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Hellblom A, Miller WP, Soller M, Samuelsson C. Malignant hyperthermia safety - A nationwide survey of publicly funded Swedish healthcare. Acta Anaesthesiol Scand 2024; 68:788-793. [PMID: 38566397 DOI: 10.1111/aas.14417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 03/11/2024] [Accepted: 03/16/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Malignant hyperthermia (MH) is a rare pharmacogenetic disorder that can lead to a life-threatening reaction during general anaesthesia with triggering agents. Prompt life-saving treatment includes the immediate administration of the antidote dantrolene. This study investigated Swedish healthcare providers' awareness and adherence to guidelines and recommendations with respect to MH and whether adherence to safe MH-praxis varies with hospital care-complexity level and private versus public management form. METHOD Agreements and procurement specifications between all 21 Swedish County Councils and privately run surgical care providers were reviewed alongside with questionnaire-aided collection of information from 62 publicly funded health care providers (both privately and publicly run). RESULTS No procurement requirement specification or contract contained requirements on anaesthesia or aspects of MH. All publicly run hospitals stocked dantrolene and 28 out of 52 (54%) stocked the recommended amount. Seven out of nine (78%) of the privately run institutions stocked dantrolene, and one stocked the recommended amount. Publicly run hospitals adhered to recommendations to a greater extent than privately run institutions, both with respect to stocking of dantrolene (p = .02) and to stocking the recommended amount (p = .03). CONCLUSIONS Contracts between Swedish county councils and private surgical care subcontractors rarely outline expectations of standards for the safe practice of anaesthesia such as preparedness to handle a life-threatening MH reaction. Among Swedish publicly funded anaesthesia providers there is room for improvement in adherence to the EMHG guideline on dantrolene availability. Publicly run hospitals seem to have better compliance with these recommendations than privately run institutions. Raising awareness about current guidelines is important to improve safety for known and unknown MH-susceptible individuals.
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Affiliation(s)
- Anna Hellblom
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
- Department of Laboratory Medicine, Clinical Genetics, Lund University, Lund, Sweden
| | | | - Maria Soller
- Department of Laboratory Medicine, Clinical Genetics, Lund University, Lund, Sweden
- Department of Clinical Genetics and Genomics, Karolinska University Hospital, Stockholm, Sweden
| | - Carolina Samuelsson
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden
- Halland Hospitals, Region Halland, Halland, Sweden
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Wang J, Yu Y, Gao Y, Wan T, Cong Z, Li Z, Zhou Y, Wang X, Feng L, Han Y, Zhang J, Qu Y, Guo X. The Anesthesiologists' Perception of Malignant Hyperthermia and Availability of Dantrolene in China: A Cross-Sectional Survey. Risk Manag Healthc Policy 2024; 17:763-773. [PMID: 38562250 PMCID: PMC10984096 DOI: 10.2147/rmhp.s454895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024] Open
Abstract
Background Malignant hyperthermia (MH) is a hypermetabolic syndrome with high mortality rates. Early detection and prompt intravenous administration of dantrolene are crucial for effective management of MH. However, there is currently a lack of comprehensive nationwide surveys on the availability of dantrolene and anesthesiologists' understanding of MH in China. Methods A nationwide survey was conducted between January 2022 and June 2022. Online questionnaires on the cognition of MH among anesthesiologists in China were sent through social platforms to anesthesiologists in mainland China. Data regarding participants' perception of MH-related knowledge, availability of domestic dantrolene, and reported MH cases were collected in this study. Results Responses were collected from a total of 11,354 anesthesiologists representing 31 provinces across the Chinese mainland. Among the 11 scoring questions, the highest accuracy rates were observed for the question regarding therapeutic drugs for MH (99.3%) and the characteristics of MH (98.0%). Conversely, the question pertaining to the earliest clinical signs of MH had the lowest accuracy rate (23.5%). Significant variations were observed in the scores among different professional titles (P=0.003), academic degree (P<0.001), hospital classification (P<0.001), and urban hierarchy (P<0.001). Of the respondents, 919 (8.1%) anesthesiologists reported dantrolene availability in their hospitals, and 631 (5.6%) indicated unclear. A total of 136 hospitals in this survey reported at least one previous case of MH. Conclusion Mainland China faces challenges such as insufficient experience in diagnosing and treating MH, as well as difficulty in obtaining dantrolene. To improve the public awareness of MH, it is imperative to establish and promote a refined MH training system. Additionally, a streamlined and rapid dantrolene linkage emergency system should be implemented to ensure prompt access to the drug.
