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Bin X, Wang B, Tang Z. Malignant Hyperthermia: A Killer If Ignored. J Perianesth Nurs 2022; 37:435-444. [DOI: 10.1016/j.jopan.2021.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
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2
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Total Intravenous Anesthesia in a Malignant Hyperthermia-Susceptible Patient with Klinefelter Syndrome Undergoing Orthognathic Surgery. J Craniofac Surg 2021; 33:e290-e292. [PMID: 34636754 DOI: 10.1097/scs.0000000000008147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
ABSTRACT A patient with Klinefelter syndrome and skeletal Class III malocclusion experienced a malignant hyperthermia-like reaction while undergoing orthognathic surgery. The patient fully recovered after prompt diagnosis and management, and surgery was reattempted under total intravenous anesthesia. The patient was discharged without any anesthetic complications and was satisfied with the surgical results. This is the first described case of a malignant hyperthermia-like event in a patient with Klinefelter syndrome. Total intravenous anesthesia may be safely administered in malignant hyperthermia-susceptible patients who require orthognathic surgery.
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Hudig K, Pollock N, Bulger T, Machon RG, Woodhead A, Schiemann AH, Stowell KM. Masseter muscle rigidity and the role of DNA analysis to confirm malignant hyperthermia susceptibility. Anaesth Intensive Care 2019; 47:60-68. [PMID: 30864471 DOI: 10.1177/0310057x18811816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Malignant hyperthermia (MH) is an uncommon, autosomal dominant disorder of skeletal muscle, triggered by inhalational anaesthetics or depolarizing muscle relaxants. Masseter muscle rigidity (MMR) can be regarded as potentially a preceding sign for an MH reaction. Susceptibility to MH can be determined by the in vitro contracture test (IVCT) or DNA analysis where a familial variant is known. Our aims were to review patients with MMR, where IVCT and DNA analysis had been undertaken, to determine if DNA analysis could be used as an initial screening tool for MH susceptibility, and, by reviewing standard monitored variables (SMVs), to determine if any clinical characteristics could be used to differentiate between MMR patients who are MH susceptible (MHS) and those who are not. Patients with MMR were identified from the Palmerston North Hospital MH Reactions Database. IVCT and DNA analysis results were documented. DNA testing was performed retrospectively in the majority of patients as many patients had presented before DNA analysis was available. Forty-one patients were analysed. Fourteen were DNA positive/IVCT positive and six DNA positive only (48% in total), seven were IVCT positive/DNA negative and 14 were IVCT normal. Increased creatine kinase (>18,000 units/L) was consistent with MH susceptibility. Severity of MMR was not linked to MH susceptibility. This study confirmed that DNA analysis can be used as a first-line test for MH susceptibility in patients presenting with MMR (consistent with European MH Group recommendations). Creatine kinase was the only SMV that was significantly different between MHS and MH normal individuals.
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Affiliation(s)
- Kate Hudig
- 1 Department of Anaesthesia, Starship Children's Hospital, New Zealand
| | - Neil Pollock
- 2 Department of Anaesthesia and Intensive Care, Palmerston North Hospital, New Zealand
| | - Terasa Bulger
- 2 Department of Anaesthesia and Intensive Care, Palmerston North Hospital, New Zealand
| | - Roslyn G Machon
- 2 Department of Anaesthesia and Intensive Care, Palmerston North Hospital, New Zealand
| | - Andrew Woodhead
- 3 Department of Anaesthesia and Pain Management, Wellington Regional Hospital, New Zealand
| | - Anja H Schiemann
- 4 Institute of Fundamental Sciences, Massey University, New Zealand
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A Novel Dantrolene Sodium-Loaded Mixed Micelle Containing a Small Amount of Cremophor EL: Characterization, Stability, Safety and Pharmacokinetics. MOLECULES (BASEL, SWITZERLAND) 2019; 24:molecules24040728. [PMID: 30781606 PMCID: PMC6412801 DOI: 10.3390/molecules24040728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 11/30/2022]
Abstract
Dantrolene sodium (DS) is the only drug specifically used for the treatment of malignant hyperthermia. Nevertheless, its clinical application is significantly restricted due to its aqueous insolubility and the limited formulations available in clinical practice. In order to solve these problems, a novel mixed micelle composed of phospholipid and Cremophor EL was designed and evaluated. The mixed micelle was prepared using a stirring- ultrasonic method. The Dynamic Light Scattering (DLS) results showed that the micelle was small in size (12.14 nm) and narrowly distributed (PdI = 0.073). Transmission Electron Microscopy (TEM) images showed that the micelle was homogeneous and spherical. The stability study indicated that the system was stable for storage and dilution with distilled water, while the safety testing showed that the micelle was safe for intravenous administration with low hemolysis rates and low allergic reaction rates. In the pharmaceutics study, the Cmax and AUC0-t of the DS-loaded micelle were 4- and 4.5- folds higher than that of the DS. Therefore, the constructed phospholipid-Cremophor EL mixed micelle is a promising drug delivery system for DS.
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Rosen GP, Escobar M, Fumero P, Viswanath O, Wright J. The importance of a prepared and ready malignant hyperthermia response team. J Clin Anesth 2019; 56:109-110. [PMID: 30743151 DOI: 10.1016/j.jclinane.2019.01.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/19/2019] [Accepted: 01/22/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Gerald P Rosen
- Mount Sinai Medical Center of Florida, Department of Anesthesiology, Miami Beach, FL, United States of America.
| | | | - Pablo Fumero
- Mount Sinai Medical Center of Florida, Department of Anesthesiology, Miami Beach, FL, United States of America
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, United States of America; Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America; Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, United States of America
| | - Jennifer Wright
- Mount Sinai Medical Center of Florida, Department of Anesthesiology, Miami Beach, FL, United States of America
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Abstract
Serotonin syndrome results from excessive activation of serotonin (5-hydroxytryptamine; 5-HT) receptors in the nervous system, on the surface of platelets, and on the vascular endothelium. The clinical manifestations are a triad of altered conscious state, autonomic dysfunction, and neuromuscular excitability. Clinical diagnostic criteria remain poorly defined and unvalidated, and there are no available investigations to confirm the diagnosis. The syndrome is caused by the administration of one or more drugs possessing serotonergic activity. Severe forms of the syndrome usually result from overdose, but can be induced by monotherapy. The exact incidence of serotonin syndrome remains unknown, but is likely to be increasing due to increased prescription of selective serotonin reuptake inhibitor anti-depressants and tramadol, as well as recreational use of amphetamine-like substances. Serotonin syndrome may complicate the administration of drugs frequently used in anaesthetic practice, including pethidine and tramadol. Although the majority of cases improve with symptomatic and supportive care, severe cases need intensive care and frequently require mechanical ventilation. Neuromuscular excitability is likely to be the cause of rhabdomyolysis seen in severe cases and should be treated with benzodiazepines and muscle relaxants. Supportive therapies are required to treat hyperthermia and autonomic dysfunction. Cyproheptadine is the most commonly administered serotonergic antagonist, but is unavailable in parenteral form.
