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Kondo H, Mukaida K, Sasai K, Nao Y, Hashimoto K, Miyoshi H, Kanzaki R, Tsutsumi YM. Remimazolam-based total intravenous anesthesia in a patient with a confirmed diagnosis of malignant hyperthermia: a case report. JA Clin Rep 2024; 10:26. [PMID: 38647904 PMCID: PMC11035517 DOI: 10.1186/s40981-024-00710-7] [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: 03/25/2024] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Malignant hyperthermia (MH) is a rare, life-threatening disorder of calcium homeostasis in skeletal muscle cells that is triggered by volatile anesthetics and succinylcholine, leading to a hypermetabolic reaction. The pathogenic ryanodine receptor 1 (RYR1) gene variant is critical. Patients susceptible to MH should avoid triggering agents, and total intravenous anesthesia (TIVA) is preferred. Remimazolam is safe in patients with suspected MH. CASE PRESENTATION We present the first case of remimazolam treatment in a genetically confirmed patient with MH without MH development. A 72-year-old man with a family history of MH underwent remimazolam-based TIVA. After informed consent was obtained, a muscle biopsy and genetic testing were performed. Intraoperatively and postoperatively, the patient exhibited no signs of MH. An enhanced function of the RYR1 channel into releasing calcium was indicated, and the genetic testing revealed a pathogenic variant of RYR1. CONCLUSIONS Remimazolam-based TIVA is safe in patients confirming the diagnosis of MH.
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Affiliation(s)
- Hiroshi Kondo
- Department of Anesthesiology, National Hospital Organization Higashihiroshima Medical Center, Higashihiroshima, Japan
| | - Keiko Mukaida
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, 734-8551, Japan
| | - Kurumi Sasai
- Department of Anesthesiology, National Hospital Organization Higashihiroshima Medical Center, Higashihiroshima, Japan
| | - Yukiko Nao
- Department of Anesthesiology, National Hospital Organization Higashihiroshima Medical Center, Higashihiroshima, Japan
| | - Ken Hashimoto
- Department of Anesthesiology, National Hospital Organization Higashihiroshima Medical Center, Higashihiroshima, Japan
| | - Hirotsugu Miyoshi
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, 734-8551, Japan
| | - Rieko Kanzaki
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, 734-8551, Japan
| | - Yasuo M Tsutsumi
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, 734-8551, Japan.
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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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Figueroa L, Kraeva N, Manno C, Ibarra-Moreno CA, Tammineni ER, Riazi S, Rios E. Distinct pathophysiological characteristics in developing muscle from patients susceptible to malignant hyperthermia. Br J Anaesth 2023; 131:47-55. [PMID: 36792386 PMCID: PMC10308439 DOI: 10.1016/j.bja.2023.01.008] [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: 03/14/2022] [Revised: 12/19/2022] [Accepted: 01/02/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Most patients with malignant hyperthermia susceptibility diagnosed by the in vitro caffeine-halothane contracture test (CHCT) develop excessive force in response to halothane but not caffeine (halothane-hypersensitive). Hallmarks of halothane-hypersensitive patients include high incidence of musculoskeletal symptoms at rest and abnormal calcium events in muscle. By measuring sensitivity to halothane of myotubes and extending clinical observations and cell-level studies to a large group of patients, we reach new insights into the pathological mechanism of malignant hyperthermia susceptibility. METHODS Patients with malignant hyperthermia susceptibility were classified into subgroups HH and HS (positive to halothane only and positive to both caffeine and halothane). The effects on [Ca2+]cyto of halothane concentrations between 0.5 and 3 % were measured in myotubes and compared with CHCT responses of muscle. A clinical index that summarises patient symptoms was determined for 67 patients, together with a calcium index summarising resting [Ca2+]cyto and spontaneous and electrically evoked Ca2+ events in their primary myotubes. RESULTS Halothane-hypersensitive myotubes showed a higher response to halothane 0.5% than the caffeine-halothane hypersensitive myotubes (P<0.001), but a lower response to higher concentrations, comparable with that used in the CHCT (P=0.055). The HH group had a higher calcium index (P<0.001), but their clinical index was not significantly elevated vs the HS. Principal component analysis identified electrically evoked Ca2+ spikes and resting [Ca2+]cyto as the strongest variables for separation of subgroups. CONCLUSIONS Enhanced sensitivity to depolarisation and to halothane appear to be the primary, mutually reinforcing and phenotype-defining defects of halothane-hypersensitive patients with malignant hyperthermia susceptibility.