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Affiliation(s)
- Jiechu Wang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Anesthesia and Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, People’s Republic of China
| | - Yao Yu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
| | - Ya Gao
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Anesthesia and Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, People’s Republic of China
| | - Tingting Wan
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Anesthesia and Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, People’s Republic of China
| | - Zhukai Cong
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Anesthesia and Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, People’s Republic of China
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Anesthesia and Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, People’s Republic of China
| | - Yang Zhou
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Anesthesia and Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, People’s Republic of China
| | - Xiaoxiao Wang
- Research Center for Clinical Epidemiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
| | - Luyang Feng
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Anesthesia and Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, People’s Republic of China
| | - Yongzheng Han
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Anesthesia and Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, People’s Republic of China
| | - Jing Zhang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Anesthesia and Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, People’s Republic of China
| | - Yinyin Qu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Anesthesia and Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, People’s Republic of China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Beijing Center of Quality Control and Improvement on Clinical Anesthesia, Peking University Third Hospital, Beijing, 100191, People’s Republic of China
- Anesthesia and Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, People’s Republic of China
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Yang HS, Choi JM, In J, Sung TY, Kim YB, Sultana S. Current clinical application of dantrolene sodium. Anesth Pain Med (Seoul) 2023; 18:220-232. [PMID: 37691593 PMCID: PMC10410554 DOI: 10.17085/apm.22260] [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: 12/06/2022] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 09/12/2023] Open
Abstract
Dantrolene sodium (DS) was first introduced as an oral antispasmodic drug. However, in 1975, DS was demonstrated to be effective for managing malignant hyperthermia (MH) and was adopted as the primary therapeutic drug after intravenous administration. However, it is difficult to administer DS intravenously to manage MH. MH is life-threatening, pharmacogenomically related, and induced by depolarizing neuromuscular blocking agents or inhalational anesthetics. All anesthesiologists should know the pharmacology of DS. DS suppresses Ca2+ release from ryanodine receptors (RyRs). RyRs are expressed in various tissues, although their distribution differs among subtypes. The anatomical and physiological functions of RyRs have also been demonstrated as effective therapeutic drugs for cardiac arrhythmias, Alzheimer's disease, and other RyR-related diseases. Recently, a new formulation was introduced that enhanced the hydrophilicity of the lipophilic DS. The authors summarize the pharmacological properties of DS and comment on its indications, contraindications, adverse effects, and interactions with other drugs by reviewing reference articles.
