department of Genomic Health, Geisinger, Danville, Pennsylvania
| | - Megan N Betts
- Department of Genomic Health, Geisinger, Danville, Pennsylvania; WellSpan Health, York, Pennsylvania
| | | | - Marci L B Schwartz
- Department of Genomic Health, Geisinger, Danville, Pennsylvania; Division of Clinical and Metabolic Genetics, and Ted Rogers Centre for Heart Research, Cardiac Genome Clinic, The Hospital for Sick Children, Toronto, Canada
| | | | - Robert J Moyer
- Department of Anesthesiology, Geisinger, Danville, Pennsylvania
| | - Scott W Taddonio
- Department of Anesthesiology, Geisinger, Danville, Pennsylvania; Department of Anesthesiology, Jefferson Health, Philadelphia, Pennsylvania
| | - Anasuya Vasudevan
- Department of Anesthesiology, Geisinger, Danville, Pennsylvania; Vigilant Anesthesia PC, New York, New York
| | - Alicia Johns
- Department of Population Health Sciences, Geisinger, Danville, Pennsylvania
| | - Amy C Sturm
- Department of Genomic Health, Geisinger, Danville, Pennsylvania; 23andMe, Sunnyvale, California
| | - Melissa A Kelly
- Department of Genomic Health, Geisinger, Danville, Pennsylvania
| | - Marc S Williams
- Department of Genomic Health, Geisinger, Danville, Pennsylvania
| | - S Mark Poler
- Department of Anesthesiology, Geisinger, Danville, Pennsylvania
| | - Adam H Buchanan
- Department of Genomic Health, Geisinger, Danville, Pennsylvania
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Lan H, Duan G, Zuo Y, Lou T, Xu J, Shao C, Wu J. Malignant hyperthermia: Report on a successful rescue of a case with the highest temperature of 44.2°C. Open Med (Wars) 2023; 18:20230808. [PMID: 37873543 PMCID: PMC10590604 DOI: 10.1515/med-2023-0808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/30/2023] [Accepted: 09/01/2023] [Indexed: 10/25/2023] Open
Abstract
Malignant hyperthermia (MH) is an inherited skeletal muscle disorder caused primarily by a genetic mutation, usually in the calcium channel gene of the muscle. This mutation can lead to muscle hypersensitivity to volatile anesthetics (such as sevoflurane) and the depolarizing muscle relaxant succinylcholine, resulting in hyperthermia, muscle stiffness, metabolic disturbances, and other severe physiological reactions. This condition may prove fatal unless it is recognized in its early stages and treatment is administered promptly and aggressively. We report a 13-year-old adolescent who underwent laparoscopic appendectomy and developed MH after the use of inhalational anesthetics, manifested by unremitting hyperthermia with a maximum temperature of 44.2°C, muscle rigidity, tachycardia, hypercapnia; and malignant arrhythmias, cardiogenic shock, hyperkalemia, metabolic, and respiratory acidosis. After early and timely recognition, multidisciplinary management and administration of dantrolene, the case was successfully treated. Exome sequencing revealed a point mutation (amino acid change) on the RYR1 gene: c.12700G>C(p.Val4234Leu). Due to the lack of ready-made dantrolene in our hospital, the patient in this case received dantrolene treatment only 6 h after the first observation of high body temperature. We review the development of the disease and summarize the success of treatment and what can be done to improve the chances of saving the patient's life if dantrolene is not available in time.
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Affiliation(s)
- Haiyan Lan
- Department of Anesthesiology, Lishui City People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang, 323000, China
| | - Gongchen Duan
- Department of Anesthesiology, Lishui City People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang, 323000, China
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Tianzheng Lou
- Department of Anesthesiology, Lishui City People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang, 323000, China
| | - Junlong Xu
- Department of Anesthesiology, Lishui City People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang, 323000, China
| | - Chuxiao Shao
- Department of Anesthesiology, Lishui City People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang, 323000, China
| | - Jimin Wu
- Department of Anesthesiology, Lishui City People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, No. 15, Dazhong Street, Lishui, Zhejiang, 323000, China
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6
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Aronson JK, Heneghan C, Ferner RE. Drug shortages. Part 2: Trends, causes and solutions. Br J Clin Pharmacol 2023; 89:2957-2963. [PMID: 37455465 DOI: 10.1111/bcp.15853] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 06/10/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
Drug shortages make it difficult or impossible to meet the therapeutic needs of individual patients or populations. In the first part of this review we proposed an operational definition that incorporates the processes by which products are manufactured, the causes of shortages and stock-outs (local shortages), and the contributory factors. Here we discuss causes and possible solutions. Drug shortages have complex causes, and a single cause cannot always be identified. Reasons include lack or shortage of raw materials, manufacturing difficulties, regulatory and political actions, voluntary recalls, just-in-time inventory systems, halts in production for financial or other business reasons, low demand (eg, orphan products, reduced usage), mergers, market shifts (eg, diversion to home markets) and unexpected increases in demand (eg, improved diagnosis, new trial information, epidemics and pandemics, inappropriate use, off-label use). Potential solutions are as diverse as the potential causes. Prevention is hard, because shortages are not easily predicted. Everyone in the supply chain is involved in anticipating and managing shortages, with responsibilities for preventing them or at least trying to mitigate their effects. This includes manufacturers and suppliers, particularly of generic formulations, pharmacists, prescribers, patients and governments. Solutions can therefore be linked to the causes and classified according to where the responsibility for implementing them lies.
