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Schwaiger D, Ruzsanyi V, Mayhew CA, Lederer W. Postoperative Sevoflurane Exposure in the Recovery Room. J Craniofac Surg 2024:00001665-990000000-01853. [PMID: 39207143 DOI: 10.1097/scs.0000000000010558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/22/2024] [Indexed: 09/04/2024] Open
Affiliation(s)
- Daniel Schwaiger
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Austria
| | - Veronika Ruzsanyi
- Institute for Breath Research, Universität of Innsbruck, Innrain 66, 6020 Innsbruck Austria
| | - Chris A Mayhew
- Institute for Breath Research, Universität of Innsbruck, Innrain 66, 6020 Innsbruck Austria
| | - Wolfgang Lederer
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Austria
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2
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Ibarra Moreno CA, Silva HCA, Voermans NC, Jungbluth H, van den Bersselaar LR, Rendu J, Cieniewicz A, Hopkins PM, Riazi S. Myopathic manifestations across the adult lifespan of patients with malignant hyperthermia susceptibility: a narrative review. Br J Anaesth 2024:S0007-0912(24)00419-7. [PMID: 39107166 DOI: 10.1016/j.bja.2024.05.046] [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: 02/17/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 08/09/2024] Open
Abstract
Malignant hyperthermia susceptibility (MHS) designates individuals at risk of developing a hypermetabolic reaction triggered by halogenated anaesthetics or the depolarising neuromuscular blocking agent suxamethonium. Over the past few decades, beyond the operating theatre, myopathic manifestations impacting daily life are increasingly recognised as a prevalent phenomenon in MHS patients. At the request of the European Malignant Hyperthermia Group, we reviewed the literature and gathered the opinion of experts to define MHS-related myopathy as a distinct phenotype expressed across the adult lifespan of MHS patients unrelated to anaesthetic exposure; this serves to raise awareness about non-anaesthetic manifestations, potential therapies, and management of MHS-related myopathy. We focused on the clinical presentation, biochemical and histopathological findings, and the impact on patient well-being. The spectrum of symptoms of MHS-related myopathy encompasses muscle cramps, stiffness, myalgias, rhabdomyolysis, and weakness, with a wide age range of onset mainly during adulthood. Histopathological analysis can reveal nonspecific abnormalities suggestive of RYR1 involvement, while metabolic profiling reflects altered energy metabolism in MHS muscle. Myopathic manifestations can significantly impact patient quality of life and lead to functional limitations and socio-economic burden. While currently available therapies can provide symptomatic relief, there is a need for further research into targeted treatments addressing the underlying pathophysiology. Counselling early after establishing the MHS diagnosis, followed by multidisciplinary management involving various medical specialties, is crucial to optimise patient care.
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Affiliation(s)
- Carlos A Ibarra Moreno
- Malignant Hyperthermia Investigation Unit, Department of Anesthesiology and Pain Management, University Health Network, Toronto, ON, Canada
| | - Helga C A Silva
- Malignant Hyperthermia Unit, Department of Anesthesiology, Pain and Intensive Care, Federal University of São Paulo, São Paulo, Brazil
| | - Nicol C Voermans
- Department of Neurology, Radboudumc Research Institute for Medical Innovation, Nijmegen, The Netherlands
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina London Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK; Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and Medicine (FoLSM), King's College London, London, UK
| | - Luuk R van den Bersselaar
- Malignant Hyperthermia Investigation Unit, Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands; Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - John Rendu
- Universite Grenoble Alpes, INSERM, Grenoble Institut Neurosciences, U1216, CHU Grenoble Alpes, Grenoble, France
| | - Agnieszka Cieniewicz
- Department of Anaesthesiology and Intensive Therapy, Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - Philip M Hopkins
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK; Department of Anaesthesia, St James's University Hospital, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Sheila Riazi
- Malignant Hyperthermia Investigation Unit, Department of Anesthesiology and Pain Management, University Health Network, Toronto, ON, Canada.
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3
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Contreras S, Giménez-Esparza Vich C, Caballero J. Practical approach to inhaled sedation in the critically ill patient. Sedation, analgesia and Delirium Working Group (GTSAD) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2024; 48:467-476. [PMID: 38862301 DOI: 10.1016/j.medine.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/16/2024] [Indexed: 06/13/2024]
Abstract
The use of sedatives in Intensive Care Units (ICU) is essential for relieving anxiety and stress in mechanically ventilated patients, and it is related to clinical outcomes, duration of mechanical ventilation, and length of stay in the ICU. Inhaled sedatives offer benefits such as faster awakening and extubation, decreased total opioid and neuromuscular blocking agents (NMB) doses, as well as bronchodilator, anticonvulsant, and cardiopulmonary and neurological protective effects. Inhaled sedation is administered using a specific vaporizer. Isoflurane is the recommended agent due to its efficacy and safety profile. Inhaled sedation is recommended for moderate and deep sedation, prolonged sedation, difficult sedation, patients with acute respiratory distress syndrome (ARDS), status asthmaticus, and super-refractory status epilepticus. By offering these significant advantages, the use of inhaled sedatives allows for a personalized and controlled approach to optimize sedation in the ICU.
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Affiliation(s)
- Sofía Contreras
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
| | | | - Jesús Caballero
- Servicio de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
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Baba H, Wakabayashi R, Ichiyanagi H, Suzuki A, Sato N. Anesthetic Management of a Patient With Central Core Disease Undergoing Thoracoscopic Lung Resection: The Importance of Neuromuscular Monitoring at the Masseter Muscle. Cureus 2024; 16:e52456. [PMID: 38371001 PMCID: PMC10872652 DOI: 10.7759/cureus.52456] [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] [Accepted: 01/17/2024] [Indexed: 02/20/2024] Open
Abstract
Central core disease is a rare muscular disorder in which anesthetic considerations for the prevention of malignant hyperthermia and for avoidance of residual neuromuscular block are required. A 63-year-old woman with central core disease underwent thoracoscopic sublobar lung resection under total IV anesthesia with a prepared anesthetic workstation. The rocuronium-induced neuromuscular block was monitored by using acceleromyography at the left adductor pollicis muscle and the right masseter muscle. The recovery of neuromuscular block at the masseter was slower than that at the adductor pollicis. The patient showed no symptoms of malignant hyperthermia and residual neuromuscular block and had an uneventful postoperative course. In the present case, malignant hyperthermia was successfully prevented with general anesthesia that is free of triggering agents using a prepared anesthetic machine. The authors speculate that the masseter may be an auxiliary site for neuromuscular monitoring to ensure recovery from neuromuscular block in patients with central core disease.
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Affiliation(s)
- Hiroko Baba
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Ryo Wakabayashi
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Hiroki Ichiyanagi
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Aki Suzuki
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
| | - Nobukazu Sato
- Department of Anesthesiology, Tokyo Saiseikai Central Hospital, Tokyo, JPN
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5
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Nelson O, Greenwood E, Simpao AF, Matava CT. Refocusing on work-based hazards for the anaesthesiologist in a post-pandemic era. BJA OPEN 2023; 8:100234. [PMID: 37942056 PMCID: PMC10630594 DOI: 10.1016/j.bjao.2023.100234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 09/18/2023] [Accepted: 10/03/2023] [Indexed: 11/10/2023]
Abstract
The coronavirus pandemic has raised public awareness of one of the many hazards that healthcare workers face daily: exposure to harmful pathogens. The anaesthesia workplace encompasses the operating room, interventional radiology suite, and other sites that contain many other potential occupational and environmental hazards. This review article highlights the work-based hazards that anaesthesiologists and other clinicians may encounter in the anaesthesia workplace: ergonomic design, physical, chemical, fire, biological, or psychological hazards. As the anaesthesia work environment enters a post-COVID-19 pandemic phase, anaesthesiologists will do well to review and consider these hazards. The current review includes proposed solutions to some hazards and identifies opportunities for future research.
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Affiliation(s)
- Olivia Nelson
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Eric Greenwood
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Allan F. Simpao
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Clyde T. Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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6
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Miyoshi H, Otsuki S, Mukaida K, Kido K, Sumii A, Ikeda T, Noda Y, Yasuda T, Narasaki S, Kato T, Kamiya S, Horikawa YT, Tsutsumi YM. Effects of Remimazolam on Intracellular Calcium Dynamics in Myotubes Derived from Patients with Malignant Hyperthermia and Functional Analysis of Type 1 Ryanodine Receptor Gene Variants. Genes (Basel) 2023; 14:2009. [PMID: 38002952 PMCID: PMC10671487 DOI: 10.3390/genes14112009] [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: 09/26/2023] [Revised: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023] Open
Abstract
Remimazolam is a novel general anesthetic and its safety in patients with malignant hyperthermia (MH) is unknown. We used myotubes derived from the skeletal muscle of patients with MH to examine the response to ryanodine receptor 1 (RYR1) agonist and remimazolam in MH-susceptible patients. Patients underwent muscle biopsy for the Ca2+-induced Ca2+ release (CICR) rate test, a diagnostic tool for MH in Japan. Ten patients had myotubes obtained from skeletal muscle cultures, and the genes associated with malignant hyperthermia in these patients were analyzed. The EC50 of caffeine, cresol, and remimazolam to induce intracellular calcium concentration change were compared between myotubes from CICR-negative genetic test patients and myotubes from other patients. Eight of the ten were CICR-positive, five of whom had RYR1 causative gene mutations or variants. Two patients had CICR-negative genetic tests, and as expected had the highest EC50 (the concentration of a drug that gives a half-maximal response) in response to caffeine, 4CmC and remimazolam. Three patients had a positive CICR but no known variants in RYR1 or CACNA1S (voltage-gated calcium channel subunit alpha1S). Myotubes in these patients had significantly lower EC50s for all agents than myotubes in CICR-negative patients. When myotubes from a patient who was CICR-negative and had no gene variant were used as a control, myotubes from CICR-positive patients were more hyper-responsive than controls to all stimulants used. The EC50 for remimazolam was lowest for myotubes from CICR-positive, RYR1-mutant patients, at 206 µM (corresponding to 123 µg/mL). The concentration was more than 80-times higher than the clinical concentration. RYR1 gene variants in R4645Q and W5020G were shown to be causative gene mutations for MH. Intracellular calcium in myotubes from MH patients are elevated at high concentrations of remimazolam but not at clinically used concentrations of remimazolam. Remimazolam appears to be safe to use in patients with MH.