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Affiliation(s)
- Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Jae Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Junyong In
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Dongguk University, Goyang, Korea
| | - Tae-yun Sung
- Department of Anesthesiology and Pain Medicine, Konyang University Hopsital, Konyang University College of Medicine, Daejeon, Korea
| | - Yong Beom Kim
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Shofina Sultana
- Department of Anesthesia, Analgesia and lntensive Care lVedicine, Bangabandhu Sheikh Mujib Medical University Dhaka, Bangladesh
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Tan L, Yu H, Yan J, Liu C, Xiao K, Yin J, Zuo Y, Zhu T, Deng X. The Knowledge Profile, Competence and Pending Problems of Chinese Anesthesiologists in Dealing with Malignant Hyperthermia: A Cross-Sectional Survey. J Multidiscip Healthc 2023; 16:133-142. [PMID: 36691603 PMCID: PMC9863447 DOI: 10.2147/jmdh.s387025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/05/2022] [Indexed: 01/18/2023] Open
Abstract
Purpose The National Remote Emergency System for Malignant Hyperthermia (MH-NRES) is an applet in China, designed to help anesthesiologists manage MH crisis. However, there is limited information about encountered difficulties in dealing with MH among Chinese anesthesiologists. The purpose of the study was to explore the current competency and encountered difficulties in the management of MH, as a key first step for assessing the potential user needs to develop the MH-NRES. Methods The hospitals of different levels in different provinces across China were invited to participate in an online survey from November to December 2021. Anesthesiologists completed the online questionnaire containing four sections including demographic information, knowledge, competency, and continuing education about MH. Results A total of 1357 valid questionnaires were completed from anesthesiologists, most respondents (66.7%, n = 905) correctly answered the MH trigger drugs included volatile anesthetics and succinylcholine. However, most respondents (77.0%, n = 1045) did not know that the recommended initial dose of domestic dantrolene. Up to 83.9% (n = 1138) stated that their hospitals did not store dantrolene for MH emergency. More than half of respondents thought that it would take more than one hour to obtain dantrolene in emergency. Less work experiences, lower levels of hospital and educations and professional titles were associated with lower competency scores in managing MH. Only 31.0% (n = 936) reported that their hospital had ever conducted MH continuing education curricula. Scenario simulation is the training method that most interests the participants (79.0%, n = 1072) but a whopping 46.9% (n = 637) never received simulation. Conclusion The study indicated that difficulty in obtaining dantrolene, lack of competency in management of MH, difficulty in obtaining professional help, and poor teamwork were the main problems of most anesthesiologists in face of MH.
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Affiliation(s)
- Lingcan Tan
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Hong Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Junyu Yan
- Department of Anesthesiology, Karamay Hospital of Integrated Traditional Chinese and Western Medicine, Karamay, People’s Republic of China
| | - Chunyuan Liu
- Department of Anesthesiology, Chongqing Liangping District People’s Hospital, Chongqing, 405200, People’s Republic of China
| | - Kun Xiao
- School of Information and Software Engineering, University of Electronic Science and Technology of China, Chengdu, 610054, People’s Republic of China
| | - Jin Yin
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Xiaoqian Deng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China,Correspondence: Xiaoqian Deng, Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, People’s Republic of China, Email
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5
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Caroff SN, Roberts CB, Rosenberg H, Tobin JR, Watt S, Mashman D, Riazi S, Berkowitz RM. Intravenous dantrolene in hypermetabolic syndromes: a survey of the U.S. Veterans Health Administration database. BMC Anesthesiol 2022; 22:298. [PMID: 36123618 PMCID: PMC9484236 DOI: 10.1186/s12871-022-01841-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intravenous dantrolene is often prescribed for hypermetabolic syndromes other than the approved indication of malignant hyperthermia (MH). To clarify the extent of and indications for dantrolene use in conditions other than MH, we sought to document current practices in the frequency, diagnoses, clinical characteristics and outcomes associated with dantrolene treatment in critical care settings. METHODS Inpatients receiving intravenous dantrolene from October 1, 2004 to September 30, 2014 were identified retrospectively in the U.S. Veterans Health Administration national database. Extracted data included; diagnoses of hypermetabolic syndromes; triggering drugs; dantrolene dosages; demographics; vital signs; laboratory values; in-hospital mortality; complications; and lengths of stay. Frequency and mortality of patients who did not receive dantrolene were obtained in selected diagnoses for exploratory comparisons. RESULTS Dantrolene was administered to 304 inpatients. The most frequent diagnoses associated