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Affiliation(s)
- D Jones
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria
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Pollock N, Langtont E, Stowell K, Simpson C, McDonnell N. Safe Duration of Postoperative Monitoring for Malignant Hyperthermia Susceptible Patients. Anaesth Intensive Care 2019; 32:502-9. [PMID: 15675210 DOI: 10.1177/0310057x0403200407] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Postoperative management of malignant hyperthermia (MH) susceptible patients has changed substantially over the last 20 years, with many patients now managed as day cases. Our previous policy was to monitor known MH susceptible patients (and relatives of known MH susceptible individuals not yet investigated by muscle biopsy) for four hours in the Post Anaesthetic Care Unit. However, anaesthetic literature reports suggest that MH reactions usually commence within one hour of anaesthesia. For this reason we conducted a retrospective review of Post Anaesthetic Care Unit data in 254 MH susceptible/related patients treated between 1991 and late 2000. On the basis of this review we instituted a policy change and reduced our monitoring time to one hour in the Post Anaesthetic Care Unit with a further 1.5h in a step-down unit if indicated. A prospective study in a further 68 MH susceptible/related patients showed that no MH reactions were missed due to the shorter monitoring period.
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Affiliation(s)
- N Pollock
- Department of Anaesthesia & Intensive Care, Palmerston North Hospital, Palmerston North, New Zealand
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8
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Breed D, Meyer LCR, Steyl JCA, Goddard A, Burroughs R, Kohn TA. Conserving wildlife in a changing world: Understanding capture myopathy-a malignant outcome of stress during capture and translocation. CONSERVATION PHYSIOLOGY 2019; 7:coz027. [PMID: 31304016 PMCID: PMC6612673 DOI: 10.1093/conphys/coz027] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 04/22/2019] [Accepted: 05/03/2019] [Indexed: 05/18/2023]
Abstract
The number of species that merit conservation interventions is increasing daily with ongoing habitat destruction, increased fragmentation and loss of population connectivity. Desertification and climate change reduce suitable conservation areas. Physiological stress is an inevitable part of the capture and translocation process of wild animals. Globally, capture myopathy-a malignant outcome of stress during capture operations-accounts for the highest number of deaths associated with wildlife translocation. These deaths may not only have considerable impacts on conservation efforts but also have direct and indirect financial implications. Such deaths usually are indicative of how well animal welfare was considered and addressed during a translocation exercise. Importantly, devastating consequences on the continued existence of threatened and endangered species succumbing to this known risk during capture and movement may result. Since first recorded in 1964 in Kenya, many cases of capture myopathy have been described, but the exact causes, pathophysiological mechanisms and treatment for this condition remain to be adequately studied and fully elucidated. Capture myopathy is a condition with marked morbidity and mortality that occur predominantly in wild animals around the globe. It arises from inflicted stress and physical exertion that would typically occur with prolonged or short intense pursuit, capture, restraint or transportation of wild animals. The condition carries a grave prognosis, and despite intensive extended and largely non-specific supportive treatment, the success rate is poor. Although not as common as in wildlife, domestic animals and humans are also affected by conditions with similar pathophysiology. This review aims to highlight the current state of knowledge related to the clinical and pathophysiological presentation, potential treatments, preventative measures and, importantly, the hypothetical causes and proposed pathomechanisms by comparing conditions found in domestic animals and humans. Future comparative strategies and research directions are proposed to help better understand the pathophysiology of capture myopathy.
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Affiliation(s)
- Dorothy Breed
- Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town, South Africa
- Biodiversity Management Branch, Environmental Management Department, City of Cape Town, Maitland, South Africa
| | - Leith C R Meyer
- Department of Paraclinical Sciences, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
| | - Johan C A Steyl
- Department of Paraclinical Sciences, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
| | - Amelia Goddard
- Department of Companion Animal Clinical Studies, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
| | - Richard Burroughs
- Department of Production Animal Studies, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
- Mammal Research Institute, University of Pretoria, Onderstepoort, South Africa
| | - Tertius A Kohn
- Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town, South Africa
- Department of Paraclinical Sciences, University of Pretoria, Onderstepoort, South Africa
- Corresponding author: Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Boundary Road, Cape Town 7725, South Africa. Tel.: +27 21 406 6235;
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10
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Kollmann-Camaiora A, Alsina E, Domínguez A, Del Blanco B, Yepes MJ, Guerrero JL, García A. Clinical protocol for the management of malignant hyperthermia. ACTA ACUST UNITED AC 2016; 64:32-40. [PMID: 27633384 DOI: 10.1016/j.redar.2016.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 06/16/2016] [Accepted: 06/17/2016] [Indexed: 11/24/2022]
Abstract
Malignant hyperthermia is a hypermetabolic syndrome that appears in susceptible patients after exposure to certain anaesthetic drugs (succinylcholine, inhalation anaesthetics). Its incidence in Spain is 1 in 40,000 adults, with a 10% mortality rate. It is induced by an abnormal regulation of the ryanodine receptors, producing a massive release of calcium from the sarcoplasmic reticulum in the striate muscle. Clinical manifestations include: CO2 increase, tachycardia, haemodynamic instability, metabolic and respiratory acidosis, profuse sweating, hyperpyrexia, CPK increase, myoglobinuria, kidney failure, disseminated intravascular coagulation (DIC), and ending in cardiac arrest. Dantrolene sodium is a ryanodine receptor antagonist, and inhibits the release of intracellular calcium. Definitive diagnosis is achieved by the exposure of muscle fibres to caffeine and halothane. Protocols can help guarantee a reliable and secure management when this severe event occurs.
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Affiliation(s)
- A Kollmann-Camaiora
- Departamento de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España.
| | - E Alsina
- Departamento de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - A Domínguez
- Departamento de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - B Del Blanco
- Departamento de Anestesiología y Reanimación, Hospital Clínico Universitario San Carlos, Madrid, España
| | - M J Yepes
- Departamento de Anestesiología y Reanimación, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - J L Guerrero
- Departamento de Anestesiología y Reanimación, Hospital Virgen de la Victoria, Málaga, España
| | - A García
- Departamento de Anestesiología y Reanimación, Hospital Virgen de la Victoria, Málaga, España
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Scalco RS, Snoeck M, Quinlivan R, Treves S, Laforét P, Jungbluth H, Voermans NC. Exertional rhabdomyolysis: physiological response or manifestation of an underlying myopathy? BMJ Open Sport Exerc Med 2016; 2:e000151. [PMID: 27900193 PMCID: PMC5117086 DOI: 10.1136/bmjsem-2016-000151] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2016] [Indexed: 12/14/2022] Open
Abstract
Exertional rhabdomyolysis is characterised by muscle breakdown associated with strenuous exercise or normal exercise under extreme circumstances. Key features are severe muscle pain and sudden transient elevation of serum creatine kinase (CK) levels with or without associated myoglobinuria. Mild cases may remain unnoticed or undiagnosed. Exertional rhabdomyolysis is well described among athletes and military personnel, but may occur in anybody exposed to unaccustomed exercise. In contrast, exertional rhabdomyolysis may be the first manifestation of a genetic muscle disease that lowers the exercise threshold for developing muscle breakdown. Repeated episodes of exertional rhabdomyolysis should raise the suspicion of such an underlying disorder, in particular in individuals in whom the severity of the rhabdomyolysis episodes exceeds the expected response to the exercise performed. The present review aims to provide a practical guideline for the acute management and postepisode counselling of patients with exertional rhabdomyolysis, with a particular emphasis on when to suspect an underlying genetic disorder. The pathophysiology and its clinical features are reviewed, emphasising four main stepwise approaches: (1) the clinical significance of an acute episode, (2) risks of renal impairment, (3) clinical indicators of an underlying genetic disorders and (4) when and how to recommence sport activity following an acute episode of rhabdomyolysis. Genetic backgrounds that appear to be associated with both enhanced athletic performance and increased rhabdomyolysis risk are briefly reviewed.