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Affiliation(s)
- Hirotsugu Miyoshi
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima 734-8551, Japan; (S.O.); (K.M.); (K.K.); (A.S.); (T.I.); (Y.N.); (S.N.); (T.K.); (S.K.); (Y.M.T.)
| | - Sachiko Otsuki
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima 734-8551, Japan; (S.O.); (K.M.); (K.K.); (A.S.); (T.I.); (Y.N.); (S.N.); (T.K.); (S.K.); (Y.M.T.)
| | - Keiko Mukaida
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima 734-8551, Japan; (S.O.); (K.M.); (K.K.); (A.S.); (T.I.); (Y.N.); (S.N.); (T.K.); (S.K.); (Y.M.T.)
| | - Kenshiro Kido
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima 734-8551, Japan; (S.O.); (K.M.); (K.K.); (A.S.); (T.I.); (Y.N.); (S.N.); (T.K.); (S.K.); (Y.M.T.)
| | - Ayako Sumii
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima 734-8551, Japan; (S.O.); (K.M.); (K.K.); (A.S.); (T.I.); (Y.N.); (S.N.); (T.K.); (S.K.); (Y.M.T.)
| | - Tsuyoshi Ikeda
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima 734-8551, Japan; (S.O.); (K.M.); (K.K.); (A.S.); (T.I.); (Y.N.); (S.N.); (T.K.); (S.K.); (Y.M.T.)
| | - Yuko Noda
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima 734-8551, Japan; (S.O.); (K.M.); (K.K.); (A.S.); (T.I.); (Y.N.); (S.N.); (T.K.); (S.K.); (Y.M.T.)
| | - Toshimichi Yasuda
- Department of Anesthesiology, Hiroshima Prefectural Rehabilitation Center, Hiroshima 739-0036, Japan;
| | - Soshi Narasaki
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima 734-8551, Japan; (S.O.); (K.M.); (K.K.); (A.S.); (T.I.); (Y.N.); (S.N.); (T.K.); (S.K.); (Y.M.T.)
| | - Takahiro Kato
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima 734-8551, Japan; (S.O.); (K.M.); (K.K.); (A.S.); (T.I.); (Y.N.); (S.N.); (T.K.); (S.K.); (Y.M.T.)
| | - Satoshi Kamiya
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima 734-8551, Japan; (S.O.); (K.M.); (K.K.); (A.S.); (T.I.); (Y.N.); (S.N.); (T.K.); (S.K.); (Y.M.T.)
| | - Yousuke T. Horikawa
- CHOC Health Alliance, Children’s Hospital Orange County, Orange, CA 92868, USA;
| | - Yasuo M. Tsutsumi
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima 734-8551, Japan; (S.O.); (K.M.); (K.K.); (A.S.); (T.I.); (Y.N.); (S.N.); (T.K.); (S.K.); (Y.M.T.)
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7
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Osman V, Speigel I, Patel K, Hemmings HC. Isoflurane Alters Presynaptic Endoplasmic Reticulum Calcium Dynamics in Wild-Type and Malignant Hyperthermia-Susceptible Rodent Hippocampal Neurons. eNeuro 2023; 10:ENEURO.0114-23.2023. [PMID: 37591734 PMCID: PMC10467020 DOI: 10.1523/eneuro.0114-23.2023] [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: 04/05/2023] [Revised: 07/28/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023] Open
Abstract
Volatile anesthetics reduce excitatory synaptic transmission by both presynaptic and postsynaptic mechanisms which include inhibition of depolarization-evoked increases in presynaptic Ca2+ concentration and blockade of postsynaptic excitatory glutamate receptors. The presynaptic sites of action leading to reduced electrically evoked increases in presynaptic Ca2+ concentration and Ca2+-dependent exocytosis are unknown. Endoplasmic reticulum (ER) of Ca2+ release via ryanodine receptor 1 (RyR1) and uptake by SERCA are essential for regulation intracellular Ca2+ and are potential targets for anesthetic action. Mutations in sarcoplasmic reticulum (SR) release channels mediate volatile anesthetic-induced malignant hyperthermia (MH), a potentially fatal pharmacogenetic condition characterized by unregulated Ca2+ release and muscle hypermetabolism. However, the impact of MH mutations on neuronal function are unknown. We used primary cultures of postnatal hippocampal neurons to analyze volatile anesthetic-induced changes in ER Ca2+ dynamics using a genetically encoded ER-targeted fluorescent Ca2+ sensor in both rat and mouse wild-type (WT) neurons and in mouse mutant neurons harboring the RYR1 T4826I MH-susceptibility mutation. The volatile anesthetic isoflurane reduced both baseline and electrical stimulation-evoked increases in ER Ca2+ concentration in neurons independent of its depression of presynaptic cytoplasmic Ca2+ concentrations. Isoflurane and sevoflurane, but not propofol, depressed depolarization-evoked increases in ER Ca2+ concentration significantly more in mouse RYR1 T4826I mutant neurons than in wild-type neurons. The RYR1 T4826I mutant neurons also showed markedly greater isoflurane-induced reductions in presynaptic cytosolic Ca2+ concentration and synaptic vesicle (SV) exocytosis. These findings implicate RyR1 as a molecular target for the effects of isoflurane on presynaptic Ca2+ handling.
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Affiliation(s)
- Vanessa Osman
- Department of Pharmacology, Weill Cornell Medical College, New York, NY 10065
| | - Iris Speigel
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY 10065
| | - Kishan Patel
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY 10065
| | - Hugh C Hemmings
- Department of Pharmacology, Weill Cornell Medical College, New York, NY 10065
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY 10065
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8
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Heiderich S, Bastian B, Johannsen S, Klingler W, Rüffert H, Schuster F. [Trigger-free anesthesia : Indications and safe application]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01311-2. [PMID: 37382624 DOI: 10.1007/s00101-023-01311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
The safe anesthesiological care of patients with neuromuscular diseases poses a particular challenge for anesthetists. Only a small group of muscle diseases and syndromes are associated with an increased risk of malignant hyperthermia and therefore require trigger-free anesthetic procedures avoiding volatile anesthetics and succinylcholine. These diseases are frequently associated with mutations in the RYR1, CACNA1S or STAC-3 genes. In other neuromuscular diseases, anesthetic-induced rhabdomyolysis can occur. Therefore, volatile anesthetics should be avoided in these patients in addition to the contraindication for succinylcholine. In other neuromuscular diseases the risk of a propofol infusion syndrome or myotonic crises can be elevated or the duration of the effect of non-depolarizing muscle relaxants can be changed in an incalculable way. In every case an individual anesthetic aproach including the avoidance of potential pharmacological or non-pharmacological triggers is essential for the safety of the patients.
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Affiliation(s)
- Sebastian Heiderich
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - Börge Bastian
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Stephan Johannsen
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Werner Klingler
- Fachabteilung für Anästhesie, Intensivmedizin und Schmerztherapie, SRH Kliniken Landkreis Sigmaringen, Sigmaringen, Deutschland
| | - Henrik Rüffert
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Helios Klinikum Schkeuditz, Schkeuditz, Deutschland
| | - Frank Schuster
- Institut für Anästhesiologie, Intensivmedizin und Notfallmedizin, Donau-Isar-Klinikum Deggendorf-Dingolfing-Landau, Deggendorf, Deutschland
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MATSUKAWA HIROYUKI, MURAYAMA TAKASHI. Development of Ryanodine Receptor (RyR) Inhibitors for Skeletal Muscle and Heart Diseases. JUNTENDO IJI ZASSHI = JUNTENDO MEDICAL JOURNAL 2023; 69:180-187. [PMID: 38855953 PMCID: PMC11153067 DOI: 10.14789/jmj.jmj22-0045-r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/13/2023] [Indexed: 06/11/2024]
Abstract
Ryanodine receptors (RyR) are intracellular calcium (Ca2+) release channels on the sarcoplasmic reticulum of skeletal and cardiac muscles that play a central role in excitation-contraction coupling. Genetic mutations or posttranslational modifications of RyR causes hyperactivation of the channel, leading to various skeletal muscle and heart diseases. Currently, no specific treatments exist for most RyR-associated diseases. Recently, high-throughput screening (HTS) assays have been developed to identify potential candidates for treating RyR-related muscle diseases. These assays have successfully identified several compounds as novel RyR inhibitors, which are effective in animal models. In this review, we will focus on recent progress in HTS assays and discuss future perspectives of these promising approaches.