with dantrolene treatment were neuroleptic malignant syndrome (NMS; N = 108, 35.53%) and sepsis (N = 47, 15.46%), with MH accounting for only 13 (4.28%) cases. Over half the patients had psychiatric comorbidities and received psychotropic drugs before dantrolene treatment. Common clinical findings in patients receiving dantrolene included elevated temperature (mean ± SD; 38.7 ± 1.3 °C), pulse (116.33 ± 22.80/bpm), respirations (27.75 ± 9.58/min), creatine kinase levels (2,859.37 ± 6,646.88 IU/L) and low pO2 (74.93 ± 40.16 mmHg). Respiratory, renal or cardiac failure were common complications. Mortality rates in-hospital were 24.01% overall, 7.69% in MH, 20.37% in NMS and 42.55% in sepsis, compared with mortality rates in larger and possibly less severe groups of unmatched patients with MH (5.26%), NMS (6.66%), or sepsis (41.91%) who did not receive dantrolene. CONCLUSIONS In over 95% of cases, dantrolene administration was associated with diagnoses other than MH in critically-ill patients with hypermetabolic symptoms and medical and psychiatric comorbidities. Exploratory survey data suggested that the efficacy and safety of dantrolene in preventing mortality in hypermetabolic syndromes other than MH remain uncertain. However, randomized and controlled studies using standardized criteria between groups matched for severity are essential to guide practice in using dantrolene.
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Affiliation(s)
- Stanley N Caroff
- Department of Psychiatry, Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
| | - Christopher B Roberts
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Henry Rosenberg
- Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
| | | | | | - Darlene Mashman
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Rosalind M Berkowitz
- Department of Psychiatry, Corporal Michael J. Crescenz VA Medical Center and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
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Kim JH, Lee CK, Chung CE, Min BD, Kim DC. Malignant hyperthermia: a case report with a literature review. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2022. [DOI: 10.14730/aaps.2022.00395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Malignant hyperthermia is an extremely rare, potentially lethal disorder that occurs in susceptible patients who are exposed to triggering agents such as volatile anesthetic gases or depolarizing muscle relaxants. The clinical manifestations of malignant hyperthermia include hypermetabolism, hyperthermia, hypercapnia, and sustained skeletal muscle rigidity, which result in cardiac arrest, brain damage, and death. It is associated with a high morbidity and mortality rate if not recognized immediately and treated appropriately. We report a case of suspected malignant hyperthermia in a young male patient undergoing axillary osmidrosis surgery.
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Economic Analysis of Perioperative Optimization. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00044-7] [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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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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Katz AE, Nussbaum RL, Solomon BD, Rehm HL, Williams MS, Biesecker LG. Management of Secondary Genomic Findings. Am J Hum Genet 2020; 107:3-14. [PMID: 32619490 DOI: 10.1016/j.ajhg.2020.05.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Secondary genomic findings are increasingly being returned to individuals as opportunistic screening results. A secondary finding offers the chance to identify and mitigate disease that may otherwise be unrecognized in an individual. As a form of screening, secondary findings must be considered differently from sequencing results in a diagnostic setting. For these reasons, clinicians should employ an evaluation and long-term management strategy that accounts for both the increased disease risk associated with a secondary finding and the lower positive predictive value of a screening result compared to an indication-based testing result. Here we describe an approach to the clinical evaluation and management of an individual who presents with a secondary finding. This approach enumerates five domains of evaluation-(1) medical history, (2) physical exam, (3) family history, (4) diagnostic phenotypic testing, and (5) variant correlation-through which a clinician can distinguish a molecular finding from a clinicomolecular diagnosis of genomic disease. With this framework, both geneticists and non-geneticist clinicians can optimize their ability to detect and mitigate genomic disease while avoiding the pitfalls of overdiagnosis. Our goal with this approach is to help clinicians translate secondary findings into meaningful recognition, treatment, and prevention of disease.
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Cost-benefit relationship of keeping dantrolene stocks from the point of view of healthcare institutions. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.1097/cj9.0000000000000147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction:
Malignant hyperthermia (MH) is an acute syndrome triggered by certain anesthetic medications. Dantrolene is the only specific treatment for MH crises. Without treatment, lethality may be as high as 80%. In Colombia, it is not mandatory to keep dantrolene supplies in stock.