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Affiliation(s)
- Lourdes Figueroa
- Department of Physiology and Biophysics, Rush University Medical Centre, Chicago, IL, USA.
| | - Natalia Kraeva
- Malignant Hyperthermia Unit, Department of Anaesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Carlo Manno
- Department of Physiology and Biophysics, Rush University Medical Centre, Chicago, IL, USA
| | - Carlos A Ibarra-Moreno
- Malignant Hyperthermia Unit, Department of Anaesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Eshwar R Tammineni
- Department of Physiology and Biophysics, Rush University Medical Centre, Chicago, IL, USA
| | - Sheila Riazi
- Malignant Hyperthermia Unit, Department of Anaesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Eduardo Rios
- Department of Physiology and Biophysics, Rush University Medical Centre, Chicago, IL, USA
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van den Bersselaar LR, Greven T, Bulger T, Voermans NC, van Petegem F, Schiemann AH, Parker R, Burling SM, Jungbluth H, Stowell KM, Kamsteeg EJ, Snoeck MMJ. RYR1 variant c.38T>G, p.Leu13Arg causes hypersensitivity of the ryanodine receptor-1 and is pathogenic for malignant hyperthermia. Br J Anaesth 2021; 127:e63-e65. [PMID: 34127251 DOI: 10.1016/j.bja.2021.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/05/2021] [Accepted: 05/12/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - T Greven
- Department of Anaesthesia, Nijmegen, the Netherlands
| | | | - N C Voermans
- Department of Anaesthesia, Nijmegen, the Netherlands
| | | | | | | | | | | | | | - E J Kamsteeg
- Department of Anaesthesia, Nijmegen, the Netherlands
| | - M M J Snoeck
- Department of Anaesthesia, Nijmegen, the Netherlands.
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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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Sheng C, Yang C, Jing Z, Li Y. The Use of Continuous Blood Purification for the Treatment of Malignant Hyperthermia in an Infant. J Cardiothorac Vasc Anesth 2020; 35:3307-3310. [PMID: 33223381 DOI: 10.1053/j.jvca.2020.10.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/24/2020] [Accepted: 10/28/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND Malignant hyperthermia (MH) is a rare and potentially life-threatening pharmacogenetic disorder encountered during general anesthesia, with the incidence higher in children than in adults. Dantrolene is the specific antagonist of MH, but it is not readily available in China, thus developing alternative treatment protocols is of great practical importance. CASE PRESENTATION Herein, the authors report a two-month-old infant who underwent holmium laser epiglottis retrofitting through a bronchoscope, but developed limb muscular stiffness, tachypnea, tachycardia, and hyperthermia after sevoflurane exposure. After the diagnosis of MH, corresponding supportive treatment was implemented. Because there was no dantrolene available, continuous blood purification and mechanical ventilation were performed. A few days later, the boy recovered without any complications. CONCLUSION Based on the authors' successful clinical practice, the authors consider continuous blood purification as a reliable treatment for MH. But its feasibility still needs to be clarified after multicenter clinical observations.
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Affiliation(s)
- Chuqiao Sheng
- Department of Pediatric Intensive Care Unit, First Hospital of Jilin University, Jilin, China
| | - Chunfeng Yang
- Department of Pediatric Intensive Care Unit, First Hospital of Jilin University, Jilin, China
| | - Zhe Jing
- Department of Laboratory Medicine, First Hospital of Jilin University, Jilin, China
| | - Yumei Li
- Department of Pediatric Intensive Care Unit, First Hospital of Jilin University, Jilin, China.
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