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Affiliation(s)
- Renata S Scalco
- MRC Centre for Neuromuscular Diseases , Institute of Neurology, University College London , London , UK
| | - Marc Snoeck
- MH-investigation Unit, Department of Anesthesia , Canisius-Wilhelmina Hospital , Nijmegen , The Netherlands
| | - Ros Quinlivan
- MRC Centre for Neuromuscular Diseases , Institute of Neurology, University College London , London , UK
| | - Susan Treves
- Departments of Anesthesia and of Biomedicine, Basel University Hospital, Basel, Switzerland; Department of Life Sciences, General Pathology Section, University of Ferrara, Ferrara, Italy
| | - Pascal Laforét
- Institut de Myologie, Hôpital Pitié-Salpêtrière , Paris , France
| | - Heinz Jungbluth
- Department of Paediatric Neurology-Neuromuscular Service, Evelina Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Randall Division of Cell and Molecular Biophysics, Muscle Signalling Section, London, UK; Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK
| | - Nicol C Voermans
- Department of Neurology , Radboud University Medical Centre , Nijmegen , The Netherlands
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12
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Stephens J, Schiemann AH, Roesl C, Miller D, Massey S, Pollock N, Bulger T, Stowell K. Functional analysis of RYR1 variants linked to malignant hyperthermia. Temperature (Austin) 2016; 3:328-339. [PMID: 27857962 PMCID: PMC4964997 DOI: 10.1080/23328940.2016.1153360] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 02/04/2016] [Accepted: 02/05/2016] [Indexed: 11/04/2022] Open
Abstract
Malignant hyperthermia manifests as a rapid and sustained rise in temperature in response to pharmacological triggering agents, e.g. inhalational anesthetics and the muscle relaxant suxamethonium. Other clinical signs include an increase in end-tidal CO2, increased O2 consumption, as well as tachycardia, and if untreated a malignant hyperthermia episode can result in death. The metabolic changes are caused by dysregulation of skeletal muscle Ca2+ homeostasis, resulting from a defective ryanodine receptor Ca2+ channel, which resides in the sarcoplasmic reticulum and controls the flux of Ca2+ ions from intracellular stores to the cytoplasm. Most genetic variants associated with susceptibility to malignant hyperthermia occur in the RYR1 gene encoding the ryanodine receptor type 1. While malignant hyperthermia susceptibility can be diagnosed by in vitro contracture testing of skeletal muscle biopsy tissue, it is advantageous to use DNA testing. Currently only 35 of over 400 potential variants in RYR1 have been classed as functionally causative of malignant hyperthermia and thus can be used for DNA diagnostic tests. Here we describe functional analysis of 2 RYR1 variants (c. 7042_7044delCAG, p.ΔGlu2348 and c.641C>T, p.Thr214Met) that occur in the same malignant hyperthermia susceptible family. The p.Glu2348 deletion, causes hypersensitivity to ryanodine receptor agonists using in vitro analysis of cloned human RYR1 cDNA expressed in HEK293T cells, while the Thr214Met substitution, does not appear to significantly alter sensitivity to agonist in the same system. We suggest that the c. 7042_7044delCAG, p.ΔGlu2348 RYR1 variant could be added to the list of diagnostic mutations for susceptibility to malignant hyperthermia.
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Affiliation(s)
- Jeremy Stephens
- Institute of Fundamental Sciences, Massey University , Palmerston North, New Zealand
| | - Anja H Schiemann
- Institute of Fundamental Sciences, Massey University , Palmerston North, New Zealand
| | - Cornelia Roesl
- Centre for Integrative Physiology, The University of Edinburgh , Edinburgh, United Kingdom
| | - Dorota Miller
- UK Malignant Hyperthermia Investigation Unit, Leeds Institute of Biomedical & Clinical Sciences, School of Medicine, University of Leeds, St. James's University Hospital , Leeds, United Kingdom
| | - Sean Massey
- Institute of Fundamental Sciences, Massey University , Palmerston North, New Zealand
| | - Neil Pollock
- Anaesthetic Department, Palmerston North Hospital , Palmerston North, New Zealand
| | - Terasa Bulger
- Anaesthetic Department, Palmerston North Hospital , Palmerston North, New Zealand
| | - Kathryn Stowell
- Institute of Fundamental Sciences, Massey University , Palmerston North, New Zealand
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13
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Jaehn T, Sievers R, Junger A, Graunke F, Blings A, Reichert B. [Fatal hyperpyrexia in an adolescent patient with severe burns after a traffic accident]. Unfallchirurg 2016; 119:609-12. [PMID: 26767381 DOI: 10.1007/s00113-015-0132-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
After a motorcycle accident a 16-year-old patient suffered severe burns to 40.5 % of the total body surface area (TBSA) of which 37 % were deep subdermal burns. After tangential and partly epifascial necrosectomy, Integra® was used as a temporary dermis replacement material for the lower extremities, combined with extensive negative pressure wound therapy (NPWT). In the further course of the treatment the patient developed uncontrollable hyperpyrexia with a fatal outcome. Possible influencing factors, such as the dermis replacement material combined with NPWT over large areas as well as the differential diagnoses propofol infusion syndrome, heatstroke and malignant hyperthermia are discussed.
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Affiliation(s)
- T Jaehn
- Universitätsklinik für Plastische, Wiederherstellende und Handchirurgie, Zentrum für Schwerbrandverletzte, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg, Nürnberg, Deutschland.
| | - R Sievers
- Universitätsklinik für Plastische, Wiederherstellende und Handchirurgie, Zentrum für Schwerbrandverletzte, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg, Nürnberg, Deutschland
| | - A Junger
- Universitätsklinik für Anästhesiologie und operative Intensivmedizin, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg, Nürnberg, Deutschland
| | - F Graunke
- Universitätsklinik für Plastische, Wiederherstellende und Handchirurgie, Zentrum für Schwerbrandverletzte, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg, Nürnberg, Deutschland
| | - A Blings
- Universitätsklinik für Anästhesiologie und operative Intensivmedizin, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg, Nürnberg, Deutschland
| | - B Reichert
- Universitätsklinik für Plastische, Wiederherstellende und Handchirurgie, Zentrum für Schwerbrandverletzte, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg, Nürnberg, Deutschland
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15
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Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, Brattebø G, Brugger H, Dunning J, Hunyadi-Antičević S, Koster RW, Lockey DJ, Lott C, Paal P, Perkins GD, Sandroni C, Thies KC, Zideman DA, Nolan JP, Böttiger BW, Georgiou M, Handley AJ, Lindner T, Midwinter MJ, Monsieurs KG, Wetsch WA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95:148-201. [PMID: 26477412 DOI: 10.1016/j.resuscitation.2015.07.017] [Citation(s) in RCA: 532] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic.