Objective:
To establish the cost-benefit ratio, from the perspective of healthcare institutions, of keeping dantrolene supplies in stock in the operating theater.
Methods:
Using a decision tree, a Monte Carlo simulation was run with 10,000 scenarios to determine the median annual cost of keeping full or partial stocks (36 or 12 vials x 20 mg, respectively) of dantrolene. For the option of not keeping supplies in stock, the cost threshold was calculated where the expected value of both alternatives of the decision tree is equalized. Indifference curves were constructed for complete and partial supplies.
Results:
The median annual cost was estimated at 6.6 million Colombian pesos (COP) for full dantrolene supplies, and at COP 2.2 million for partial supplies. The median economic consequence threshold for 1 death due to the unavailability of dantrolene was estimated at COP 18.5 million for full supplies, and at COP 57.0 million for partial supplies.
Conclusion:
If, as a result of the unavailability of dantrolene, the economic consequences of a death due to MH exceed the threshold of COP 57.0 or COP 18.5 million, the purchase of full or partial stocks, respectively, is justified.
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Abstract
Malignant hyperthermia (MH) is a rare but potentially lethal skeletal muscle disorder affecting calcium release channels. It is inherited in a mendelian autosomal dominant pattern with variable penetration. The initial clinical manifestations are of a hypermetabolic state with increased CO2 production, respiratory acidosis, increased temperature, and increased oxygen demands. If diagnosed late, MH progresses to multi-organ system failure and death. Current data suggest that mortality has improved to less than 5%. The gold standard for ruling out MH is the contracture test. Genetic testing is also available. MH-susceptible individuals should be clearly identified for safe administration of future anesthetics.
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Affiliation(s)
- Herodotos Ellinas
- Department of Anesthesiology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
| | - Meredith A Albrecht
- Department of Anesthesiology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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Guglielminotti J, Rosenberg H, Li G. Prevalence of malignant hyperthermia diagnosis in obstetric patients in the United States, 2003 to 2014. BMC Anesthesiol 2020; 20:19. [PMID: 31959119 PMCID: PMC6971943 DOI: 10.1186/s12871-020-0934-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 01/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background The cost-benefit of stocking dantrolene in maternity units for treating malignant hyperthermia (MH) has been recently questioned because of the low incidence of MH crisis in the general population and the low utilization of general anesthesia in obstetrics. However, no study has examined the prevalence of MH susceptibility in obstetrics. This study aimed to assess the prevalence of MH diagnosis and associated factors in obstetric patients. Methods Data for this study came from the National Inpatient Sample from 2003 to 2014, a 20% nationally representative sample of discharge records from community hospitals. A diagnosis of MH due to anesthesia was identified using the International Classification of Diseases, Ninth Revision, Clinical Modification code 995.86. MH prevalence was estimated according to the delivery mode and patient and hospital characteristics. Results During the 12-year study period, 47,178,322 delivery-related discharges [including 15,175,127 (32.2%) cesarean deliveries] were identified. Of them, 215 recorded a diagnosis of MH, yielding a prevalence of 0.46 per 100,000 [95% confidence interval (CI), 0.40 to 0.52]. The prevalence of MH diagnosis in cesarean deliveries was 0.81 per 100,000 (95% CI, 0.67 to 0.97), compared with 0.29 per 100,000 (95% CI, 0.23 to 0.35) in vaginal deliveries (P < 0.001). Multivariable logistic regression revealed that cesarean delivery was associated with a significantly increased risk of MH diagnosis [adjusted rate ratio (aOR) 2.88; 95% CI, 2.19 to 3.80]. Prevalence of MH diagnosis was lower in Hispanics than in non-Hispanic whites (aOR 0.47; 95% CI, 0.29 to 0.76) and higher in the South than in the Northeast census regions (aOR 2.44; 95% CI, 1.50 to 3.96). Conclusion The prevalence of MH-susceptibility is about 1 in 125,000 in cesarean deliveries, similar to the prevalence reported in non-obstetrical surgery inpatients. The findings of this study suggest that stocking dantrolene in maternity units is justified.