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Affiliation(s)
- Jeffrey K Aronson
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, Oxford, UK
| | - Carl Heneghan
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, Oxford, UK
| | - Robin E Ferner
- West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, UK
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
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7
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Xu H, Wang Z, Peng Z, Zhang J, Li X, Liu D, Qi J, Li J. Suspected malignant hyperthermia in a young Chinese patient undergoing a micro varicocelectomy surgery. Chin Med J (Engl) 2023; 136:2116-2118. [PMID: 36939613 PMCID: PMC10476765 DOI: 10.1097/cm9.0000000000002317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Indexed: 03/21/2023] Open
Affiliation(s)
- Hongjiao Xu
- Department of Anesthesiology, Shanghai Jiaotong University First People's Hospital (Shanghai General Hospital), Shanghai 200080, China
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8
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Frassanito L, Sbaraglia F, Piersanti A, Vassalli F, Lucente M, Filetici N, Zanfini BA, Catarci S, Draisci G. Real Evidence and Misconceptions about Malignant Hyperthermia in Children: A Narrative Review. J Clin Med 2023; 12:3869. [PMID: 37373564 DOI: 10.3390/jcm12123869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 05/29/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
Malignant hyperthermia is a rare but life-threatening pharmacogenetic disorder triggered by exposure to specific anesthetic agents. Although this occurrence could affect virtually any patient during the perioperative time, the pediatric population is particularly vulnerable, and it has a five-fold higher incidence in children compared to adults. In the last few decades, synergistic efforts among leading anesthesiology, pediatrics, and neurology associations have produced new evidence concerning the diagnostic pathway, avoiding unnecessary testing and limiting false diagnoses. However, a personalized approach and an effective prevention policy focused on clearly recognizing the high-risk population, defining perioperative trigger-free hospitalization, and rapid activation of supportive therapy should be improved. Based on epidemiological data, many national scientific societies have produced consistent guidelines, but many misconceptions are common among physicians and healthcare workers. This review shall consider all these aspects and summarize the most recent updates.
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Affiliation(s)
- Luciano Frassanito
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Fabio Sbaraglia
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Alessandra Piersanti
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Francesco Vassalli
- Department of Critical Care and Perinatal Medicine, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Monica Lucente
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Nicoletta Filetici
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Bruno Antonio Zanfini
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Stefano Catarci
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Gaetano Draisci
- Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione-IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
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Cieniewicz A, Trzebicki J. Malignant hyperthermia in Poland: A survey study. Medicine (Baltimore) 2023; 102:e33238. [PMID: 36897682 PMCID: PMC9997818 DOI: 10.1097/md.0000000000033238] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/17/2023] [Indexed: 03/11/2023] Open
Abstract
Malignant hyperthermia (MH) is a life-threatening syndrome caused by sudden, uncontrolled skeletal muscle hypermetabolism in response to inhalation anesthetics and depolarizing relaxants. The estimated incidence of MH is between 1:10,000 and 1:250,000 anesthetic procedures. In Poland, due to lack of reporting, the incidence of MH is unknown. Dantrolene is imported as a life-saving drug (target import) and temporally authorized for sale. The aim of the study was to evaluate the prevalence of malignant hyperthermia in Poland and to assess the accessibility to dantrolene in Poland. A questionnaire was conducted among the chiefs of anesthesia and intensive care units in Poland. During the years 2014 to 2019, 10 episodes of MH have been reported in 238 surveyed polish anesthesia departments. The estimated prevalence is 1:350,000. Eight patients survived the MH crisis. Dantrolene is stocked in 48 (20%) anesthesiology departments. Among the surveyed hospitals, only in 38 (16%) it is possible to administer dantrolene within 5 minutes of suspecting a MH reaction. Less than half units (44%) have an algorithm for the management of MH episode in the operating theaters. The results of the study revealed, that the prevalence of MH in Poland is lower than the prevalence reported in other countries. Access to dantrolene in Poland is limited.
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Affiliation(s)
- Agnieszka Cieniewicz
- 1st Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Trzebicki
- 1st Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
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10
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Donniacuo M, De Angelis A, Telesca M, Bellocchio G, Riemma MA, Paolisso P, Scisciola L, Cianflone E, Torella D, Castaldo G, Capuano A, Urbanek K, Berrino L, Rossi F, Cappetta D. Atrial fibrillation: Epigenetic aspects and role of sodium-glucose cotransporter 2 inhibitors. Pharmacol Res 2023; 188:106591. [PMID: 36502999 DOI: 10.1016/j.phrs.2022.106591] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/30/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022]
Abstract
Atrial fibrillation (AF) is the most frequent arrhythmia and is associated with substantial morbidity and mortality. Pathophysiological aspects consist in the activation of pro-fibrotic signaling and Ca2+ handling abnormalities at atrial level. Structural and electrical remodeling creates a substrate for AF by triggering conduction abnormalities and cardiac arrhythmias. The care of AF patients focuses predominantly on anticoagulation, symptoms control and the management of risk factors and comorbidities. The goal of AF therapy points to restore sinus rhythm, re-establish atrioventricular synchrony and improve atrial contribution to the stroke volume. New layer of information to better comprehend AF pathophysiology, and identify targets for novel pharmacological interventions consists of the epigenetic phenomena including, among others, DNA methylation, histone modifications and noncoding RNAs. Moreover, the benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in diabetic and non-diabetic patients at cardiovascular risk as well as emerging evidence on the ability of SGLT2i to modify epigenetic signature in cardiovascular diseases provide a solid background to investigate a possible role of this drug class in the onset and progression of AF. In this review, following a summary of pathophysiology and management, epigenetic mechanisms in AF and the potential of sodium-glucose SGLT2i in AF patients are discussed.