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, Southampton University Hospital NHS Trust, Southampton, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | | | - Guttorm Brattebø
- Bergen Emergency Medical Services, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Hermann Brugger
- EURAC Institute of Mountain Emergency Medicine, Bozen, Italy
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Rudolph W Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - David J Lockey
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; School of Clinical Sciences, University of Bristol, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet, Mainz, Germany
| | - Peter Paal
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, UK; Department of Anaesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | | | - David A Zideman
- Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
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16
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Barnes C, Stowell KM, Bulger T, Langton E, Pollock N. Safe duration of postoperative monitoring for malignant hyperthermia patients administered non-triggering anaesthesia: an update. Anaesth Intensive Care 2015; 43:98-104. [PMID: 25579296 DOI: 10.1177/0310057x1504300115] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The postoperative care of malignant hyperthermia (MH) patients is subject to international variation, with a paucity of data in the literature to guide management. Over a series of three studies, our aim was to evaluate whether MH-susceptible patients (and relatives who had not yet been investigated), who had received a non-triggering anaesthetic, could be managed in the same way as the standard surgical population. Following a retrospective study, 206 anaesthetics were administered in a prospective second study to MH-susceptible/related individuals who were monitored for a minimum of one hour in the post anaesthesia care unit and a further 90 minutes in a step-down facility. No problems relating to MH were encountered. The postoperative monitoring time was subsequently changed and, in a third study, patients were managed no differently from standard surgical patients. One hundred and twenty-five anaesthetics were administered with no evidence of problems. This data shows that standard postoperative monitoring times are safe and appropriate in MH-susceptible patients.
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Affiliation(s)
- C Barnes
- Department of Anaesthesia, Hutt Hospital, Lower Hutt, New Zealand
| | - K M Stowell
- Institute of Fundamental Sciences, Massey University, Palmerston North, New Zealand
| | - T Bulger
- Department of Anaesthesia and Intensive Care, Palmerston North Hospital, Palmerston North, New Zealand
| | - E Langton
- Department of Anaesthesia and Pain Medicine, Wellington Regional Hospital, Wellington, New Zealand
| | - N Pollock
- Department of Anaesthesia and Intensive Care, Palmerston North Hospital, Palmerston North, New Zealand
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Koo BS, Kim YK, Kim SH, Lee JS, Kim YI. A suspected malignant hyperthermia managed without dantrolene sodium. Korean J Anesthesiol 2014; 67:S81-2. [PMID: 25598920 PMCID: PMC4295994 DOI: 10.4097/kjae.2014.67.s.s81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Bon-Sung Koo
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Young-Kwon Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Sang-Hyun Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jeong-Seok Lee
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Yong-Ik Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
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Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother 2013; 48:62-76. [PMID: 24259635 DOI: 10.1177/1060028013510488] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To summarize published data regarding the steps of rapid-sequence intubation (RSI); review premedications, induction agents, neuromuscular blockers (NMB), and studies supporting use or avoidance; and discuss the benefits and deficits of combinations of induction agents and NMBs used when drug shortages occur. DATA SOURCE A search of Medline databases (1966-October 2013) was conducted. STUDY SELECTION AND DATA EXTRACTION Databases were searched using the terms rapid-sequence intubation, fentanyl, midazolam, atropine, lidocaine, phenylephrine, ketamine, propofol, etomidate thiopental, succinylcholine, vecuronium, atracurium, and rocuronium. Citations from publications were reviewed for additional references. DATA SYNTHESIS Data were reviewed to support the use or avoidance of premedications, induction agents, and paralytics and combinations to consider when drug shortages occur. CONCLUSIONS RSI is used to secure a definitive airway in often uncooperative, nonfasted, unstable, and/or critically ill patients. Choosing the appropriate premedication, induction drug, and paralytic will maximize the success of tracheal intubation and minimize complications.
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Musselman ME, Saely S. Diagnosis and treatment of drug-induced hyperthermia. Am J Health Syst Pharm 2013; 70:34-42. [PMID: 23261898 DOI: 10.2146/ajhp110543] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The etiology, pathophysiology, clinical presentation, and management of drug-induced hyperthermia (DIH) syndromes are reviewed. SUMMARY DIH syndromes are a rare and often overlooked cause of body temperature elevation and can be fatal if not recognized promptly and managed appropriately. There are five major DIH syndromes: (1) neuroleptic malignant syndrome, (2) serotonin syndrome, (3) anticholinergic poisoning, (4) sympathomimetic poisoning, and (5) malignant hyperthermia. The differential diagnosis of DIH syndromes can be challenging because symptoms are generally nonspecific, ranging from blood pressure changes and excessive sweating to altered mental status, muscle rigidity, convulsions, and metabolic acidosis. Evidence from the professional literature (per a MEDLINE search for articles published through November 2011) indicates that few currently available treatment options can reduce the duration of hyperthermia; therefore, prompt identification of the provoking agent based on the patient's medication history, the clinical presentation, and the timing of symptom onset is essential to determine the appropriate treatment and mitigate potentially life-threatening sequelae. For all DIH syndromes, appropriate management includes the immediate discontinuation of the suspected offending agent(s) and supportive care (external cooling, volume resuscitation as needed); in some cases, pharmacologic therapy (e.g., a benzodiazepine, bromocriptine, dantrolene) may be appropriate, with the selection of a specific agent primarily determined by the medication history and suspected DIH syndrome. CONCLUSION DIH is a hypermetabolic state caused by medications and other agents that alter neurotransmitter levels. The treatment of DIH syndromes includes supportive care and pharmacotherapy as appropriate.
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Affiliation(s)
- Megan E Musselman
- Emergency Medicine/Critical Care, University of Kansas Hospital, Kansas City, MO, USA
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Holtzclaw BJ. Managing Fever and Febrile Symptoms in HIV: Evidence-Based Approaches. J Assoc Nurses AIDS Care 2013; 24:S86-102. [DOI: 10.1016/j.jana.2012.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 07/24/2012] [Indexed: 11/24/2022]
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Abstract
Malignant hyperthermia (MH) is an uncommon, life-threatening pharmacogenetic disorder of the skeletal muscle. It presents as a hypermetabolic response in susceptible individuals to potent volatile anesthetics with/without depolarizing muscle relaxants; in rare cases, to stress from exertion or heat stress. Susceptibility to malignant hyperthermia (MHS) is inherited as an autosomally dominant trait with variable expression and incomplete penetrance. It is known that the pathophysiology of MH is related to an uncontrolled rise of myoplasmic calcium, which activates biochemical processes resulting in hypermetabolism of the skeletal muscle. In most cases, defects in the ryanodine receptor are responsible for the functional changes of calcium regulation in MH, and more than 300 mutations have been identified in the RYR1 gene, located on chromosome 19q13.1. The classic signs of MH include increase of end-tidal carbon dioxide, tachycardia, skeletal muscle rigidity, tachycardia, hyperthermia and acidosis. Up to now, muscle contracture test is regarded as the gold standard for the diagnosis of MHS though molecular genetic test is used, on a limited basis so far to diagnose MHS. The mortality of MH is dramatically decreased from 70-80% to less than 5%, due to an introduction of dantrolene sodium for treatment of MH, early detection of MH episode using capnography, and the introduction of diagnostic testing for MHS. This review summarizes the clinically essential and important knowledge of MH, and presents new developments in the field.