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Affiliation(s)
| | - TAKASHI MURAYAMA
- Corresponding author: Takashi Murayama, Department of Pharmacology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan, TEL: +81-3-5802-1035 E-mail: Research of the 4th Alumni Scientific Award for Medical Student, Juntendo University School of Medicine
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10
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Mattaliano G, Heberlein M, Cruz Benedetti I. Unanticipated hyperkalaemia and associated perioperative complications in three captive grey wolves (
Canis lupus
) undergoing general anaesthesia. VETERINARY RECORD CASE REPORTS 2023. [DOI: 10.1002/vrc2.597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Giorgio Mattaliano
- Department for Companion Animals and Horses Anaesthesiology and Perioperative Intensive‐Care Medicine, Vetmeduni Vienna Vienna Austria
| | | | - Inga‐Catalina Cruz Benedetti
- Department of Clinical Sciences, Faculty of Veterinary Medicine Université de Montréal Saint‐Hyacinthe Quebec Canada
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Murayama T, Kurebayashi N, Ishida R, Kagechika H. Drug development for the treatment of RyR1-related skeletal muscle diseases. Curr Opin Pharmacol 2023; 69:102356. [PMID: 36842386 DOI: 10.1016/j.coph.2023.102356] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 02/27/2023]
Abstract
Type 1 ryanodine receptor (RyR1) is an intracellular Ca2+ release channel on the sarcoplasmic reticulum of skeletal muscle, and it plays a central role in excitation-contraction (E-C) coupling. Mutations in RyR1 are implicated in various muscle diseases including malignant hyperthermia, central core disease, and myopathies. Currently, no specific treatment exists for most of these diseases. Recently, high-throughput screening (HTS) assays have been developed for identifying potential candidates for treating RyR-related muscle diseases. Currently, two different methods, namely a FRET-based assay and an endoplasmic reticulum Ca2+-based assay, are available. These assays identified several compounds as novel RyR1 inhibitors. In addition, the development of a reconstituted platform permitted HTS assays for E-C coupling modulators. In this review, we will focus on recent progress in HTS assays and discuss future perspectives of these promising approaches.
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Affiliation(s)
- Takashi Murayama
- Department of Pharmacology, Juntendo University School of Medicine, Tokyo, Japan.
| | - Nagomi Kurebayashi
- Department of Pharmacology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ryosuke Ishida
- Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Kagechika
- Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, Tokyo, Japan
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12
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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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13
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Janssens L, De Puydt J, Milazzo M, Symoens S, De Bleecker JL, Herdewyn S. Risk of malignant hyperthermia in patients carrying a variant in the skeletal muscle ryanodine receptor 1 gene. Neuromuscul Disord 2022; 32:864-869. [PMID: 36283893 DOI: 10.1016/j.nmd.2022.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 12/15/2022]
Abstract
Malignant hyperthermia is a life-threatening disorder, which can be prevented by avoiding certain anesthetic agents. Pathogenic variants in the skeletal muscle ryanodine receptor 1-gene are linked to malignant hyperthermia. We retrospectively studied 15 patients who presented to our clinic with symptoms of muscle dysfunction (weakness, myalgia or cramps) and were later found to have a variant in the skeletal muscle ryanodine receptor 1-gene. Symptoms, creatine kinase levels, electromyography, muscle biopsy and in vitro contracture test results were reviewed. Six out of the eleven patients, with a variant of unknown significance in the skeletal muscle ryanodine receptor 1-gene, had a positive in vitro contracture test, indicating malignant hyperthermia susceptibility. In one patient, with two variants of unknown significance, both variants were required to express the malignant hyperthermia-susceptibility trait. Neurologists should consider screening the skeletal muscle ryanodine receptor 1-gene in patients with myalgia or cramps, even when few to no abnormalities on ancillary testing.
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Affiliation(s)
- Lise Janssens
- Faculty of medical and health sciences, Ghent University, Corneel Heymanslaan 10, Ghent 9000, Belgium
| | - Joris De Puydt
- University Hospital of Antwerp, Drie Eikenstraat 655, Edegem 2650, Belgium; Faculty of medical and health sciences, Antwerp University, Prinsstraat 13, Antwerp 2000, Belgium
| | - Mauro Milazzo
- Center for Medical Genetics Ghent, Ghent University Hospital, Corneel Heymanslaan 10, Ghent 9000, Belgium
| | - Sofie Symoens
- Faculty of medical and health sciences, Ghent University, Corneel Heymanslaan 10, Ghent 9000, Belgium; Center for Medical Genetics Ghent, Ghent University Hospital, Corneel Heymanslaan 10, Ghent 9000, Belgium
| | - Jan L De Bleecker
- Faculty of medical and health sciences, Ghent University, Corneel Heymanslaan 10, Ghent 9000, Belgium; Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent 9000, Belgium
| | - Sarah Herdewyn
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent 9000, Belgium.
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14
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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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15
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Grover KM, Sripathi N. Prevention of Adverse Outcomes and Treatment Side Effects in Patients with Neuromuscular Disorders. Semin Neurol 2022; 42:594-610. [PMID: 36400111 DOI: 10.1055/s-0042-1758779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In this article, we review prevention of serious adverse clinical outcomes and treatment side effects in patients with neuromuscular disorders including myopathies and myasthenia gravis. While neither of these entities is preventable, their course can often be modified, and severe sequelae may be prevented, with the identification of risk factors and proactive attention toward treatment planning.
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Affiliation(s)
- Kavita M Grover
- Department of Neurology, Henry Ford Medical Group, Wayne State University, Detroit, Michigan
| | - Naganand Sripathi
- Department of Neurology, Henry Ford Medical Group, Wayne State University, Detroit, Michigan
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16
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Gene Panel Sequencing Identifies a Novel RYR1 p.Ser2300Pro Variant as Candidate for Malignant Hyperthermia with Multi-Minicore Myopathy. Genes (Basel) 2022; 13:genes13101726. [PMID: 36292611 PMCID: PMC9601532 DOI: 10.3390/genes13101726] [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: 08/17/2022] [Revised: 09/17/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Malignant hyperthermia (MH), a rare autosomal dominant pharmacogenetic disorder of skeletal muscle calcium regulation, is triggered by sevoflurane in susceptible individuals. We report a Korean having MH with multi-minicore myopathy functionally supported by RYR1-mediated intracellular Ca2+ release testing in B lymphocytes. A 14-year-old boy was admitted for the evaluation of progressive torticollis accompanied by cervicothoracic scoliosis. During the preoperative drape of the patient for the release of the sternocleidomastoid muscle under general anesthesia, his wrist and ankle were observed to have severe flexion contracture. The body temperature was 37.1 °C. To treat MH, the patient was administered a bolus of dantrolene intravenously (1.5 mg/kg) and sodium bicarbonate. After a few minutes, muscle rigidity, tachycardia, and EtCO2 all resolved. Next-generation panel sequencing for hereditary myopathy identified a novel RYR1 heterozygous missense variant (NM_000540.2: c.6898T > C; p.Ser2300Pro), which mapped to the MH2 domain of the protein, a hot spot for MH mutations. Ex vivo RYR1-mediated intracellular Ca2+ release testing in B lymphocytes showed hypersensitive Ca2+ responses to isoflurane and caffeine, resulting in an abnormal Ca2+ release only in the proband, not in his family members. Our findings expand the clinical and pathological spectra of information associated with MH with multi-minicore myopathy.
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17
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Rossi D, Catallo MR, Pierantozzi E, Sorrentino V. Mutations in proteins involved in E-C coupling and SOCE and congenital myopathies. J Gen Physiol 2022; 154:e202213115. [PMID: 35980353 PMCID: PMC9391951 DOI: 10.1085/jgp.202213115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022] Open
Abstract
In skeletal muscle, Ca2+ necessary for muscle contraction is stored and released from the sarcoplasmic reticulum (SR), a specialized form of endoplasmic reticulum through the mechanism known as excitation-contraction (E-C) coupling. Following activation of skeletal muscle contraction by the E-C coupling mechanism, replenishment of intracellular stores requires reuptake of cytosolic Ca2+ into the SR by the activity of SR Ca2+-ATPases, but also Ca2+ entry from the extracellular space, through a mechanism called store-operated calcium entry (SOCE). The fine orchestration of these processes requires several proteins, including Ca2+ channels, Ca2+ sensors, and Ca2+ buffers, as well as the active involvement of mitochondria. Mutations in genes coding for proteins participating in E-C coupling and SOCE are causative of several myopathies characterized by a wide spectrum of clinical phenotypes, a variety of histological features, and alterations in intracellular Ca2+ balance. This review summarizes current knowledge on these myopathies and discusses available knowledge on the pathogenic mechanisms of disease.
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Affiliation(s)
- Daniela Rossi
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
- Interdepartmental Program of Molecular Diagnosis and Pathogenetic Mechanisms of Rare Genetic Diseases, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Maria Rosaria Catallo
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Enrico Pierantozzi
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Vincenzo Sorrentino
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
- Interdepartmental Program of Molecular Diagnosis and Pathogenetic Mechanisms of Rare Genetic Diseases, Azienda Ospedaliero Universitaria Senese, Siena, Italy
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18
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Horseman M, Panahi L, Udeani G, Tenpas AS, Verduzco Jr. R, Patel PH, Bazan DZ, Mora A, Samuel N, Mingle AC, Leon LR, Varon J, Surani S. Drug-Induced Hyperthermia Review. Cureus 2022; 14:e27278. [PMID: 36039261 PMCID: PMC9403255 DOI: 10.7759/cureus.27278] [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] [Accepted: 07/22/2022] [Indexed: 11/26/2022] Open
Abstract
Humans maintain core body temperature via a complicated system of physiologic mechanisms that counteract heat/cold fluctuations from metabolism, exertion, and the environment. Overextension of these mechanisms or disruption of body temperature homeostasis leads to bodily dysfunction, culminating in a syndrome analogous to exertional heat stroke (EHS). The inability of this thermoregulatory process to maintain the body temperature is caused by either thermal stress or certain drugs. EHS is a syndrome characterized by hyperthermia and the activation of systemic inflammation. Several drug-induced hyperthermic syndromes may resemble EHS and share common mechanisms. The purpose of this article is to review the current literature and compare exertional heat stroke (EHS) to three of the most widely studied drug-induced hyperthermic syndromes: malignant hyperthermia (MH), neuroleptic malignant syndrome (NMS), and serotonin syndrome (SS). Drugs and drug classes that have been implicated in these conditions include amphetamines, diuretics, cocaine, antipsychotics, metoclopramide, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and many more. Observations suggest that severe or fulminant cases of drug-induced hyperthermia may evolve into an inflammatory syndrome best described as heat stroke. Their underlying mechanisms, symptoms, and treatment approaches will be reviewed to assist in accurate diagnosis, which will impact the management of potentially life-threatening complications.