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Affiliation(s)
- M Donniacuo
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - A De Angelis
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - M Telesca
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - G Bellocchio
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - M A Riemma
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - P Paolisso
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium; Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via A. Pansini 5, 80131 Naples, Italy
| | - L Scisciola
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - E Cianflone
- Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, 88100 Catanzaro, Italy
| | - D Torella
- Department of Experimental and Clinical Medicine, Magna Graecia University, Viale Europa, 88100 Catanzaro, Italy
| | - G Castaldo
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples "Federico II", Via A. Pansini 5, 80131 Naples, Italy; CEINGE-Advanced, Via G. Salvatore 486, 80131 Naples, Italy
| | - A Capuano
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - K Urbanek
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples "Federico II", Via A. Pansini 5, 80131 Naples, Italy; CEINGE-Advanced, Via G. Salvatore 486, 80131 Naples, Italy.
| | - L Berrino
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - F Rossi
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
| | - D Cappetta
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Via Costantinopoli 16, 80138 Naples, Italy
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11
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Dalmas-Laurent AF, Bruneau B, Roux-Buisson N. Hyperthermie maligne de l’anesthésie. ANESTHÉSIE & RÉANIMATION 2023. [DOI: 10.1016/j.anrea.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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Tan L, Yu H, Yan J, Liu C, Xiao K, Yin J, Zuo Y, Zhu T, Deng X. The Knowledge Profile, Competence and Pending Problems of Chinese Anesthesiologists in Dealing with Malignant Hyperthermia: A Cross-Sectional Survey. J Multidiscip Healthc 2023; 16:133-142. [PMID: 36691603 PMCID: PMC9863447 DOI: 10.2147/jmdh.s387025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/05/2022] [Indexed: 01/18/2023] Open
Abstract
Purpose The National Remote Emergency System for Malignant Hyperthermia (MH-NRES) is an applet in China, designed to help anesthesiologists manage MH crisis. However, there is limited information about encountered difficulties in dealing with MH among Chinese anesthesiologists. The purpose of the study was to explore the current competency and encountered difficulties in the management of MH, as a key first step for assessing the potential user needs to develop the MH-NRES. Methods The hospitals of different levels in different provinces across China were invited to participate in an online survey from November to December 2021. Anesthesiologists completed the online questionnaire containing four sections including demographic information, knowledge, competency, and continuing education about MH. Results A total of 1357 valid questionnaires were completed from anesthesiologists, most respondents (66.7%, n = 905) correctly answered the MH trigger drugs included volatile anesthetics and succinylcholine. However, most respondents (77.0%, n = 1045) did not know that the recommended initial dose of domestic dantrolene. Up to 83.9% (n = 1138) stated that their hospitals did not store dantrolene for MH emergency. More than half of respondents thought that it would take more than one hour to obtain dantrolene in emergency. Less work experiences, lower levels of hospital and educations and professional titles were associated with lower competency scores in managing MH. Only 31.0% (n = 936) reported that their hospital had ever conducted MH continuing education curricula. Scenario simulation is the training method that most interests the participants (79.0%, n = 1072) but a whopping 46.9% (n = 637) never received simulation. Conclusion The study indicated that difficulty in obtaining dantrolene, lack of competency in management of MH, difficulty in obtaining professional help, and poor teamwork were the main problems of most anesthesiologists in face of MH.
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Affiliation(s)
- Lingcan Tan
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Hong Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Junyu Yan
- Department of Anesthesiology, Karamay Hospital of Integrated Traditional Chinese and Western Medicine, Karamay, People’s Republic of China
| | - Chunyuan Liu
- Department of Anesthesiology, Chongqing Liangping District People’s Hospital, Chongqing, 405200, People’s Republic of China
| | - Kun Xiao
- School of Information and Software Engineering, University of Electronic Science and Technology of China, Chengdu, 610054, People’s Republic of China
| | - Jin Yin
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Xiaoqian Deng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China,Correspondence: Xiaoqian Deng, Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, People’s Republic of China, Email
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Rapid Dantrolene Administration with Body Temperature Monitoring Is Associated with Decreased Mortality in Japanese Malignant Hyperthermia Events. BIOMED RESEARCH INTERNATIONAL 2023; 2023:8340209. [PMID: 36874927 PMCID: PMC9977521 DOI: 10.1155/2023/8340209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 01/18/2023] [Accepted: 01/31/2023] [Indexed: 02/24/2023]
Abstract
Purpose Malignant hyperthermia (MH) is a rare genetic disorder but one of the most severe complications of general anesthesia. The mortality rate of MH has dropped from 70% in the 1960s to 15% because of dantrolene, the only currently accepted specific treatment for MH. In this study, we retrospectively identified the optimal dantrolene administration conditions to reduce MH mortality further. Methods Our database performed a retrospective analysis of patients with MH clinical grading scale (CGS) grade 5 (very likely) or 6 (almost certain) between 1995 and 2020. We examined whether dantrolene administration affected mortality and compared the clinical variables associated with improved prognosis. Furthermore, a multivariable logistic regression analysis was used to identify specific variables associated with improved prognosis. Results 128 patients met the inclusion criteria. 115 patients were administered dantrolene; 104 survived, and 11 died. The mortality rate of patients who were not administered dantrolene was 30.8%, which was significantly higher than those of patients who were administered dantrolene (P = 0.047). Among patients administered dantrolene, the interval from the first sign of MH to the start of dantrolene administration was significantly longer in the deceased than in the survivors (100 min vs. 45.0 min, P < 0.001), and the temperature at the start of dantrolene administration was also significantly higher in the deceased (41.6°C vs. 39.1°C, P < 0.001). There was no significant difference in the rate of increase in temperature between the two, but there was a substantial difference in the maximum temperature (P < 0.001). The multivariable analysis also showed that the patient's temperature at dantrolene administration and interval from the first MH sign to dantrolene administration was significantly associated with improved prognosis. Conclusions Dantrolene should be given as rapidly as possible once MH has been diagnosed. Beginning treatment at a more normal body temperature can prevent critical elevations associated with a worse prognosis.