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Affiliation(s)
- Dong-Chan Kim
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School, Jeonju, Korea
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A mathematical model to improve on phenotyping for molecular genetic research in malignant hyperthermia. Pharmacogenet Genomics 2012; 19:972-8. [PMID: 19890226 DOI: 10.1097/fpc.0b013e3283339c08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The in-vitro contracture test is the standard test to diagnose malignant hyperthermia (MH) susceptibility. Maximum sensitivity is important for patient safety. For scientific purposes, the reduced specificity of contracture testing is a major drawback, and precise phenotyping is of utmost importance. Our study aimed to improve phenotyping for MH susceptibility to more accurately select patients for molecular genetic research in MH, thus, improving the probability to detect novel MH associated variants. METHODS Patients who underwent contracture and molecular genetic testing were selected from the database of two MH investigation centres (Basel and Leipzig). The area under the curve of halothane and caffeine contracture tests was calculated and a logistic regression model was applied to determine the odds of carrying a MH associated genetic variant. This model was subsequently applied to patients without familial MH related genetic variant. RESULTS Validation of the logistic regression model showed 98% concordance with molecular genetic results. Among patients with unclear in-vitro contracture test diagnosis (MH equivocal), half of the mutation carriers were classified as positive by the model, whereas 86% of those without familial mutation were classified as negative. Excluding the MH equivocal group, the model showed sensitivity of 0.99 (95% confidence interval: 0.95-0.99) and specificity 0.98 (95% confidence interval: 0.94-0.99), respectively, to identify genetically positive MH individuals. CONCLUSION Our model is a valuable tool to select patients from MH families for further molecular genetic research. This preselection increases the probability of successful molecular genetic research and is important when available resources are limited.
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Patil PM. Malignant hyperthermia in the oral and maxillofacial surgery patient: an update. ACTA ACUST UNITED AC 2012; 112:e1-7. [PMID: 21827956 DOI: 10.1016/j.tripleo.2011.04.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 04/15/2011] [Accepted: 04/20/2011] [Indexed: 10/17/2022]
Abstract
Malignant hyperthermia (MH) is a pharmacogenetic disorder of skeletal muscle that presents as a hypermetabolic response to potent volatile anesthetic gases, such as halothane, sevoflurane, desflurane, the depolarizing muscle relaxant succinylcholine, and, rarely in humans, to stresses, such as vigorous exercise and heat. The syndrome is likely to be fatal if untreated. Early recognition of the signs of MH provides the clinical diagnostic clues. Diagnostic testing relies on assessing the in vitro contracture response of biopsied muscle to halothane, caffeine, and other drugs. Dantrolene sodium is a specific antagonist of the pathophysiologic changes of MH and should be available wherever general anesthesia is administered. The prevention and treatment of acute episodes of this disorder is of paramount importance to the oral and maxillofacial surgeon. The management of such patients in the oral and maxillofacial surgery setting and the recent advances in the field of MH are presented.
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Pollock N, Langton EE, Stowell KM, Bulger TF. Safety of exposure of malignant hyperthermia non-susceptible patients and their relatives to anaesthetic triggering agents. Anaesth Intensive Care 2011; 39:887-94. [PMID: 21970134 DOI: 10.1177/0310057x1103900514] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As the reliability of malignant hyperthermia normal in vitro contracture test results has been questioned, this study set out to determine the reliability of malignant hyperthermia normal results in New Zealand. Three hundred and twenty-nine anaesthetics were administered to malignant hyperthermia normal patients, identified through the Palmerston North Hospital malignant hyperthermia database. Anaesthetic records were retrieved and scrutinised for a malignant hyperthermia reaction using the Malignant Hyperthermia Clinical Grading Scale. Patients were exposed to one or more of eight triggering agents and multiple anaesthetic agents were administered in 41% of cases. Six variables were analysed, and although a minority of variables were abnormal in a small number of patients, none of the findings supported a malignant hyperthermia reaction. While the analysis was limited by the adequacy of the anaesthesia records, it was supported by negative DNA analysis in 55% of patients. This study supports several previous studies in demonstrating that patients in New Zealand tested non-susceptible to malignant hyperthermia can safely be given triggering agents.
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Affiliation(s)
- N Pollock
- Department of Anaesthesia, Palmerston North Hospital, Palmerston North, New Zealand.
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Cardiopulmonary bypass in malignant hyperthermia susceptible patients: A systematic review of published cases. J Thorac Cardiovasc Surg 2011; 141:1488-95. [DOI: 10.1016/j.jtcvs.2011.01.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 11/03/2010] [Accepted: 01/20/2011] [Indexed: 11/22/2022]
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Metterlein T, Schuster F, Palmer E, Roewer N, Anetseder M. Succinylcholine in malignant hyperthermia: evaluation of a novel in vivo model. Muscle Nerve 2011; 44:213-6. [PMID: 21607984 DOI: 10.1002/mus.22025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2011] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Malignant hyperthermia (MH) is a potentially lethal anesthetic complication characterized by muscle hypermetabolism and generalized rigor. The exact mechanism of succinylcholine as an MH trigger cannot be examined in existing in vitro models. Therefore, a novel in vivo model was used to examine the metabolic response to succinylcholine. METHODS With institutional review board approval, 6 MH susceptible (MHS) and 6 MH non-susceptible (MHN) pigs were anesthetized with hemodynamic and systemic metabolic monitoring. Microdialysis catheters were placed intramuscularly. After equilibration, succinylcholine, halothane, and Ringer solution were injected. Lactate was measured in the dialysate and statistically analyzed by Mann-Whitney U-test (significance level P < 0.05). RESULTS Hemodynamic and systemic metabolic parameters were not different between the groups throughout the experiment. In the MHS pigs, halothane induced a significant increase of lactate. In MHN pigs, no substance induced a reaction. CONCLUSIONS Halothane, but not succinylcholine, induced a hypermetabolic reaction in this model. Therefore, the role of succinylcholine as an MH trigger remains questionable.
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Affiliation(s)
- Thomas Metterlein
- Department of Anesthesiology, University Hospital Würzburg, Würzburg, Germany.
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Hipertermia maligna. REVISTA MÉDICA CLÍNICA LAS CONDES 2011. [DOI: 10.1016/s0716-8640(11)70431-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Metterlein T, Schuster F, Kranke P, Hager M, Roewer N, Anetseder M. Magnesium does not influence the clinical course of succinylcholine-induced malignant hyperthermia. Anesth Analg 2011; 112:1174-8. [PMID: 21474662 DOI: 10.1213/ane.0b013e31821263d6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Malignant hyperthermia (MH) is a potentially lethal hypermetabolic syndrome. Volatile anesthetics and/or succinylcholine lead to an increase of the intracellular calcium concentration resulting in activation of various intracellular processes. A production of carbon dioxide, and later lactate, are early signs of increased cellular energy consumption. On a cellular level, magnesium acts as a physiological calcium inhibitor resulting in less-intense calcium liberation from the sarcoplasmic reticulum. In this study, we examined the effects of IV magnesium administration on the clinical course of an MH crisis. METHODS Sixteen Pietrain pigs (10 MH-susceptible [MHS] and 6 MH-nonsusceptible [MHN]) were anesthetized without an MH trigger substance. Invasive hemodynamic monitoring was established before 4 mg/kg succinylcholine was administered. Four of the MHS pigs received 10 mg/kg magnesium sulfate 10 minutes later. Hemodynamic changes (heart rate, mean arterial blood pressure, and oxygen saturation as measured by pulse oximetry) were continuously monitored. Venous and arterial blood gases (pH, Pco(2), Po(2), base excess, and lactate) were taken at 15-minute intervals. The H test and U test were used with P < 0.05 for significant differences among the groups. RESULTS No differences among the groups were seen for weight, hemodynamic, and metabolic variables before administration of succinylcholine. In all MHS animals, succinylcholine led to a marked decrease of mean arterial blood pressure and increase of heart rate. Animals in both MHS groups developed combined metabolic and respiratory acidosis. Succinylcholine had no effect on animals in the MHN group. Hemodynamic and metabolic values were not different between the 2 MHS groups but were between groups MHS and MHN. CONCLUSION Succinylcholine led to a hemodynamic and metabolic reaction in only MHS pigs. Treatment with magnesium did not influence the clinical course. The intervention had no beneficial effect in the acute phase of an MH crisis.