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Hashimoto M, Sato-Boku A, Tachi N, Okumura Y, Okuda M, Goto Y, Ito HI, Kitoh T. Comparison of Emergence Agitation Scale Scores and Creatine Kinase Levels After General Anesthesia in Children: A Prospective Cohort Study. Cureus 2022; 14:e26991. [PMID: 35989850 PMCID: PMC9386302 DOI: 10.7759/cureus.26991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2022] [Indexed: 11/05/2022] Open
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Cirino G, Szabo C, Papapetropoulos A. Physiological roles of hydrogen sulfide in mammalian cells, tissues and organs. Physiol Rev 2022; 103:31-276. [DOI: 10.1152/physrev.00028.2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
H2S belongs to the class of molecules known as gasotransmitters, which also includes nitric oxide (NO) and carbon monoxide (CO). Three enzymes are recognized as endogenous sources of H2S in various cells and tissues: cystathionine g-lyase (CSE), cystathionine β-synthase (CBS) and 3-mercaptopyruvate sulfurtransferase (3-MST). The current article reviews the regulation of these enzymes as well as the pathways of their enzymatic and non-enzymatic degradation and elimination. The multiple interactions of H2S with other labile endogenous molecules (e.g. NO) and reactive oxygen species are also outlined. The various biological targets and signaling pathways are discussed, with special reference to H2S and oxidative posttranscriptional modification of proteins, the effect of H2S on channels and intracellular second messenger pathways, the regulation of gene transcription and translation and the regulation of cellular bioenergetics and metabolism. The pharmacological and molecular tools currently available to study H2S physiology are also reviewed, including their utility and limitations. In subsequent sections, the role of H2S in the regulation of various physiological and cellular functions is reviewed. The physiological role of H2S in various cell types and organ systems are overviewed. Finally, the role of H2S in the regulation of various organ functions is discussed as well as the characteristic bell-shaped biphasic effects of H2S. In addition, key pathophysiological aspects, debated areas, and future research and translational areas are identified A wide array of significant roles of H2S in the physiological regulation of all organ functions emerges from this review.
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Affiliation(s)
- Giuseppe Cirino
- Department of Pharmacy, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Csaba Szabo
- Chair of Pharmacology, Section of Medicine, University of Fribourg, Switzerland
| | - Andreas Papapetropoulos
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece & Clinical, Experimental Surgery and Translational Research Center, Biomedical Research Foundation of the Academy of Athens, Greece
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21
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Rossi D, Pierantozzi E, Amadsun DO, Buonocore S, Rubino EM, Sorrentino V. The Sarcoplasmic Reticulum of Skeletal Muscle Cells: A Labyrinth of Membrane Contact Sites. Biomolecules 2022; 12:488. [PMID: 35454077 PMCID: PMC9026860 DOI: 10.3390/biom12040488] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 12/17/2022] Open
Abstract
The sarcoplasmic reticulum of skeletal muscle cells is a highly ordered structure consisting of an intricate network of tubules and cisternae specialized for regulating Ca2+ homeostasis in the context of muscle contraction. The sarcoplasmic reticulum contains several proteins, some of which support Ca2+ storage and release, while others regulate the formation and maintenance of this highly convoluted organelle and mediate the interaction with other components of the muscle fiber. In this review, some of the main issues concerning the biology of the sarcoplasmic reticulum will be described and discussed; particular attention will be addressed to the structure and function of the two domains of the sarcoplasmic reticulum supporting the excitation-contraction coupling and Ca2+-uptake mechanisms.
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Affiliation(s)
- Daniela Rossi
- Department of Molecular and Developmental Medicine, University of Siena, Via Aldo Moro 2, 53100 Siena, Italy; (E.P.); (D.O.A.); (S.B.); (E.M.R.); (V.S.)
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22
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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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23
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Vellecco V, Panza E, Bibli SI, Casillo GM, Raucci F, Manzo OL, Smimmo M, Villani R, Cavezza MR, Fleming I, d'Emmanuele di Villa Bianca R, Maione F, Cirino G, Bucci M. Phosphodiesterases S-sulfhydration contributes to human skeletal muscle function. Pharmacol Res 2022; 177:106108. [PMID: 35121122 DOI: 10.1016/j.phrs.2022.106108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 01/08/2023]
Abstract
The increase in intracellular calcium is influenced by cyclic nucleotides (cAMP and cGMP) content, which rating is governed by phosphodiesterases (PDEs) activity.Despite it has been demonstrated a beneficial effect of PDEs inhibitors in different pathological conditions involving SKM, not much is known on the role exerted by cAMP-cGMP/PDEs axis in human SKM contractility. Here, we show that Ssulfhydration of PDEs modulates human SKM contractility in physiological and pathological conditions. Having previously demonstrated that, in the rare human syndrome Malignant Hyperthermia (MH), there is an overproduction of hydrogen sulfide (H 2S) within SKM contributing to hyper-contractility, here we have used MH negative diagnosed biopsies (MHN) as healthy SKM, and MH susceptible diagnosed biopsies (MHS) as a pathological model of SKM hypercontractility. The study has been performed on MHS and MHN human biopsies after diagnosis has been made and on primary SKM cells derived from both MHN and MHS biopsies. Our data demonstrate that in normal conditions PDEs are S-sulfhydrated in both quadriceps' biopsies and primary SKM cells. This post translational modification (PTM) negatively regulates PDEs activity with consequent increase of both cAMP and cGMP levels. In hypercontractile biopsies, due to an excessive H2S content, there is an enhanced Ssulfhydration of PDEs that further increases cyclic nucleotides levels contributing to SKM hyper-contractility. Thus, the identification of a new endogenous PTM modulating PDEs activity represents an advancement in SKM physiopathology understanding.
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Affiliation(s)
- Valentina Vellecco
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Elisabetta Panza
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Sofia-Iris Bibli
- Institute for Vascular Signalling, Centre for Molecular Medicine, Goethe University, Frankfurt am Main, Germany; German Center of Cardiovascular Research (DZHK), Partner site RheinMain, Frankfurt am Main, Germany
| | - Gian Marco Casillo
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Federica Raucci
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Onorina Laura Manzo
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy; Center for Vascular Biology, Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, Cornell University, New York, New York, USA
| | - Martina Smimmo
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Romolo Villani
- U.O.C. Terapia Intensiva Grandi Ustionati (T.I.G.U.) Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli"
| | | | - Ingrid Fleming
- Institute for Vascular Signalling, Centre for Molecular Medicine, Goethe University, Frankfurt am Main, Germany; German Center of Cardiovascular Research (DZHK), Partner site RheinMain, Frankfurt am Main, Germany
| | | | - Francesco Maione
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Giuseppe Cirino
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy
| | - Mariarosaria Bucci
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II-, Via D. Montesano, 49, 80131 Naples, Italy.
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24
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Dhillon N, Baniak N, Nosib S. Hypertensive crisis precatheter ablation for resistant atrial fibrillation: a case of undiagnosed bilateral pheochromocytomas. BMJ Case Rep 2021; 14:e244484. [PMID: 34716146 PMCID: PMC8559091 DOI: 10.1136/bcr-2021-244484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2021] [Indexed: 11/03/2022] Open
Abstract
A 63-year-old man with hypertension was referred for catheter ablation of persistent atrial fibrillation. He was diagnosed with paroxysmal atrial fibrillation approximately 6 years prior. Over the previous 12 months, his atrial fibrillation had become persistent despite medication optimisation for rate control and elective cardioversion. Sinus rhythm was restored briefly. The decision was made to pursue catheter ablation and isolation of the pulmonary veins. On anaesthetic induction, the patient suffered from a hypertensive crisis. The procedure was aborted, and the patient was admitted to hospital for investigations of secondary hypertension. Ultimately, the patient was diagnosed with bilateral pheochromocytomas. This case outlines the diagnostic challenges and cardiac comorbidities associated with bilateral pheochromocytomas.