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Malignant Hyperthermia in PICU—From Diagnosis to Treatment in the Light of Up-to-Date Knowledge. CHILDREN 2022; 9:children9111692. [DOI: 10.3390/children9111692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/04/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
Malignant Hyperthermia (MH) is a rare, hereditary, life-threatening disease triggered by volatile anesthetics and succinylcholine. Rarely, MH can occur after non-pharmacological triggers too. MH was detected more often in children and young adults, which makes this topic very important for every pediatric specialist, both anesthesiologists and intensivists. MH crisis is a life-threatening severe hypermetabolic whole-body reaction. Triggers of MH are used in pediatric intensive care unit (PICU) as well, volatile anesthetics in difficult sedation, status asthmaticus or epilepticus, and succinylcholine still sometimes in airway management. Recrudescence or delayed onset of MH crisis hours after anesthesia was previously described. MH can also be a cause of rhabdomyolysis and hyperpyrexia in the PICU. In addition, patients with neuromuscular diseases are often admitted to PICU and they might be at risk for MH. The most typical symptoms of MH are hypercapnia, tachycardia, hyperthermia, and muscle rigidity. Thinking of the MH as the possible cause of deterioration of a patient’s clinical condition is the key to early diagnosis and treatment. The sooner the correct treatment is commenced, the better patient´s outcome. This narrative review article aims to summarize current knowledge and guidelines about recognition, treatment, and further management of MH in PICU.
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Chi X, Xu Y, Liao H, Chen T, Li Q, Fu Q. Perioperative management of malignant hyperthermia during general anesthesia: A report of two cases. Clin Case Rep 2022; 10:e6426. [PMID: 36245440 PMCID: PMC9552991 DOI: 10.1002/ccr3.6426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/18/2022] [Accepted: 09/20/2022] [Indexed: 11/12/2022] Open
Abstract
Malignant hyperthermia (MH) is a lethal complication associated with general anesthesia characterized by sudden onset, rapid progression, and high mortality. We present two seemingly typical cases of intraoperative MH development, with details on perioperative assessment and rescue. Postoperative genetic test showed mutations in the ryanodine receptor type 1 gene.
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Affiliation(s)
- Xiaowei Chi
- Department of Anesthesiology, Third People's Hospital of ChengduSouthwest Jiaotong UniversityChengduChina
| | - Yi Xu
- Department of AnesthesiologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Hongbing Liao
- Department of Anesthesiology, Third People's Hospital of ChengduSouthwest Jiaotong UniversityChengduChina
| | - Tao Chen
- Department of Anesthesiology, Third People's Hospital of ChengduSouthwest Jiaotong UniversityChengduChina
| | - Qiang Li
- Department of Anesthesiology, Third People's Hospital of ChengduSouthwest Jiaotong UniversityChengduChina
| | - Qiang Fu
- Department of Anesthesiology, Third People's Hospital of ChengduSouthwest Jiaotong UniversityChengduChina
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16
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Emerging Antiarrhythmic Drugs for Atrial Fibrillation. Int J Mol Sci 2022; 23:ijms23084096. [PMID: 35456912 PMCID: PMC9029767 DOI: 10.3390/ijms23084096] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF), the most common cardiac arrhythmia worldwide, is driven by complex mechanisms that differ between subgroups of patients. This complexity is apparent from the different forms in which AF presents itself (post-operative, paroxysmal and persistent), each with heterogeneous patterns and variable progression. Our current understanding of the mechanisms responsible for initiation, maintenance and progression of the different forms of AF has increased significantly in recent years. Nevertheless, antiarrhythmic drugs for the management of AF have not been developed based on the underlying arrhythmia mechanisms and none of the currently used drugs were specifically developed to target AF. With the increased knowledge on the mechanisms underlying different forms of AF, new opportunities for developing more effective and safer AF therapies are emerging. In this review, we provide an overview of potential novel antiarrhythmic approaches based on the underlying mechanisms of AF, focusing both on the development of novel antiarrhythmic agents and on the possibility of repurposing already marketed drugs. In addition, we discuss the opportunity of targeting some of the key players involved in the underlying AF mechanisms, such as ryanodine receptor type-2 (RyR2) channels and atrial-selective K+-currents (IK2P and ISK) for antiarrhythmic therapy. In addition, we highlight the opportunities for targeting components of inflammatory signaling (e.g., the NLRP3-inflammasome) and upstream mechanisms targeting fibroblast function to prevent structural remodeling and progression of AF. Finally, we critically appraise emerging antiarrhythmic drug principles and future directions for antiarrhythmic drug development, as well as their potential for improving AF management.