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Affiliation(s)
- Thomas Metterlein
- Department of Anesthesiology, University Hospital Regensburg, Franz-Josef-Strauss-Alle 11, 93053 Regensburg, Germany.
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Comparison of the therapeutic effectiveness of a dantrolene sodium solution and a novel nanocrystalline suspension of dantrolene sodium in malignant hyperthermia normal and susceptible pigs. Eur J Anaesthesiol 2011. [DOI: 10.1097/eja.0b013e3283439545] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Giulivi C, Ross-Inta C, Omanska-Klusek A, Napoli E, Sakaguchi D, Barrientos G, Allen PD, Pessah IN. Basal bioenergetic abnormalities in skeletal muscle from ryanodine receptor malignant hyperthermia-susceptible R163C knock-in mice. J Biol Chem 2011; 286:99-113. [PMID: 20978128 PMCID: PMC3013050 DOI: 10.1074/jbc.m110.153247] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 10/13/2010] [Indexed: 12/25/2022] Open
Abstract
Malignant hyperthermia (MH) and central core disease in humans have been associated with mutations in the skeletal ryanodine receptor (RyR1). Heterozygous mice expressing the human MH/central core disease RyR1 R163C mutation exhibit MH when exposed to halothane or heat stress. Considering that many MH symptoms resemble those that could ensue from a mitochondrial dysfunction (e.g. metabolic acidosis and hyperthermia) and that MH-susceptible mice or humans have a higher than normal cytoplasmic Ca(2+) concentration at rest, we evaluated the role of mitochondria in skeletal muscle from R163C compared with wild type mice under basal (untriggered) conditions. R163C skeletal muscle exhibited a significant increase in matrix Ca(2+), increased reactive oxygen species production, lower expression of mitochondrial proteins, and higher mtDNA copy number. These changes, in conjunction with lower myoglobin and glycogen contents, Myh4 and GAPDH transcript levels, GAPDH activity, and lower glucose utilization suggested a switch to a compromised bioenergetic state characterized by both low oxidative phosphorylation and glycolysis. The shift in bioenergetic state was accompanied by a dysregulation of Ca(2+)-responsive signaling pathways regulated by calcineurin and ERK1/2. Chronically elevated resting Ca(2+) in R163C skeletal muscle elicited the maintenance of a fast-twitch fiber program and the development of insulin resistance-like phenotype as part of a metabolic adaptation to the R163C RyR1 mutation.
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Affiliation(s)
- Cecilia Giulivi
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, California 95616, USA.
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Bisinotto FMB, Fabri DC, Calçado MS, Perfeito PB, Tostes LV, Sousa GD. Anesthesia for videolaparoscopic cholecystectomy in a patient with Steinert disease. Case report and review of the literature. Rev Bras Anestesiol 2010; 60:181-91, 105-10. [PMID: 20485964 DOI: 10.1016/s0034-7094(10)70024-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 12/24/2009] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Myotonic dystrophies are autosomal dominant neuromuscular diseases. Among them, myotonic dystrophy type 1 (MD1), or Steinert disease, is the most common in adults, and besides muscular involvement it also has important systemic manifestations. Myotonic dystrophy type 1 poses a challenge to the anesthesiologist. Those patients are more sensitive to anesthetics and prone to cardiac and pulmonary complications. Besides, the possibility of developing malignant hyperthermia and myotonic episodes is also present. CASE REPORT This is a 39-year old patient with DM1 who underwent general anesthesia for videolaparoscopic cholecystectomy. Total intravenous anesthesia with propofol, remifentanil, and rocuronium was the technique chosen. Intercurrences were not observed in the 90-minute surgical procedure, but after extubation, the patient developed respiratory failure and myotonia, which made tracheal intubation impossible. A laryngeal mask was used, allowing adequate oxygenation, and mechanical ventilation was maintained until full recovery of the respiratory function. The patient did not develop further complications. CONCLUSIONS Myotonic dystrophy type 1 presents several particularities to the anesthesiologist. Detailed knowledge of its systemic involvement along with the differentiated action of anesthetic drugs in those patients will provide safer anesthetic-surgical procedure.
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Affiliation(s)
- Michael Bamshad
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle Children's Hospital, 1959 Northeast Pacific Street, HSC RR349, M/S Box 356320, Seattle, WA 98195. E-mail address:
| | - Ann E. Van Heest
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue, Suite R200, Minneapolis, MN 55454
| | - David Pleasure
- Departments of Neurology and Pediatrics, UC Davis School of Medicine, c/o Shriners Hospital, 2425 Stockton Boulevard, Sacramento, CA 95817
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Girard T, Suhner M, Levano S, Singer M, Zollinger A, Hofer CK. A Fulminant Malignant Hyperthermia Episode in a Patient with Ryanodine Receptor Gene Mutation p.Tyr522Ser. Anesth Analg 2008; 107:1953-5. [DOI: 10.1213/ane.0b013e3181857903] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Barker K, Seger D, Kumar S. Letter To The Editor: “Comment on “Pediatric Fatality Following Ingestion of Dinitrophenol: Postmortem Identification of a ‘Dietary Supplement’””. Clin Toxicol (Phila) 2008; 44:351. [PMID: 16749560 DOI: 10.1080/15563650600584709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Lee JW, Moon SS, Lee JR, Kim DC. Reevaluation by Clinical Grading Scale for Malignant Hyperthermia Reported in Korean Journal of Anesthesiology. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.54.6.640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jeong-Woo Lee
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Seong-Shin Moon
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Jun-Rye Lee
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Dong-Chan Kim
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
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Kreislaufstillstand unter besonderen Umständen. Notf Rett Med 2006. [DOI: 10.1007/s10049-006-0798-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Podranski T, Bouillon T, Schumacher PM, Taguchi A, Sessler DI, Kurz A. Compartmental Pharmacokinetics of Dantrolene in Adults: Do Malignant Hyperthermia Association Dosing Guidelines Work? Anesth Analg 2005; 101:1695-1699. [PMID: 16301243 DOI: 10.1213/01.ane.0000184184.40504.f3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Dantrolene is the only drug proven effective for prevention and treatment of malignant hyperthermia (MH). Current dosing recommendations are based on noncompartmental analyses and are largely empiric. They are also divergent, as evidenced by differing recommendations from the Malignant Hyperthermia Association of the United States (MHAUS) and European Sources. We determined the compartmental pharmacokinetics of dantrolene, simulated the concentration time course based on currently recommended dosing, and suggest an optimal regimen. Nine volunteers (55-89 kg) received IV infusions of dantrolene (5 mg/kg over 30 min followed by 0.05 mg.kg(-1) . h(-1) for 5 h). Venous blood samples were drawn for up to 60 h, and dantrolene plasma concentrations were determined by reverse phase, high-performance liquid chromatography. One, two, and three compartmental models were fitted to the data, and a covariate analysis was performed. All calculations were performed with NONMEM using the population approach. The data were adequately described by a two-compartment model with the following typical variable values (median +/- se): volumes of distribution V1= 3.24 +/- 0.61 L; V2= 22.9 +/- 1.53 L; plasma clearance CL el= 0.03 +/- 0.003 L/min; and distributional clearance CL dist= 1.24 +/- 0.22 L/min. All parameters were scaled linearly with weight. Simulations of European recommendations for treatment of MH lead to plasma concentrations converging to 14-18 mg/L within 24 h. Simulating MHAUS guidelines (intermittent bolus administration) yielded peak and trough plasma concentrations ranging from 6.7-22.6 mg/L. Based on our findings, we propose an infusion regimen adjusted to the initial bolus dose(s) required to control symptoms. This strategy maintains the individualized therapeutic concentrations and improves stability of plasma concentrations.