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Affiliation(s)
- Jean Guglielminotti
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY, 10032, USA.
| | - Henry Rosenberg
- the Malignant Hyperthermia Association of the United States, Sherburne, NY, 13460, USA
| | - Guohua Li
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY, 10032, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
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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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Cost-benefit Analysis of Maintaining a Fully Stocked Malignant Hyperthermia Cart versus an Initial Dantrolene Treatment Dose for Maternity Units. Anesthesiology 2019; 129:249-259. [PMID: 29672336 DOI: 10.1097/aln.0000000000002231] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The Malignant Hyperthermia Association of the United States recommends that dantrolene be available for administration within 10 min. One approach to dantrolene availability is a malignant hyperthermia cart, stocked with dantrolene, other drugs, and supplies. However, this may not be of cost benefit for maternity units, where triggering agents are rarely used. METHODS The authors performed a cost-benefit analysis of maintaining a malignant hyperthermia cart versus a malignant hyperthermia cart readily available within the hospital versus an initial dantrolene dose of 250 mg, on every maternity unit in the United States. A decision-tree model was used to estimate the expected number of lives saved, and this benefit was compared against the expected costs of the policy. RESULTS We found that maintaining a malignant hyperthermia cart in every maternity unit in the United States would reduce morbidity and mortality costs by $3,304,641 per year nationally but would cost $5,927,040 annually. Sensitivity analyses showed that our results were largely driven by the extremely low incidence of general anesthesia. If cesarean delivery rates in the United States remained at 32% of all births, the general anesthetic rate would have to be greater than 11% to achieve cost benefit. The only cost-effective strategy is to keep a 250-mg dose of dantrolene on the unit for starting therapy. CONCLUSIONS It is not of cost benefit to maintain a fully stocked malignant hyperthermia cart with a full supply of dantrolene within 10 min of maternity units. We recommend that hospitals institute alternative strategies (e.g., maintain a small supply of dantrolene on the maternity unit for starting treatment).
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Affiliation(s)
- Philip M. Hopkins
- From the Malignant Hyperthermia Unit, St. James's University Hospital, Leeds, United Kingdom; and the Institute of Medical Research at St. James’s, University of Leeds, Leeds, United Kingdom
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Larach MG, Klumpner TT, Brandom BW, Vaughn MT, Belani KG, Herlich A, Kim TW, Limoncelli J, Riazi S, Sivak EL, Capacchione J, Mashman D, Kheterpal S, Kooij F, Wilczak J, Soto R, Berris J, Price Z, Lins S, Coles P, Harris JM, Cummings KC, Berman MF, Nanamori M, Adelman BT, Wedeven C, LaGorio J, McCormick PJ, Tom S, Aziz MF, Coffman T, Ellis TA, Molina S, Peterson W, Mackey SC, van Klei WA, Ginde AA, Biggs DA, Neuman MD, Craft RM, Pace NL, Paganelli WC, Durieux ME, Nair BJ, Wanderer JP, Miller SA, Helsten DL, Turnbull ZA, Schonberger RB. Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment: Database Analyses and Systematic Review. Anesthesiology 2019; 130:41-54. [PMID: 30550426 DOI: 10.1097/aln.0000000000002490] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. METHODS The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. RESULTS Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. CONCLUSIONS Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.