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Affiliation(s)
- Nina Dhillon
- Internal Medicine, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Nick Baniak
- Pathology, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Shravan Nosib
- Cardiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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25
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Min JY, Hong SH, Kim SJ, Chung MY. Delayed-onset malignant hyperthermia in the postanesthetic care unit: a case report. J Int Med Res 2021; 49:3000605211044201. [PMID: 34586942 PMCID: PMC8485277 DOI: 10.1177/03000605211044201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/16/2021] [Indexed: 11/24/2022] Open
Abstract
Malignant hyperthermia (MH) is a potentially fatal hypermetabolic syndrome that occurs when susceptible individuals are exposed to triggering agents. Variability in the order and time of occurrence of symptoms often makes clinical diagnosis difficult. A late diagnosis or misdiagnosis of delayed-onset MH may lead to fatal complications. We herein report a case of delayed-onset MH in the postoperative recovery room. A 77-year-old man awoke from anesthesia and was transferred to the recovery room. Ten minutes after his arrival, his mental status became stuporous and he developed masseter muscle rigidity, hyperventilation, and a body temperature of 39.8°C. The patient was suspected to have MH, and 60 mg of dantrolene sodium (1 mg/kg) was administered via intravenous drip with symptomatic treatment. Within 10 minutes of dantrolene administration, the patient's clinical signs subsided. This case report demonstrates that rapid diagnosis and treatment are crucial to ensure a good prognosis for patients with MH. A high level of suspicion based on clinical symptoms and early administration of therapeutic drugs such as dantrolene will also improve the clinical course. Therefore, suspicion and prompt diagnosis are absolutely essential. This case report emphasizes the importance of continuous education in the diagnosis and treatment of MH.
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Affiliation(s)
- Ji Young Min
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Jun Kim
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Mee Young Chung
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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26
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A novel RyR1-selective inhibitor prevents and rescues sudden death in mouse models of malignant hyperthermia and heat stroke. Nat Commun 2021; 12:4293. [PMID: 34257294 PMCID: PMC8277899 DOI: 10.1038/s41467-021-24644-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/29/2021] [Indexed: 12/03/2022] Open
Abstract
Mutations in the type 1 ryanodine receptor (RyR1), a Ca2+ release channel in skeletal muscle, hyperactivate the channel to cause malignant hyperthermia (MH) and are implicated in severe heat stroke. Dantrolene, the only approved drug for MH, has the disadvantages of having very poor water solubility and long plasma half-life. We show here that an oxolinic acid-derivative RyR1-selective inhibitor, 6,7-(methylenedioxy)-1-octyl-4-quinolone-3-carboxylic acid (Compound 1, Cpd1), effectively prevents and treats MH and heat stroke in several mouse models relevant to MH. Cpd1 reduces resting intracellular Ca2+, inhibits halothane- and isoflurane-induced Ca2+ release, suppresses caffeine-induced contracture in skeletal muscle, reduces sarcolemmal cation influx, and prevents or reverses the fulminant MH crisis induced by isoflurane anesthesia and rescues animals from heat stroke caused by environmental heat stress. Notably, Cpd1 has great advantages of better water solubility and rapid clearance in vivo over dantrolene. Cpd1 has the potential to be a promising candidate for effective treatment of patients carrying RyR1 mutations. Mutations in ryanodine receptor 1 (RyR1), a Ca2+ release channel in skeletal muscle, cause malignant hyperthermia (MH) and are involved in heat stroke. Here, the authors show that an oxolinic acid-derivative RyR1 inhibitor effectively prevents and treats MH and heat stroke in various MH mouse models.
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Gupta P, Bilmen J, Hopkins P. Anaesthetic management of a known or suspected malignant hyperthermia susceptible patient. BJA Educ 2021; 21:218-224. [PMID: 34026275 PMCID: PMC8134759 DOI: 10.1016/j.bjae.2021.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- P.K. Gupta
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | - J.G. Bilmen
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | - P.M. Hopkins
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
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28
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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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Srinivasan SP, Eldo N, Nair SG. Malignant hyperthermia during pediatric kidney transplantation-A medical and ethical quandary. Pediatr Transplant 2021; 25:e13923. [PMID: 33314641 DOI: 10.1111/petr.13923] [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: 09/15/2020] [Revised: 10/22/2020] [Accepted: 10/29/2020] [Indexed: 11/29/2022]
Abstract
Malignant hyperthermia (MH) is a rare life-threatening anesthetic complication with high mortality rates. MH during adult kidney transplant has been reported previously. However, the occurrence of MH after multiple previous uneventful anesthetic exposures in a pediatric kidney transplant recipient is rare. To our knowledge, this is the first reported case of MH in a child undergoing a live donor kidney transplant. The approaches for addressing perioperative challenges and ethical dilemmas to ensure successful outcomes are described. The recipient, a 5-year-old male child, weighing 20 kg, with a history of multiple previous uneventful anesthetic exposures, underwent live donor kidney transplant for end-stage renal disease (ESRD). Post-reperfusion he developed fulminant MH with rapidly progressing hyperthermia, hypercarbia, tachycardia, and muscle rigidity, which in addition to complicating the medical management raised several ethical issues as well. MH was successfully managed with dantrolene and other supportive measures. Judicious use of inotropes and fluids helped maintain stable hemodynamics and graft perfusion. Management of MH is complicated in a pediatric patient with ESRD undergoing live donor kidney transplant. Preference for non-depolarizing muscle relaxants instead of succinylcholine during endotracheal intubation can result in delayed onset of clinical manifestations. However, the metabolic complications may be more severe due to preexisting electrolyte and acid-base disturbances. Maintaining optimal graft perfusion while simultaneously combating MH can be very challenging in a child. Since the allograft is a precious commodity, critical decisions regarding the harvesting of the donor kidney need to be well thought out. Early diagnosis and prompt treatment with dantrolene are critical to preserving graft function and the recipient's life.
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Affiliation(s)
| | - Nidhin Eldo
- Department of Anaesthesiology and Critical Care, Aster Medcity, Kochi, India
| | - Suresh G Nair
- Department of Anaesthesiology and Critical Care, Aster Medcity, Kochi, India
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Relevance of pathogenicity prediction tools in human RYR1 variants of unknown significance. Sci Rep 2021; 11:3445. [PMID: 33564012 PMCID: PMC7873245 DOI: 10.1038/s41598-021-82024-7] [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: 01/12/2020] [Accepted: 12/29/2020] [Indexed: 12/12/2022] Open
Abstract
Malignant hyperthermia (MH) is a pharmacogenetic disorder of skeletal muscle metabolism characterized by generalized muscle rigidity, increased body temperature, rhabdomyolysis, hyperkalemia and severe metabolic acidosis. The underlying mechanism of MH involves excessive Ca2+ release from myotubes via the ryanodine receptor type 1 (RYR1) and the voltage-dependent L-type calcium channel (CACNA1S). As more than 300 variants of unknown significance have been detected to date, we examined whether freely available pathogenicity prediction tools are able to detect relevant MH causing variants. In this diagnostic accuracy study, blood samples from 235 individuals with a history of a clinical malignant hyperthermia or their close relatives were genetically screened for RYR1 variants of all 106 RYR1 exons and additionally for known variants of CACNA1S. In vitro contracture tests were conducted on muscle biopsies obtained from all individuals, independently of whether a pathogenic variant, a variant of unknown significance or no variant was detected. Comparisons were made to three established bioinformatic pathogenicity detection tools to identify the clinical impact of the variants of unknown significance. All detected genetic variants were tested for pathogenicity by three in silico approaches and compared to the in vitro contracture test. Sensitivity and specificity of exon screening of all individuals listed in our MH database was analyzed. Exon screening identified 97 (41%) of the 235 individuals as carriers of pathogenic variants. Variants of unknown significance were detected in 21 individuals. Variants of unknown significance were subdivided into 19 malignant-hyperthermia-susceptible individuals and 2 non-malignant-hyperthermia-susceptible individuals. All pathogenic variants as well as the malignant-hyperthermia-suspectible variants were correctly identified by the bioinformatic prediction tools. Sensitivity of in silico approaches ranged between 0.71 and 0.98 (Polyphen 0.94 [CI 95% 0.75; 0.99]; Sift 0.98 [CI 95% 0.81; 0.99]; MutationTaster 0.92 [CI 95% 0.75; 0.99]). Specificity differed depending on the used tool (Polphen 0.98 [CI 95% 0.32; 0.99]; Sift 0.98 [CI 95% 0.32; 0.99]; MutationTaster 0.00 [CI 95% 0.00; 0.60]). All pathogenic variants and variants of unknown significance were scored as probably damaging in individuals, demonstrating a high sensitivity. Specificity was very low in one of the three tested programs. However, due to potential genotype–phenotype discordance, bioinformatic prediction tools are currently of limited value in diagnosing pathogenicity of MH-susceptible variants.
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Hopkins PM, Girard T, Dalay S, Jenkins B, Thacker A, Patteril M, McGrady E. Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists. Anaesthesia 2021; 76:655-664. [PMID: 33399225 DOI: 10.1111/anae.15317] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2020] [Indexed: 12/12/2022]
Abstract
Malignant hyperthermia is defined in the International Classification of Diseases as a progressive life-threatening hyperthermic reaction occurring during general anaesthesia. Malignant hyperthermia has an underlying genetic basis, and genetically susceptible individuals are at risk of developing malignant hyperthermia if they are exposed to any of the potent inhalational anaesthetics or suxamethonium. It can also be described as a malignant hypermetabolic syndrome. There are no specific clinical features of malignant hyperthermia and the condition may prove fatal unless it is recognised in its early stages and treatment is promptly and aggressively implemented. The Association of Anaesthetists has previously produced crisis management guidelines intended to be displayed in all anaesthetic rooms as an aide memoire should a malignant hyperthermia reaction occur. The last iteration was produced in 2011 and since then there have been some developments requiring an update. In these guidelines we will provide background information that has been used in updating the crisis management recommendations but will also provide more detailed guidance on the clinical diagnosis of malignant hyperthermia. The scope of these guidelines is extended to include practical guidance for anaesthetists dealing with a case of suspected malignant hyperthermia once the acute reaction has been reversed. This includes information on care and monitoring during and after the event; appropriate equipment and resuscitative measures within the operating theatre and ICU; the importance of communication and teamwork; guidance on counselling of the patient and their family; and how to make a referral of the patient for confirmation of the diagnosis. We also review which patients presenting for surgery may be at increased risk of developing malignant hyperthermia under anaesthesia and what precautions should be taken during the peri-operative management of the patients.