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Affiliation(s)
- Tobias Podranski
- *Department of Anesthesiology, University of Bern, Switzerland; †Department of Anesthesia, Washington University, St. Louis, Missouri; ‡Outcomes Research™ Institute, University of Louisville, Kentucky
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Abstract
Toxicity resulting from excessive intra-synaptic serotonin, historically referred to as serotonin syndrome, is now understood to be an intra-synaptic serotonin concentration-related phenomenon. Recent research more clearly delineates serotonin toxicity as a discreet toxidrome characterized by clonus, hyper-reflexia, hyperthermia and agitation. Serotonergic side-effects occur with serotonergic drugs, and overdoses of serotonin re-uptake inhibitors (SRIs) frequently produce marked serotonergic side-effects, and in 15% of cases, moderate serotonergic toxicity, but not to a severe degree, which produces hyperthermia and risk of death. It is only combinations of serotonergic drugs acting by different mechanisms that are capable of raising intra-synaptic serotonin to a level that is life threatening. The combination that most commonly does this is a monoamine oxidase inhibitor (MAOI) drug combined with any SRI. There are a number of lesser-known drugs that are MAOIs, such as linezolid and moclobemide; and some opioid analgesics have serotonergic activity. These properties when combined can precipitate life threatening serotonin toxicity. Possibly preventable deaths are still occurring. Knowledge of the properties of these drugs will therefore help to ensure that problems can be avoided in most clinical situations, and treated appropriately (with 5-HT(2A) antagonists for severe cases) if they occur. The phenylpiperidine series opioids, pethidine (meperidine), tramadol, methadone and dextromethorphan and propoxyphene, appear to be weak serotonin re-uptake inhibitors and have all been involved in serotonin toxicity reactions with MAOIs (including some fatalities). Morphine, codeine, oxycodone and buprenorphine are known not to be SRIs, and do not precipitate serotonin toxicity with MAOIs.
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Affiliation(s)
- P K Gillman
- Pioneer Valley Private Hospital, Mackay, Queensland, Australia.
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Fiege M, Wappler F, Weisshorn R, Gerbershagen MU, Kolodzie K, Schulte am Esch J. Phosphodiesterase-III-inhibition with amrinone leads to contracture development in skeletal muscle preparations of malignant hyperthermia susceptible swine. Eur J Anaesthesiol 2005; 22:283-8. [PMID: 15892406 DOI: 10.1017/s0265021505000475] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE The phosphodiesterase-III (PDE-III) inhibitor enoximone-induced marked contractures in skeletal muscle specimens of malignant hyperthermia (MH) susceptible (MHS) human beings and swine. Whether this is a substance specific effect of enoximone or caused by inhibition of PDE-III remained unclear. Therefore, the effects of the PDE-III inhibitor amrinone in porcine MH normal (MHN) and MHS skeletal muscles were investigated. METHODS MH-trigger-free general anaesthesia was performed in eight MHS and eight MHN swine. The MH status of the swine was determined by detection of the Arg615-Cys point mutation on chromosome 6 indicating MH susceptibility. Skeletal muscle specimens were excised for the in vitro contracture tests with amrinone. Amrinone was added cumulatively every 5 min to muscle specimens in order to obtain organ bath concentrations between 20 and 400 micromol L(-1). The in vitro effects of amrinone on muscle contractures and twitches were measured. RESULTS Amrinone-induced contractures in all skeletal muscle preparations. MHS muscles developed contractures at significantly lower bath concentrations of amrinone than MHN muscles. Contractures of MHS compared to MHN muscles were significantly larger at bath concentrations of 80, 100, 150, 200 and 400 micromol L(-1) amrinone. Muscle twitches remained unchanged up to and including 200 micromol L(-1) amrinone. CONCLUSIONS Inhibition of PDE-III in general elicited higher contractures in MHS than in MHN muscles. Therefore, a contribution of PDE-III and the cyclic adenosine monophosphate (cAMP) system in the pathophysiology of MH must be suspected.
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Affiliation(s)
- M Fiege
- University-Hospital Hamburg-Eppendorf, Department of Anaesthesiology, Hamburg, Germany.
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Avila G. Intracellular Ca2+ dynamics in malignant hyperthermia and central core disease: established concepts, new cellular mechanisms involved. Cell Calcium 2005; 37:121-7. [PMID: 15589992 DOI: 10.1016/j.ceca.2004.08.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2004] [Revised: 08/02/2004] [Accepted: 08/02/2004] [Indexed: 11/22/2022]
Abstract
Malignant hyperthermia (MH) and central core disease (CCD) are inherited human disorders of skeletal muscle Ca2+ homeostasis. Both MH and CCD are linked to mutations and/or deletions in the gene encoding the skeletal muscle ryanodine receptor (RyR1), the intracellular Ca2+ release channel, which is essential to excitation-contraction (EC) coupling. Our knowledge on how mutations in RyR1 disrupt intracellular Ca2+ homeostasis and EC coupling, eventually leading to MH and CCD has been recently improved, thanks to multidisciplinary studies ranging from clinical, single channel recordings, patch-clamp experiments, and molecular biology. This review presents a brief historical perspective, on how pioneer studies resulted in associating MH and CCD to RyR1. The review is also focused on discussing novel results in regard to pathophysiological consequences of specific MH/CCD RyR1 mutant proteins, which are representative of the different cellular mechanisms that are linked to either phenotype.
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Affiliation(s)
- Guillermo Avila
- Department of Biochemistry, Cinvestav-IPN, AP 14-740, Mexico City DF 07000, Mexico.
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Kipps CM, Fung VSC, Grattan-Smith P, de Moore GM, Morris JGL. Movement disorder emergencies. Mov Disord 2005; 20:322-34. [PMID: 15584031 DOI: 10.1002/mds.20325] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Movement disorders may present acutely, and failure to recognize and exclude important differential diagnoses can result in significant morbidity or mortality. Unfortunately, much of the literature pertaining to this topic is scattered and not easily accessible. This review aims to address this deficit. Movement disorder emergencies are discussed according to their most likely mode of presentation. Diagnostic considerations and early management principles are reviewed, along with appropriate pathophysiology where relevant.