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Bouchama A, Abuyassin B, Lehe C, Laitano O, Jay O, O'Connor FG, Leon LR. Classic and exertional heatstroke. Nat Rev Dis Primers 2022; 8:8. [PMID: 35115565 DOI: 10.1038/s41572-021-00334-6] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 12/28/2022]
Abstract
In the past two decades, record-breaking heatwaves have caused an increasing number of heat-related deaths, including heatstroke, globally. Heatstroke is a heat illness characterized by the rapid rise of core body temperature above 40 °C and central nervous system dysfunction. It is categorized as classic when it results from passive exposure to extreme environmental heat and as exertional when it develops during strenuous exercise. Classic heatstroke occurs in epidemic form and contributes to 9-37% of heat-related fatalities during heatwaves. Exertional heatstroke sporadically affects predominantly young and healthy individuals. Under intensive care, mortality reaches 26.5% and 63.2% in exertional and classic heatstroke, respectively. Pathological studies disclose endothelial cell injury, inflammation, widespread thrombosis and bleeding in most organs. Survivors of heatstroke may experience long-term neurological and cardiovascular complications with a persistent risk of death. No specific therapy other than rapid cooling is available. Physiological and morphological factors contribute to the susceptibility to heatstroke. Future research should identify genetic factors that further describe individual heat illness risk and form the basis of precision-based public health response. Prioritizing research towards fundamental mechanism and diagnostic biomarker discovery is crucial for the design of specific management approaches.
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Affiliation(s)
- Abderrezak Bouchama
- King Abdullah International Medical Research Center, Experimental Medicine Department, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia.
| | - Bisher Abuyassin
- King Abdullah International Medical Research Center, Experimental Medicine Department, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Cynthia Lehe
- King Abdullah International Medical Research Center, Experimental Medicine Department, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Orlando Laitano
- Department of Nutrition & Integrative Physiology, College of Health and Human Sciences, Florida State University, Tallahassee, FL, USA
| | - Ollie Jay
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Francis G O'Connor
- Military and Emergency Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Lisa R Leon
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
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Wang QL, Fang Y, Jin SG, Liang JT, Ren YF. Atypical symptoms of malignant hyperthermia: A rare causative mutation in the RYR1 gene. Open Med (Wars) 2022; 17:239-244. [PMID: 35178478 PMCID: PMC8812711 DOI: 10.1515/med-2021-0396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 11/15/2022] Open
Abstract
Malignant hyperthermia (MH) is an autosomal dominant genetic condition of the skeletal muscle triggered by inhaled general anesthetic agents or succinylcholine and associated with a hypermetabolic state and skeletal muscle rigidity. Tachycardia, increased carbon dioxide production, hypercarbia, hyperthermia, acidosis, hyperkalemia, cardiac arrhythmias, muscle rigidity, and rhabdomyolysis are common symptoms of MH. As the progression of the syndrome could be rapid or less evident, even experienced physicians have difficulty in diagnosing MH, which can lead to delays in treatment and increased mortality. We report a rare case of a 36-year-old man, who underwent open reduction and internal fixation of the left clavicle after inhaled anesthetics. The patient developed dyspnea, hypotension, unremitting hyperthermia, tachycardia, and elevated serum myoglobin, and finally died of pyemia and disseminated intravascular coagulation. We reviewed the process of disease development, summarized the steps of diagnosis, and improved genetic testing. Exome sequencing revealed a new mutation c.8519G>A (p.arg2840 GLN) in the RYR1 gene that could be associated with MH. The gene mutation was also found in his daughter’s genetic test. This case emphasized the importance of the awareness of MH and its atypical clinical symptoms. The presence of dyspnea, hypotension, unremitting hyperthermia, tachycardia, and raised myoglobin in serum might further strengthen the clinical diagnosis of suspected MH.
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Affiliation(s)
- Qiao Ling Wang
- Department of Ministry of Science, Hospital of Chengdu University of Traditional Chinese Medicine , Chengdu , Sichuan, 610072 , China
| | - Yu Fang
- Department of Ministry of Science, Hospital of Chengdu University of Traditional Chinese Medicine , Chengdu , Sichuan, 610072 , China
| | - Shuo Guo Jin
- Department of Ministry of Science, Hospital of Chengdu University of Traditional Chinese Medicine , Chengdu , Sichuan, 610072 , China
| | - Jing Tao Liang
- Department of Ministry of Science, Hospital of Chengdu University of Traditional Chinese Medicine , Chengdu , Sichuan, 610072 , China
| | - Yi Feng Ren
- Department of Ministry of Science, Hospital of Chengdu University of Traditional Chinese Medicine , Chengdu , Sichuan, 610072 , China
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Age-Specific Clinical Features of Pediatric Malignant Hyperthermia: A Review of 187 Cases Over 60 Years in Japan. Anesth Analg 2021; 135:128-135. [PMID: 34962895 DOI: 10.1213/ane.0000000000005837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Malignant hyperthermia (MH) is an inherited muscle disorder induced by volatile anesthetics and depolarizing muscle relaxants. While the incidence of MH is high in young, there are few reports on the clinical features of pediatric MH. In this study, we selected pediatric cases from an MH database and analyzed the clinical findings by age group. We hypothesized that there would be age-related differences in the clinical characteristics. METHODS A retrospective analysis of MH data collected in our database during 1960 to 2020 was performed to identify pediatric subjects (≤18 years) with a Clinical Grading Scale of ≥35, indicating "very likely" or "almost certain" MH. We compared clinical characteristics among the 0 to 24 month, 2 to 12 year, and 13 to 18 year (youngest, middle, and oldest, respectively) age groups. RESULTS Data were available for 187 patients: 15 in the youngest age group, 123 in the middle-aged group, and 49 in the oldest age group. Of these, 55 patients (29.4%) had undergone muscle biopsy and muscle contracture test. The mortality rates during the study period were 13.3%, 13.8%, 20.4%, and 15.5% in the youngest, middle, and oldest cohorts and overall, respectively. In contrast, the overall mortality rate from 2000 to 2020 was 8.8%. The most frequent initial symptoms of MH were elevated temperature (46.7%) and generalized muscular rigidity (26.7%) in the youngest cohort, masseter spasm (35.0%) and generalized muscular rigidity (19.5%) in the middle cohort, and elevated end-tidal carbon dioxide (26.5%) and tachycardia (22.4%) in the oldest cohort. Physical examination revealed that elevated temperature, sinus tachycardia, and respiratory acidosis occurred frequently in all groups. The middle cohort had high frequencies of masseter spasm (58.4%; P = .02) and dark urine (75.5%; P = .01) compared to those in the oldest groups, and had a higher peak creatine kinase level compared to those in the 3 groups. Skeletal muscle symptoms tended to be more common in patients administered succinylcholine (generalized muscular rigidity, P = .053; masseter spasm, P < .0001; dark urine, P < .0001). In particular, masseter spasm and dark urine were more common in the middle cohort when succinylcholine was administered (masseter spasm: versus youngest cohort, P = .06, versus oldest cohort, P = .027; dark urine: versus youngest cohort, P = .0072, versus oldest cohort, P = .0015). CONCLUSIONS The clinical characteristics of pediatric patients with MH vary according to age group. The difference in initial symptoms of MH depending on age group is noteworthy information for the early diagnosis of MH.