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Affiliation(s)
- P M Hopkins
- Malignant Hyperthermia Unit, St James's University Hospital, and University of Leeds, Leeds, UK
| | - T Girard
- Department of Anaesthesia and Research, University of Basel, Switzerland
| | - S Dalay
- Department of Anaesthesia, Worcestershire Acute Hospitals NHS Trust, UK
| | - B Jenkins
- Department of Anaesthesia, University Hospitals of Cardiff, UK
| | - A Thacker
- Department of Anaesthesia, University Hospitals of Coventry and Warwickshire, UK
| | - M Patteril
- Department of Anaesthesia, University Hospitals of Coventry and Warwickshire, UK
| | - E McGrady
- Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK
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Finsterer J. Clinical Therapeutic Management of Human Mitochondrial Disorders. Pediatr Neurol 2020; 113:66-74. [PMID: 33053453 DOI: 10.1016/j.pediatrneurol.2020.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/25/2020] [Accepted: 07/03/2020] [Indexed: 12/29/2022]
Abstract
Despite recent advances in the elucidation of etiology and pathogenesis of mitochondrial disorders, their therapeutic management remains challenging. This review focuses on currently available therapeutic options for human mitochondrial disorders. Current treatment of mitochondrial disorders relies on symptomatic, multidisciplinary therapies of various manifestations in organs such as the brain, muscle, nerves, eyes, ears, endocrine organs, heart, intestines, kidneys, lungs, bones, bone marrow, cartilage, immune system, and skin. If respiratory chain functions are primarily or secondarily impaired, antioxidants or cofactors should be additionally given one by one. All patients with mitochondrial disorders should be offered an individually tailored diet and physical training program. Irrespective of the pathogenesis, all patients with mitochondrial disorders should avoid exposure to mitochondrion-toxic agents and environments. Specific treatment can be offered for stroke-like episodes, mitochondrial epilepsy, mitochondrial neurogastrointestinal encephalopathy, Leber hereditary optic neuropathy, thiamine-responsive Leigh syndrome, primary coenzyme Q deficiency, primary carnitine deficiency, Friedreich ataxia, ethylmalonic encephalopathy, acyl-CoA dehydrogenase deficiency, pyruvate dehydrogenase deficiency, and hereditary vitamin E deficiency. Preventing the transmission of mitochondrial DNA-related mitochondrial disorders can be achieved by mitochondrion replacement therapy (spindle transfer, pronuclear transfer). In conclusion, specific and nonspecific therapies for human mitochondrial disorders are available, and beneficial effects have been anecdotally reported. However, double-blind, placebo-controlled studies to confirm effectiveness are lacking for the majority of the measures applied to mitochondrial disorders. Transmission of certain mitochondrial disorders can be prevented by mitochondrion replacement therapy. A multidisciplinary approach is required to meet the therapeutic challenges of patients with mitochondrial disorders.
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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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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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35
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Baye JF, Petry NJ, Jacobson SL, Moore MM, Tucker B, Shaaban S, Massmann AK, Clark NM, Schultz AJ. Malignant hyperthermia susceptibility: utilization of genetic results in an electronic medical record to increase safety. Pharmacogenomics 2020; 21:1207-1215. [PMID: 33118445 DOI: 10.2217/pgs-2020-0088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Aim: This manuscript describes implementation of clinical decision support for providers concerned with perioperative complications of malignant hyperthermia susceptibility. Materials & methods: Clinical decision support for malignant hyperthermia susceptibility was implemented in 2018 based around our pre-emptive genotyping platform. We completed a brief descriptive review of patients who underwent pre-emptive testing, focused particularly on RYR1 and CACNA1S genes. Results: To date, we have completed pre-emptive genetic testing on more than 10,000 patients; 13 patients having been identified as a carrier of a pathogenic or likely pathogenic variant of RYR1 or CACNA1S. Conclusion: An alert system for malignant hyperthermia susceptibility - as an extension of our pre-emptive genomics platform - was implemented successfully. Implementation strategies and lessons learned are discussed herein.
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Affiliation(s)
- Jordan F Baye
- Sanford Health, Imagenetics, Sioux Falls, SD 57105, USA.,Department of Pharmacy Practice, South Dakota State University College of Pharmacy & Allied Health Professions, Brookings, SD 57006, USA.,Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Vermillion, SD, 57069, USA
| | - Natasha J Petry
- Sanford Health, Imagenetics, Sioux Falls, SD 57105, USA.,Department of Pharmacy Practice, North Dakota State University College of Health Professions, Fargo, ND 58108, USA
| | - Shauna L Jacobson
- Department of Anesthesiology, Sanford Health, Sioux Falls, SD 57117, USA
| | | | | | - Sherin Shaaban
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - Amanda K Massmann
- Sanford Health, Imagenetics, Sioux Falls, SD 57105, USA.,Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Vermillion, SD, 57069, USA
| | | | - April J Schultz
- Sanford Health, Imagenetics, Sioux Falls, SD 57105, USA.,Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Vermillion, SD, 57069, USA
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36
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Gonzalez A, Iles TL, Iaizzo PA, Bandschapp O. Impact of statin intake on malignant hyperthermia: an in vitro and in vivo swine study. BMC Anesthesiol 2020; 20:270. [PMID: 33096987 PMCID: PMC7585199 DOI: 10.1186/s12871-020-01186-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 10/13/2020] [Indexed: 01/24/2023] Open
Abstract
Background Statin intake is associated with muscular side effects, among which the unmasking of latent myopathies and of malignant hyperthermia (MH) susceptibility have been reported. These findings, together with experimental data in small animals, prompt speculation that statin therapy may compromise the performance of skeletal muscle during diagnostic in vitro contracture tests (IVCT). In addition, statins might reduce triggering thresholds in susceptible individuals (MHS), or exacerbate MH progression. We sought to obtain empirical data to address these questions. Methods We compared the responses of 3 different muscles from untreated or simvastatin treated MHS and non-susceptible (MHN) pigs. MHS animals were also invasively monitored for signs of impending MH during sevoflurane anesthesia. Results Muscles from statin treated MHS pigs responded with enhanced in vitro contractures to halothane, while responses to caffeine were unaltered by the treatment. Neither agent elicited contractures in muscles from statin treated MHN pigs. In vivo, end- tide pCO2, hemodynamic evolution, plasma pH, potassium and lactate concentrations consistently pointed to mild acceleration of MH development in statin-treated pigs, whereas masseter spasm and rigor faded compared to untreated MHS animals. Conclusions The diagnostic sensitivity and specificity of the IVCT remains unchanged by a short-term simvastatin treatment in MHS swine. Evidence of modest enhancement in cardiovascular and metabolic signs of MH, as well as masked pathognomonic muscle rigor observed under simvastatin therapy suggest a potentially misleading influence on the clinical presentation of MH. The findings deserve further study to include other statins and therapeutic regimes.
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Affiliation(s)
- Asensio Gonzalez
- Department for Anesthesia, Interdisciplinary Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
| | - Tinen L Iles
- Department of Surgery and Integrative Biology and Physiology, Institute for Engineering in Medicine, University of Minnesota, Minneapolis, USA
| | - Paul A Iaizzo
- Department of Surgery and Integrative Biology and Physiology, Institute for Engineering in Medicine, University of Minnesota, Minneapolis, USA
| | - Oliver Bandschapp
- Department for Anesthesia, Interdisciplinary Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland.
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Chang L, Liu X, Diggle CP, Boyle JP, Hopkins PM, Shaw MA, Allen PD. Bioenergetic defects in muscle fibers of RYR1 mutant knock-in mice associated with malignant hyperthermia. J Biol Chem 2020; 295:15226-15235. [PMID: 32826313 DOI: 10.1074/jbc.ra120.013537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/16/2020] [Indexed: 12/14/2022] Open
Abstract
Mutations in the skeletal muscle ryanodine receptor gene (RYR1) can cause susceptibility to malignant hyperthermia (MH), a potentially lethal genetic condition triggered by volatile anesthetics. MH is associated with hypermetabolism, which has directed research interest into oxidative phosphorylation and muscle bioenergetics. The most common cause of MH in the United Kingdom is the c.7300G>A RYR1 variant, which is present in ∼16% of MH families. Our study focuses on the MH susceptible G2435R-RYR1 knock-in mouse model, which is the murine equivalent of the human c.7300G>A genotype. Using a combination of transcriptomics, protein expression, and functional analysis, we investigated adult muscle fiber bioenergetics in this mouse model. RNA-Seq data showed reduced expression of genes associated with mitochondria and fatty acid oxidation in RYR1 mutants when compared with WT controls. Mitochondrial function was assessed by measuring oxygen consumption rates in permeabilized muscle fibers. Comparisons between WT and homozygous G2435R-RYR1 mitochondria showed a significant increase in complex I-facilitated oxidative phosphorylation in mutant muscle. Furthermore, we observed a gene-dose-specific increase in reactive oxygen species production in G2435R-RYR1 muscle fibers. Collectively, these findings provide evidence of metabolic defects in G2435R-RYR1 knock-in mouse muscle under basal conditions. Differences in metabolic profile could be the result of differential gene expression in metabolic pathways, in conjunction with mitochondrial damage accumulated from chronic exposure to increased oxidative stress.
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Affiliation(s)
- Leon Chang
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Xiaochen Liu
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Christine P Diggle
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - John P Boyle
- Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Philip M Hopkins
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom; Malignant Hyperthermia Unit, St James's University Hospital, Leeds, United Kingdom
| | - Marie-Anne Shaw
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Paul D Allen
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom.