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Kawanishi C. Genetic predisposition to neuroleptic malignant syndrome : implications for antipsychotic therapy. AMERICAN JOURNAL OF PHARMACOGENOMICS : GENOMICS-RELATED RESEARCH IN DRUG DEVELOPMENT AND CLINICAL PRACTICE 2003; 3:89-95. [PMID: 12749726 DOI: 10.2165/00129785-200303020-00002] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The pathogenetic mechanism of neuroleptic malignant syndrome (NMS), a potentially lethal adverse effect of antipsychotics, is not well understood. In addition to acquired risk factors, clinical observations suggest a number of genetic factors predisposing patients to NMS. Recent findings in pharmacogenetics indicate that the genetic polymorphisms for drug-metabolizing enzymes, drug transporters, and possibly drug-targeting molecules, are associated with the interindividual differences in drug responses concerning both efficacy and adverse reactions. Genetic association studies have sought to identify polymorphisms influencing susceptibility to NMS, especially with respect to the dopamine D(2) receptor, serotonin receptor, and cytochrome p450 2D6. While a few candidate polymorphisms were associated with NMS, a large controlled study is needed to attain statistical power. On the other hand, NMS might include heterogeneous conditions with common characteristic symptoms but different causative mechanisms. Further analysis of individuals with identified genetic mutations or polymorphisms should advance our understanding of mechanisms underlying NMS.
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Affiliation(s)
- Chiaki Kawanishi
- Department of Psychiatry, Yokohama City University School of Medicine, Yokohama, Japan.
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Multicentre evaluation of in vitro contracture testing with bolus administration of 4-chloro-m-cresol for diagnosis of malignant hyperthermia susceptibility. Eur J Anaesthesiol 2003. [DOI: 10.1097/00003643-200307000-00003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wappler F, Anetseder M, Baur CP, Censier K, Doetsch S, Felleiter P, Fiege M, Fricker R, Halsall PJ, Hartung E, Heffron JJA, Heytens L, Hopkins PM, Klingler W, Lehmann-Horn F, Nivoche Y, Tegazzin V, Tzanova I, Urwyler A, Weisshorn R, Schulte am Esch J. Multicentre evaluation of in vitro contracture testing with bolus administration of 4-chloro-m-cresol for diagnosis of malignant hyperthermia susceptibility. Eur J Anaesthesiol 2003; 20:528-36. [PMID: 12884985 DOI: 10.1017/s026502150300084x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE The in vitro contracture test with halothane and caffeine is the gold standard for the diagnosis of susceptibility to malignant hyperthermia (MH). However, the sensitivity of the in vitro contracture test is between 97 and 99% and its specificity is 78-94% with the consequence that false-negative as well as false-positive test results are possible. 4-Chloro-m-cresol is potentially a more specific test drug for the in vitro contracture test than halothane or caffeine. This multicentre study was designed to investigate whether an in vitro contracture test with bolus administration of 4-chloro-m-cresol can improve the accuracy of the diagnosis of susceptibility to MH. METHODS Three hundred and fifty-two patients from 11 European MH laboratories participated in the study. The patients were first classified as MH susceptible, MH normal or MH equivocal by the in vitro contracture test according to the European MH protocol. Muscle specimens surplus to diagnostic requirements were used in this study (MH susceptible = 103 viable samples; MH equivocal = 51; MH normal = 204). 4-Chloro-m-cresol was added to achieve a concentration of 75 micromol L(-1) in the tissue bath. The in vitro effects on contracture development and muscle twitch were observed for 60 min. RESULTS After bolus administration of 4-chloro-m-cresol, 75 micromol L(-1), 99 of 103 MH-susceptible specimens developed marked muscle contractures. In contrast, only two of 204 MH-normal specimens showed an insignificant contracture development following 4-chloro-m-cresol. From these results, a sensitivity rate of 96.1% and a specificity rate of 99.0% can be calculated for the in vitro contracture test with bolus administration of 4-chloro-m-cresol 75 micromol L(-1). Forty-three patients were diagnosed as MH equivocal, but only specimens from 16 patients developed contractures in response to 4-chloro-m-cresol, indicating susceptibility to MH. CONCLUSIONS The in vitro contracture test with halothane and caffeine is well standardized in the European and North American test protocols. However, this conventional test method is associated with the risk of false test results. Therefore, an improvement in the diagnosis of MH is needed. Regarding the results from this multicentre study, the use of 4-chloro-m-cresol could increase the reliability of in vitro contracture testing.
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Affiliation(s)
- F Wappler
- University Hospital Hamburg-Eppendorf, Department of Anaesthesiology, Hamburg, Germany.
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Abstract
Malignant hyperthermia is a rare disorder that can occur in patients who are sensitive to certain agents used in general anesthesia. The treatment of malignant hyperthermia has not changed over the years, but prevention strategies have evolved. These strategies include an increased emphasis on how patients are managed prior to a surgical procedure, on the selection of the particular anesthetic agent, and on postoperative vigilance. Susceptible patients who undergo simple excisions or a low degree of surgical stress can receive treatment safely in the office or ambulatory surgery center and be discharged the same day, provided that all known triggering agents are avoided. For more extensive procedures that cause a moderate level of surgical stress to susceptible patients, facilities for managing malignant hyperthermia should be readily available. Susceptible patients who undergo high-stress invasive procedures should be hospitalized. Routine preoperative prophylactic drug administration, even with dantrolene, is no longer considered necessary for any susceptible patients. All local anesthetics—including lidocaine, which had been previously contraindicated—are now considered to be safe for use in patients who are susceptible to malignant hyperthermia. In this article, we review the prevention, diagnosis, and management of malignant hyperthermia. We also report our experience in anesthetizing a patient who had a history of malignant hyperthermia—a case that illustrates the uncertainty that can complicate the management of such patients.
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Affiliation(s)
- Christopher Y. Chang
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Duke University Medical Center, Durham, N.C
| | - Richard L. Scher
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Duke University Medical Center, Durham, N.C
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Abstract
Malignant hyperthermia (MH) is a rare, potentially lethal, clinically and genetically heterogeneous pharmacogenic myopathy, which during or after general anesthesia manifests as MH crisis (MHC) in genetically predisposed, but otherwise mostly normal, individuals (MH susceptibles) in response to anesthetic-triggering agents. MHC can also occur in patients with central core disease. MCH-like crises have been reported in those with Duchenne/Becker muscular dystrophy, myotonic dystrophy, mitochondriopathy, and various other conditions. MH susceptibility is diagnosed if there is an MHC in the individual or family history or by the in vitro caffeine-halothane contracture test. Although screening for mutations in the ryanodine-receptor-1 gene and the dihydropyridine-receptor gene, respectively, could further substantiate the diagnosis, the caffeine-halothane-contracture test still remains the gold standard for diagnosing MH susceptibility. The most well-known triggers of an MHC are depolarizing muscle relaxants and volatile anesthetics. Therapy of an MHC comprises discontinuation of triggering agents, oxygenation, and correction of the acidosis and electrolyte disturbances, treatment of arrhythmias, cooling, and dantrolene. If MH susceptibility is not known preoperatively and an MHC unexpectedly interrupts anesthesia, consultation by a specialist in MH susceptibility after anesthesia is essential to investigate the patient for MH susceptibility or subclinical myopathy, guide laboratory investigations, manage therapy, and counsel the family on further risk. To further reduce morbidity and mortality of those with MHC, anesthesiologists and neurologists should be well educated and should strengthen their clinical vigilance. Research should be intensified and extended with regard to the development of new in vitro tests to further elucidate the heterogeneous genetic background of MH susceptibility.
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Affiliation(s)
- Josef Finsterer
- From the Neurological Department, KA Rudolfstiftung 1030 Vienna, Austria
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