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Spinal cord injury-related thermoregulatory impairment masks a fatal malignant hyperthermia crisis: a case report. Can J Anaesth 2021; 69:369-373. [PMID: 34904211 DOI: 10.1007/s12630-021-02170-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Malignant hyperthermia (MH) is a hypermetabolic disorder that can occur in genetically susceptible individuals exposed to halogenated anesthetics and succinylcholine. Spinal cord injury (SCI) above the sixth thoracic vertebra is associated with dysfunction of the sympathetic/parasympathetic nervous pathways, including thermoregulatory dysfunction, presenting as hypothermia in cold environments because of vasodilation and heat loss. This effect could mitigate or obscure an MH episode. Here, we describe development of a fatal MH crisis in a patient with SCI. CLINICAL FEATURES A 27-yr-old male patient with an SCI after fracture of the sixth cervical vertebra was admitted for spinal arthrodesis. Anesthetic medications included remifentanil, propofol, succinylcholine, rocuronium, and isoflurane. After the start of the surgery, muscular contractures resembling myoclonus were noted, which resolved with pancuronium administration. Four hours after the start of anesthesia, the patient presented with hyperthermia, hypercarbia, hypotension, muscle rigidity, arrhythmia, and cardiogenic shock, with metabolic/respiratory acidosis. Malignant hyperthermia was suspected and the treatment was started, but he developed cardiopulmonary arrest and died an hour and a half after the first cardiac arrest. Both parents were investigated and were found to have normal creatine kinase levels and positive in vitro contracture tests. His mother carried a variant in the ryanodine receptor type 1 (RYR1) gene (c.14918C>T), which is associated with MH. CONCLUSION Spinal cord injury-induced thermoregulatory dysfunction may obscure the early diagnosis of MH and lead to fatal outcome.
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van den Bersselaar LR, Hollmann MW, van den Goor JMMH, Winkelman JA, Snoeck MMJ, Corsmit OT. Malignant Hyperthermia During Cardiac Surgery Successfully Treated by Deep Hypothermia Using Cardiopulmonary Bypass: A Case Report. A A Pract 2021; 15:e01546. [PMID: 34807873 DOI: 10.1213/xaa.0000000000001546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Malignant hyperthermia (MH) is a life-threatening hypermetabolic disorder triggered by volatile anesthetics and/or succinylcholine. We report a case of a 58-year-old patient with a type-A aortic dissection. After induction of general anesthesia, a hypermetabolic reaction was successfully treated by deep hypothermia using cardiopulmonary bypass. Dantrolene became available in theater after the hypermetabolism was already treated successfully by hypothermia. Because of a low suspicion of MH, dantrolene was not administered when it became available. The patient fully recovered, and MH susceptibility was confirmed. Cardiopulmonary bypass should be considered to treat MH in case dantrolene and conservative therapy are unavailable or insufficient.
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Affiliation(s)
- Luuk R van den Bersselaar
- From the Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands.,Department of Neurology, Radboudumc, Nijmegen, the Netherlands; and Departments of
| | | | - Jeanette M M H van den Goor
- Cardiothoracic Surgery, Location Academic Medical Center, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jacobus A Winkelman
- Cardiothoracic Surgery, Location Academic Medical Center, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Marc M J Snoeck
- From the Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
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Sequence variants in malignant hyperthermia genes in Iceland: classification and actionable findings in a population database. Eur J Hum Genet 2021; 29:1819-1824. [PMID: 34462577 PMCID: PMC8633338 DOI: 10.1038/s41431-021-00954-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 12/19/2022] Open
Abstract
Malignant hyperthermia (MH) susceptibility is a rare life-threatening disorder that occurs upon exposure to a triggering agent. MH is commonly due to protein-altering variants in RYR1 and CACNA1S. The American College of Medical Genetics and Genomics recommends that when pathogenic and likely pathogenic variants in RYR1 and CACNA1S are incidentally found, they should be reported to the carriers. The detection of actionable variants allows the avoidance of exposure to triggering agents during anesthesia. First, we report a 10-year-old Icelandic proband with a suspected MH event, harboring a heterozygous missense variant NM_000540.2:c.6710G>A r.(6710g>a) p.(Cys2237Tyr) in the RYR1 gene that is likely pathogenic. The variant is private to four individuals within a three-generation family and absent from 62,240 whole-genome sequenced (WGS) Icelanders. Haplotype sharing and WGS revealed that the variant occurred as a somatic mosaicism also present in germline of the proband’s paternal grandmother. Second, using a set of 62,240 Icelanders with WGS, we assessed the carrier frequency of actionable pathogenic and likely pathogenic variants in RYR1 and CACNA1S. We observed 13 actionable variants in RYR1, based on ClinVar classifications, carried by 43 Icelanders, and no actionable variant in CACNA1S. One in 1450 Icelanders carries an actionable variant for MH. Extensive sequencing allows for better classification and precise dating of variants, and WGS of a large fraction of the population has led to incidental findings of actionable MH genotypes.