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Glahn KP, Bendixen D, Girard T, Hopkins PM, Johannsen S, Rüffert H, Snoeck MM, Urwyler A. Availability of dantrolene for the management of malignant hyperthermia crises: European Malignant Hyperthermia Group guidelines. Br J Anaesth 2020; 125:133-140. [DOI: 10.1016/j.bja.2020.04.089] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/28/2022] Open
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Robbins LV. The expert novice - living and working with malignant hyperthermia. Anaesth Rep 2020; 8:148-151. [PMID: 33210093 DOI: 10.1002/anr3.12075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 11/06/2022] Open
Abstract
Acute care common stem training involves developing competencies within anaesthesia. At this stage of their career, most doctors have little or no anaesthetic experience, and work under direct consultant supervision for the majority of the placement. An emergency medicine trainee with a known diagnosis of malignant hyperthermia undertook a 6-month anaesthetic rotation in a large teaching hospital, adding a unique set of considerations to his training. Having malignant hyperthermia posed a novel challenge to the department, and it was met with an understandable degree of uncertainty and caution. Providing the trainee with a useful and comparable introduction to anaesthesia was of concern, particularly on paediatric lists where there is increased potential for exposure to volatile anaesthetic agents. This report focuses on the trainee's personal reflection of the impact on his experience, as well as looking at how the department responded to this unfamiliar situation, and the learning points to share should a similar scenario be encountered in the future.
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Affiliation(s)
- L V Robbins
- University Hospitals Plymouth NHS Trust Plymouth UK
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40
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Cote DR, Fuentes E, Elsayes AH, Ross JJ, Quraishi SA. A "crush" course on rhabdomyolysis: risk stratification and clinical management update for the perioperative clinician. J Anesth 2020; 34:585-598. [PMID: 32424487 DOI: 10.1007/s00540-020-02792-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 05/09/2020] [Indexed: 12/14/2022]
Abstract
Rhabdomyolysis, the release of myoglobin and other cellular breakdown products from necrotic muscle tissue, is seen in patients with crush injuries, drug overdose, malignant hyperthermia, muscular dystrophy, and with increasing frequency in obese patients undergoing routine procedures. For the perioperative clinician, managing the resultant shock, hyperkalemia, acidosis, and myoglobinuric acute kidney injury can present a significant challenge. Prompt recognition, hydration, and correction of metabolic disturbances may reduce or eliminate the need for long-term renal replacement therapy. This article reviews the pathophysiology and discusses key issues in the perioperative diagnosis, risk stratification, and management of rhabdomyolysis.
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Affiliation(s)
- Devan R Cote
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Eva Fuentes
- Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Ali H Elsayes
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA
| | - Jonathan J Ross
- Department of Anesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA
| | - Sadeq A Quraishi
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA.
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Early Recognition and Treatment of Malignant Hyperthermia in Pediatric Patient during Bronchoscopy. Case Rep Anesthesiol 2020; 2020:6562896. [PMID: 32148968 PMCID: PMC7057021 DOI: 10.1155/2020/6562896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/16/2020] [Accepted: 02/05/2020] [Indexed: 11/17/2022] Open
Abstract
Malignant hyperthermia is a rare pharmacogenetic disorder triggered by depolarizing muscle relaxant and potent volatile anesthetic agents. An MH crisis is an emergency and life-threatening event requiring early recognition and prompt management. Dantrolene is the specific antagonist of MH. The authors report the case of a 9-year-old boy who underwent an emergency bronchoscopy to remove a foreign body and developed masseter rigidity after succinylcholine and sevoflurane exposure. The anesthesia team diagnosed an MH event, and the event was managed immediately with supportive treatment, dantrolene, being administered within 10 minutes. The patient survived and had a good outcome without any complications. We suggest that it is essential for anesthesia providers to recognize the need for intraoperative vigilance, prompt recognition, and treatment, and dantrolene sodium should be readily available in every hospital.
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Vellecco V, Martelli A, Bibli IS, Vallifuoco M, Manzo OL, Panza E, Citi V, Calderone V, de Dominicis G, Cozzolino C, Basso EM, Mariniello M, Fleming I, Mancini A, Bucci M, Cirino G. Anomalous K v 7 channel activity in human malignant hyperthermia syndrome unmasks a key role for H 2 S and persulfidation in skeletal muscle. Br J Pharmacol 2020; 177:810-823. [PMID: 31051045 PMCID: PMC7024712 DOI: 10.1111/bph.14700] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/05/2019] [Accepted: 04/16/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Human malignant hyperthermia (MH) syndrome is induced by volatile anaesthetics and involves increased levels of cystathionine β-synthase (CBS)-derived H2 S within skeletal muscle. This increase contributes to skeletal muscle hypercontractility. Kv 7 channels, expressed in skeletal muscle, may be a molecular target for H2 S. Here, we have investigated the role of Kv 7 channels in MH. EXPERIMENTAL APPROACH Skeletal muscle biopsies were obtained from MH-susceptible (MHS) and MH-negative (MHN) patients. Immunohistochemistry, RT-PCR, Western blot, and in vitro contracture test (IVCT) were carried out. Development and characterization of primary human skeletal muscle cells (PHSKMC) and evaluation of cell membrane potential were also performed. The persulfidation state of Kv 7 channels and polysulfide levels were measured. KEY RESULTS Kv 7 channels were similarly expressed in MHN and MHS biopsies. The IVCT revealed an anomalous contractility of MHS biopsies following exposure to the Kv 7 channel opener retigabine. Incubation of negative biopsies with NaHS, prior to retigabine addition, led to an MHS-like positive response. MHS-derived PHSKMC challenged with retigabine showed a paradoxical depolarizing effect, compared with the canonical hyperpolarizing effect. CBS expression and activity were increased in MHS biopsies, resulting in a major polysulfide bioavailability. Persulfidation of Kv 7.4 channels was significantly higher in MHS than in MHN biopsies. CONCLUSIONS AND IMPLICATIONS In skeletal muscle of MHS patients, CBS-derived H2 S induced persulfidation of Kv 7 channels. This post-translational modification switches the hyperpolarizing activity into depolarizing. This mechanism can contribute to the pathological skeletal muscle hypercontractility typical of MH syndrome. LINKED ARTICLES This article is part of a themed section on Hydrogen Sulfide in Biology & Medicine. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.4/issuetoc.
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Affiliation(s)
- Valentina Vellecco
- Department of Pharmacy, School of MedicineUniversity of Naples Federico IINaplesItaly
| | | | - Iris Sofia Bibli
- Institute for Vascular Signalling, Centre for Molecular MedicineGoethe University Frankfurt am MainFrankfurt am MainGermany
- German Center of Cardiovascular Research (DZHK), partner site RheinMainFrankfurt am MainGermany
| | | | - Onorina L. Manzo
- Department of Pharmacy, School of MedicineUniversity of Naples Federico IINaplesItaly
| | - Elisabetta Panza
- Department of Pharmacy, School of MedicineUniversity of Naples Federico IINaplesItaly
| | | | | | | | | | | | | | - Ingrid Fleming
- Institute for Vascular Signalling, Centre for Molecular MedicineGoethe University Frankfurt am MainFrankfurt am MainGermany
- German Center of Cardiovascular Research (DZHK), partner site RheinMainFrankfurt am MainGermany
| | | | - Mariarosaria Bucci
- Department of Pharmacy, School of MedicineUniversity of Naples Federico IINaplesItaly
| | - Giuseppe Cirino
- Department of Pharmacy, School of MedicineUniversity of Naples Federico IINaplesItaly
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Papapetropoulos A, Wallace JL, Wang R. From primordial gas to the medicine cabinet. Br J Pharmacol 2020; 177:715-719. [PMID: 31726475 PMCID: PMC7024704 DOI: 10.1111/bph.14929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
LINKED ARTICLES This article is part of a themed section on Hydrogen Sulfide in Biology & Medicine. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.4/issuetoc.
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Affiliation(s)
| | | | - Rui Wang
- York UniversityTorontoOntarioCanada
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Cornelius BW, Dib SO, Dowdy RA, Horton CK, Frimenko K, Mansour S, Sharkh FA, Joy MT, Hall DL, Emam HA, Jatana CA, Kennedy KS. Malignant Hyperthermia: A Case Study in the Dental Ambulatory Surgery Setting. Anesth Prog 2019; 66:202-210. [PMID: 31891296 DOI: 10.2344/anpr-66-04-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Historically, patients who developed malignant hyperthermia had an extremely high rate of mortality. Today, if treated appropriately, patients who experience an episode of malignant hyperthermia will most likely survive. This dramatic decrease in mortality associated with malignant hyperthermia is due to several factors, including an increased understanding of the disease, improved diagnostic and monitoring equipment, and the development of lifesaving pharmacologic agents. This article presents the very likely case of acute malignant hyperthermia in a 24-year-old man with special needs, who presented for restorative dentistry under general anesthesia in the outpatient clinic of The Ohio State University's College of Dentistry.