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Berrio Valencia MI, Ibarra C. Malignant hyperthermia: what we may need to have at hand. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.5554/22562087.e993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Schuster F, Johannsen S. [Malignant Hyperthermia and Pregnancy - Guidelines of the European Malignant Hyperthermia Group]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:367-372. [PMID: 34038975 DOI: 10.1055/a-1260-8975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Malignant hyperthermia is a rare, subclinical pharmacogenetic syndrome leading to potentially life-threatening skeletal muscle hypermetabolism. Providing a safe and trigger-free anesthesia in predisposed individuals is essential to avoid serious harm to the patient. Especially the management of malignant hyperthermia predisposition in the context of pregnancy poses a huge challenge to the attending anesthesiologist. In May 2019 the European Malignant Hyperthermia Group published a guideline on malignant hyperthermia during pregnancy. The article summarizes and discusses the recommendations and provides practical advice for treatment of pregnant women or their fetus with known or suspected susceptibility to malignant hyperthermia.
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Dalhat MH, Altayb HN, Khan MI, Choudhry H. Structural insights of human N-acetyltransferase 10 and identification of its potential novel inhibitors. Sci Rep 2021; 11:6051. [PMID: 33723305 PMCID: PMC7960695 DOI: 10.1038/s41598-021-84908-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/19/2021] [Indexed: 01/31/2023] Open
Abstract
N-acetyltransferase 10 (NAT10), is an acetyltransferase that regulates RNA stability and translation processes. Association of NAT10 with several diseases including cancer, makes it a promising therapeutic target. Remodelin is the only known NAT10 inhibitor, but the structural information related to its binding with NAT10 is still obscure. Here, we predicted the human NAT10 structure using homology modeling that was not available previously and used human NAT10 to identify the novel binding site(s) of Remodelin. The alignment of the modeled human NAT10 showed 24% identity and 37% positivity with crystal structure of tRNA (Met) cytidine acetyltransferase. Molecular docking showed binding of Remodelin with NAT10 in acetyl-CoA binding pocket. Additionally, we screened a library of FDA-approved drugs for the identification of novel inhibitors of NAT10 activity. Binding score showed that four drugs namely, Fosaprepitant (- 11.709), Leucal (- 10.46), Fludarabine (- 10.347) and Dantrolene (- 9.875) bind to NAT10 and have better binding capability when compared with Acetyl-CoA (- 5.691) and Remodelin (- 5.3). Acetyl-CoA, Remodelin, and others exhibit hits for hydrophobic, hydrophilic and hydrogen interactions. Interestingly, Remodelin and others interact with the amino acid residues ILE629, GLY639, GLY641, LEU719, and PHE722 in the Acetyl-CoA binding pocket of NAT10 similar to Acetyl-CoA. Our findings revealed that Fosaprepitant, Leucal, Fludarabine, and Dantrolene are promising molecules that can be tested and developed as potential inhibitors of NAT10 acetyltransferase activity.
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Affiliation(s)
- Mahmood Hassan Dalhat
- Biochemistry Department, Faculty of Science, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
- Centre for Artificial Intelligence in Precision Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
- Cancer and Mutagenesis Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Hisham N Altayb
- Biochemistry Department, Faculty of Science, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
- Centre for Artificial Intelligence in Precision Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
- Cancer and Mutagenesis Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Mohammad Imran Khan
- Biochemistry Department, Faculty of Science, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
- Centre for Artificial Intelligence in Precision Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
- Cancer and Mutagenesis Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| | - Hani Choudhry
- Biochemistry Department, Faculty of Science, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
- Centre for Artificial Intelligence in Precision Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
- Cancer and Mutagenesis Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
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Tsutsumi YM, Kakuta N, Kawanishi R, Tanaka K, Kanzaki R, Morio A, Noda Y, Miyoshi H, Kondo T, Mukaida K. Malignant hyperthermia in a 16-day-old infant with congenital diaphragmatic hernia: a case report. J Anesth 2021; 35:311-314. [PMID: 33625594 DOI: 10.1007/s00540-021-02902-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/23/2021] [Indexed: 11/28/2022]
Abstract
Malignant hyperthermia (MH) is a severe hypermetabolic disorder associated with dysregulation of calcium homeostasis and is triggered by inhalational anesthetics (isoflurane, sevoflurane, desflurane) and a depolarizing muscle relaxant (succinylcholine). We report the case of a 16-day-old infant undergoing laparoscopic surgery. The patient developed hyperthermia and hypercarbia with muscle rigidity. After the diagnosis of MH, dantrolene was administered with sufficient hydration. The patient was transferred to the pediatric intensive care unit for monitoring and treatment of acute renal injury due to myoglobinuria. Subsequently, two variants of the ryanodine receptor 1 (RYR1) gene were identified in the patient as the mutation point at c.1589G > A p.Arg530His and c.1841G > T p.Arg614Leu, which are known to be associated with MH. This was a rare case of MH in a 16-day-old infant that might be related to two RYR1 mutations inherited from the parents.
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Affiliation(s)
- Yasuo M Tsutsumi
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan.
| | - Nami Kakuta
- Department of Anesthesiology, Tokushima University, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan
| | - Ryosuke Kawanishi
- Department of Anesthesiology, Tokushima University, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan
| | - Katsuya Tanaka
- Department of Anesthesiology, Tokushima University, 3-18-15 Kuramoto, Tokushima, 770-8503, Japan
| | - Rieko Kanzaki
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Atsushi Morio
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Yuko Noda
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Hirotsugu Miyoshi
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Takashi Kondo
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Keiko Mukaida
- Department of Anesthesiology, Hiroshima Prefectural Rehabilitation Center, Higashi-Hiroshima, 739-0036, Japan
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27
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Heiderich S, Bastian B, Johannsen S, Klingler W, Rüffert H, Schuster F. [The European Malignant Hyperthermia Group consensus guidelines on perioperative management of malignant hyperthermia suspected or susceptible patients]. Anaesthesist 2020; 70:155-157. [PMID: 33269407 DOI: 10.1007/s00101-020-00893-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Sebastian Heiderich
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30659, Hannover, Deutschland.
| | - Börge Bastian
- Zentrum für Maligne Hyperthermie, Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Stephan Johannsen
- Zentrum für Maligne Hyperthermie, Klinik und Poliklinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Werner Klingler
- Klinik für Anästhesie und Intensivmedizin, SRH Kliniken Landkreis Sigmaringen, Sigmaringen, Deutschland
| | - Henrik Rüffert
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Helios Klinik Schkeuditz, Schkeuditz, Deutschland
| | - Frank Schuster
- Zentrum für Maligne Hyperthermie, Klinik und Poliklinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
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28
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Kaura V, Hopkins PM. Sevoflurane may not be a complete sigh of relief in COVID-19. Br J Anaesth 2020; 125:e487-e488. [PMID: 33012516 PMCID: PMC7494294 DOI: 10.1016/j.bja.2020.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/10/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- Vikas Kaura
- Academic Unit of Anaesthesia, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK.
| | - Philip M Hopkins
- Academic Unit of Anaesthesia, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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29
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Rüffert H, Bastian B, Bendixen D, Girard T, Heiderich S, Hellblom A, Hopkins PM, Johannsen S, Snoeck MM, Urwyler A, Glahn KPE. Consensus guidelines on perioperative management of malignant hyperthermia suspected or susceptible patients from the European Malignant Hyperthermia Group. Br J Anaesth 2020; 126:120-130. [PMID: 33131754 DOI: 10.1016/j.bja.2020.09.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/24/2020] [Accepted: 09/26/2020] [Indexed: 11/15/2022] Open
Abstract
Malignant hyperthermia is a potentially fatal condition, in which genetically predisposed individuals develop a hypermetabolic reaction to potent inhalation anaesthetics or succinylcholine. Because of the rarity of malignant hyperthermia and ethical limitations, there is no evidence from interventional trials to inform the optimal perioperative management of patients known or suspected with malignant hyperthermia who present for surgery. Furthermore, as the concentrations of residual volatile anaesthetics that might trigger a malignant hyperthermia crisis are unknown and manufacturers' instructions differ considerably, there are uncertainties about how individual anaesthetic machines or workstations need to be prepared to avoid inadvertent exposure of susceptible patients to trigger anaesthetic drugs. The present guidelines are intended to bundle the available knowledge about perioperative management of malignant hyperthermia-susceptible patients and the preparation of anaesthesia workstations. The latter aspect includes guidance on the use of activated charcoal filters. The guidelines were developed by members of the European Malignant Hyperthermia Group, and they are based on evaluation of the available literature and a formal consensus process. The most crucial recommendation is that malignant hyperthermia-susceptible patients should receive anaesthesia that is free of triggering agents. Providing that this can be achieved, other key recommendations include avoidance of prophylactic administration of dantrolene; that preoperative management, intraoperative monitoring, and care in the PACU are unaltered by malignant hyperthermia susceptibility; and that malignant hyperthermia patients may be anaesthetised in an outpatient setting.
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Affiliation(s)
- Henrik Rüffert
- Klinik für Anästhesie, Intensivmedizin, Schmerztherapie, Helios Klinik Schkeuditz, Leipzig-Schkeuditz, Germany; Department of Anaesthesiology and Intensive Care Medicine, MH Centre, University Hospital Leipzig, Leipzig, Germany.
| | - Börge Bastian
- Department of Anaesthesiology and Intensive Care Medicine, MH Centre, University Hospital Leipzig, Leipzig, Germany
| | - Diana Bendixen
- Danish Malignant Hyperthermia Centre, Department of Anaesthesia, University Hospital Herlev, Copenhagen, Denmark
| | - Thierry Girard
- Department of Anaesthesia and Research, University of Basel, Basel, Switzerland
| | - Sebastian Heiderich
- Clinic of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Anna Hellblom
- Department of Anaesthesia, University Hospital, Lund, Sweden
| | - Philip M Hopkins
- Malignant Hyperthermia Unit, St James's University Hospital, Leeds, UK
| | - Stephan Johannsen
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Marc M Snoeck
- Department of Anaesthesiology, Canisius-Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Albert Urwyler
- Department of Anaesthesia and Research, University of Basel, Basel, Switzerland
| | - Klaus P E Glahn
- Danish Malignant Hyperthermia Centre, Department of Anaesthesia, University Hospital Herlev, Copenhagen, Denmark
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30
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Bastian B, Heiderich S, Schuster F, Johannsen S, Klingler W, Rüffert H. Kommentar zur Leitlinie der European Malignant Hyperthermia Group zur Verfügbarkeit von Dantrolen für die Behandlung der Malignen Hyperthermie. Anaesthesist 2020; 69:751-752. [DOI: 10.1007/s00101-020-00839-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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