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Affiliation(s)
- Bryant W. Cornelius
- Assistant Professor and Program Director of Dental/Oral Maxillofacial Anesthesiology, The Ohio State University College of Dentistry, Columbus, Ohio
| | - Shelby Olsen Dib
- Resident, Dental/Oral Maxillofacial Anesthesiology, The Ohio State University College of Dentistry, Columbus, Ohio
| | - Regina A. Dowdy
- Resident, Dental/Oral Maxillofacial Anesthesiology, The Ohio State University College of Dentistry, Columbus, Ohio
| | - Christina K. Horton
- Chief Resident, General Practice Residency Program, The Ohio State University College of Dentistry, Columbus, Ohio
| | - Katherine Frimenko
- Chief Resident, General Practice Residency Program, The Ohio State University College of Dentistry, Columbus, Ohio
| | - Shadee Mansour
- Resident, General Practice Residency Program, The Ohio State University College of Dentistry, Columbus, Ohio
| | - Farah Abu Sharkh
- Resident, General Practice Residency Program, The Ohio State University College of Dentistry, Columbus, Ohio
| | - Marcus T. Joy
- Resident, Oral and Maxillofacial Surgery, The Ohio State University College of Dentistry, Columbus, Ohio
| | - David L. Hall
- Associate Professor, General Practice Residency Program, The Ohio State University College of Dentistry, Columbus, Ohio
| | - Hany A. Emam
- Assistant Professor, Oral and Maxillofacial Surgery, The Ohio State University College of Dentistry, Columbus, Ohio
| | - Courtney A. Jatana
- Assistant Professor, Oral and Maxillofacial Surgery, The Ohio State University College of Dentistry, Columbus, Ohio
| | - Kelly S. Kennedy
- Associate Professor and Program Director of Oral and Maxillofacial Surgery, The Ohio State University College of Dentistry, Columbus, Ohio
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Nguyen TT, Le NT, Nguyen TMT, Nguyen HH, Nguyen KLT, Dinh LD, Nguyen TB, Do AT, Nguyen CH, Nguyen TH, Pham HNT, Vu TT. Whole exome sequencing revealed a pathogenic variant in a gene related to malignant hyperthermia in a Vietnamese cardiac surgical patient: A case report. Ann Med Surg (Lond) 2019; 48:88-90. [PMID: 31737266 PMCID: PMC6849130 DOI: 10.1016/j.amsu.2019.10.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 11/26/2022] Open
Abstract
Introduction Malignant hyperthermia (MH) is a rare autosomal dominant pharmacogenetic disorder which known associated with some genes such as CACNA1S and RYR1. Using whole exome analysis, we aimed to find out the genetic variant data in a malignant hyperthermia patient undergoing cardiac surgery. Presentation of case Patient was 59 years old male with dull left chest pain, mild breathing difficulty, thrombosis in the left atrium, mitral valve stenosis that needed a surgery to remove the thrombus and replace the mitral valve. After 5-h operation of left mitral heart valve replacement using both intravenous and inhaled anaesthetics, the patient showed suddenly hyperthermia (39.5 °C), low blood pressure (90/50 mmHg), heavy sweating, 1 mm dilated pupils on both sides, positive light reflection. Whole exome analysis showed 96,286 of SNPs including 11,705 of synonymous variants, 11,388 of missense variants, 106 of stop gained, and 39 of stop lost. One variant of RYR1 gene was found as mutation point at c.7048G > A (p.Ala2350Thr) known related to MH. Discussion This was a rare case of MH during cardiac surgery reported in Vietnam that might related to mutation point at c.7048G > A (p.Ala2350Thr) of RYR1 gene. Conclusion Patient carried a mutant of RYR1 gene could possibly lead to MH development post anaesthesia of cardiac surgery. A male cardiac surgery patient got malignant hyperthermia post anaesthesia. Whole exome variant analysis showed a mutant variant in RYR1 gene of patient. RYR1 gene testing might need to avoid MH during surgery using inhaled anaesthetics.
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Affiliation(s)
- Tran-Thuy Nguyen
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, 87-89 Tran Cung, Cau Giay, Hanoi, Viet Nam
| | - Ngoc-Thanh Le
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, 87-89 Tran Cung, Cau Giay, Hanoi, Viet Nam.,School of Medicine and Pharmacy, Vietnam National University Hanoi, 144 Xuan Thuy Street, Cau Giay, Hanoi, Viet Nam
| | - Thuy-Mau Thi Nguyen
- School of Medicine and Pharmacy, Vietnam National University Hanoi, 144 Xuan Thuy Street, Cau Giay, Hanoi, Viet Nam
| | - Huy-Hoang Nguyen
- Institute of Genome Research, Vietnam Academy of Science and Technology, 18 Hoang Quoc Viet, Cau Giay, Hanoi, Viet Nam.,Graduate University of Science and Technology, Vietnam Academy of Science and Technology, 18 Hoang Quoc Viet, Cau Giay, Hanoi, Viet Nam
| | - Kim-Lien Thi Nguyen
- Institute of Genome Research, Vietnam Academy of Science and Technology, 18 Hoang Quoc Viet, Cau Giay, Hanoi, Viet Nam
| | - Long Doan Dinh
- School of Medicine and Pharmacy, Vietnam National University Hanoi, 144 Xuan Thuy Street, Cau Giay, Hanoi, Viet Nam
| | - The-Binh Nguyen
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, 87-89 Tran Cung, Cau Giay, Hanoi, Viet Nam
| | - Anh Tien Do
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, 87-89 Tran Cung, Cau Giay, Hanoi, Viet Nam
| | - Cong Huu Nguyen
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, 87-89 Tran Cung, Cau Giay, Hanoi, Viet Nam
| | - Trung-Hieu Nguyen
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, 87-89 Tran Cung, Cau Giay, Hanoi, Viet Nam
| | - Hong-Nhung Thi Pham
- School of Medicine and Pharmacy, Vietnam National University Hanoi, 144 Xuan Thuy Street, Cau Giay, Hanoi, Viet Nam
| | - Thom Thi Vu
- School of Medicine and Pharmacy, Vietnam National University Hanoi, 144 Xuan Thuy Street, Cau Giay, Hanoi, Viet Nam
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Affiliation(s)
- Kyeong Seon M Kim
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, PSSB Suite 1200, Sacramento, CA 95817, USA
| | - Robert Scott Kriss
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, PSSB Suite 1200, Sacramento, CA 95817, USA
| | - Timothy J Tautz
- UC Davis Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, PSSB Suite 1200, Sacramento, CA 95817, USA.
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An Assessment of Penetrance and Clinical Expression of Malignant Hyperthermia in Individuals Carrying Diagnostic Ryanodine Receptor 1 Gene Mutations. Anesthesiology 2019; 131:983-991. [PMID: 31206373 PMCID: PMC9912949 DOI: 10.1097/aln.0000000000002813] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Malignant hyperthermia (MH) is a potentially lethal disorder triggered by certain anesthetics. Mutations in the ryanodine receptor 1 (RYR1) gene account for about half of MH cases. Discordance between the low incidence of MH and a high prevalence of mutations has been attributed to incomplete penetrance, which has not been quantified yet. The authors aimed to examine penetrance of MH-diagnostic RYR1 mutations and the likelihood of mutation carriers to develop MH, and to identify factors affecting severity of MH clinical expression. METHODS In this multicenter case-control study, data from 125 MH pedigrees between 1994 and 2017 were collected from four European registries and one Canadian registry. Probands (survivors of MH reaction) and their relatives with at least one exposure to anesthetic triggers, carrying one diagnostic RYR1 mutation, were included. Penetrance (percentage of probands among all genotype-positive) and the probability of a mutation carrier to develop MH were obtained. MH onset time and Clinical Grading Scale score were used to assess MH reaction severity. RESULTS The overall penetrance of nine RYR1 diagnostic mutations was 40.6% (93 of 229), without statistical differences among mutations. Likelihood to develop MH on exposure to triggers was 0.25 among all RYR1 mutation carriers, and 0.76 in probands (95% CI of the difference 0.41 to 0.59). Penetrance in males was significantly higher than in females (50% [62 of 124] vs. 29.7% [30 of 101]; P = 0.002). Males had increased odds of developing MH (odds ratio, 2.37; 95% CI, 1.36 to 4.12) despite similar levels of exposure to trigger anesthetics. Proband's median age was 12 yr (interquartile range 6 to 32.5). CONCLUSIONS Nine MH-diagnostic RYR1 mutations have sex-dependent incomplete penetrance, whereas MH clinical expression is influenced by patient's age and the type of anesthetic. Our quantitative evaluation of MH penetrance reinforces the notion that a previous uneventful anesthetic does not preclude the possibility of developing MH.
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Orsucci D, Ienco EC, Siciliano G, Mancuso M. Mitochondrial disorders and drugs: what every physician should know. Drugs Context 2019; 8:212588. [PMID: 31391854 PMCID: PMC6668504 DOI: 10.7573/dic.212588] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 02/07/2023] Open
Abstract
Mitochondrial disorders are a group of metabolic conditions caused by impairment of the oxidative phosphorylation system. There is currently no clear evidence supporting any pharmacological interventions for most mitochondrial disorders, except for coenzyme Q10 deficiencies, Leber hereditary optic neuropathy, and mitochondrial neurogastrointestinal encephalomyopathy. Furthermore, some drugs may potentially have detrimental effects on mitochondrial dysfunction. Drugs known to be toxic for mitochondrial functions should be avoided whenever possible. Mitochondrial patients needing one of these treatments should be carefully monitored, clinically and by laboratory exams, including creatine kinase and lactate. In the era of molecular and ‘personalized’ medicine, many different physicians (not only neurologists) should be aware of the basic principles of mitochondrial medicine and its therapeutic implications. Multicenter collaboration is essential for the advancement of therapy for mitochondrial disorders. Whenever possible, randomized clinical trials are necessary to establish efficacy and safety of drugs. In this review we discuss in an accessible way the therapeutic approaches and perspectives in mitochondrial disorders. We will also provide an overview of the drugs that should be used with caution in these patients.
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