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Affiliation(s)
- Marilyn Green Larach
- From The North American Malignant Hyperthermia Registry of the Malignant Hyperthermia Association of the United States, University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, Pennsylvania (2000 through 2017; M.G.L., B.W.B.) Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida (2018; M.G.L.) Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan (T.T.K., M.T.V., S.K.) Department of Nurse Anesthesia, University of Pittsburgh, Pittsburgh, Pennsylvania (2016 through 2018; B.W.B.) Department of Anesthesiology, School of Medicine (K.G.B., T.W.K., J.C.) School of Public Health (K.G.B.), University of Minnesota, Minneapolis, Minnesota Department of Anesthesiology, Children's Hospital of Pittsburgh (E.L.S.) Department of Anesthesiology (A.H.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Department of Anesthesiology, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, New York (J.L.) Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Canada (S.R.) Department of Anesthesiology and Pediatrics, Emory University School of Medicine, and Children's Healthcare of Atlanta, Egleston Hospital, Atlanta, Georgia (D.M.). Current positions: Dr. Larach is now at the Department of Anesthesiology, University of Florida, Gainesville, Florida. Dr. Sivak is now at the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio. Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands Beaumont Health, Dearborn, Michigan Beaumont Health, Royal Oak, Michigan Beaumont Health, Farmington Hills, Michigan Beaumont Health, Grosse Pointe, Michigan Bronson Healthcare, Battle Creek, Michigan Bronson Healthcare, Kalamazoo, Michigan CHOC Children's Hospital, Orange, California Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio Department of Anesthesiology, Columbia University Medical Center, New York, New York Henry Ford Health System, Detroit, Michigan Henry Ford Health System, West Bloomfield, Michigan Holland Hospital, Holland, Michigan Mercy Health, Muskegon, Michigan Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Medical Center, New York, New York Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon St. Joseph Mercy, Ann Arbor, Michigan St. Joseph Mercy Oakland, Pontiac, Michigan St. Mary Mercy Hospital, Livonia, Michigan Sparrow Health System, Lansing, Michigan Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands Department of Anesthesiology, University of Colorado, Aurora, Colorado Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania Department of Anesthesiology, University of Tennessee Medical Center, Knoxville, Tennessee Department of Anesthesiology, University of Utah, Salt Lake City, Utah Department of Anesthesiology, University of Vermont, Larner College of Medicine, Burlington, Vermont Department of Anesthesiology, University of Virginia, Charlottesville, Virginia Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Weill Cornell Medical College, New York, New York Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
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Kim HJ, Koh WU, Choi JM, Ro YJ, Yang HS. Malignant hyperthermia and dantrolene sodium. Korean J Anesthesiol 2018; 72:78-79. [PMID: 29921086 PMCID: PMC6369340 DOI: 10.4097/kja.d.18.00139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/01/2018] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ha Jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Uk Koh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Jin Ro
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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In J, Ahn EJ, Lee DK, Kang H. Incidence of malignant hyperthermia in patients undergoing general anesthesia: Protocol for a systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e9115. [PMID: 29245345 PMCID: PMC5728960 DOI: 10.1097/md.0000000000009115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/15/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Malignant hyperthermia (MH) continues to be of potential concern for clinicians whenever inhalational anesthetic agents or succinylcholine are used, because MH is a potentially fatal metabolic disorder. METHODS A systematic and comprehensive search will be performed using MEDLINE, EMBASE, and Google Scholar, for studies published up to November 2017. Peer-reviewed prospective cohort studies, retrospective cohort studies, and cross-sectional studies or reports issued by government organizations reporting the incidence or prevalence of MH will be eligible for inclusion. The quality of included studies will be assessed using the Newcastle-Ottawa scale and the modified risk of bias tool. Heterogeneity of estimates across studies as well as publication bias will be assessed. This systematic review and meta-analysis will be performed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. All statistical analyses will be conducted using the Stata SE version 15.0. RESULTS The results of this systematic review and meta-analysis will be published in a peer-reviewed journal. CONCLUSION To our knowledge, this systematic review and meta-analysis will be the first to evaluate existing research on the incidence of MH. Our study will provide an overall estimate of the incidence of MH. Subgroup analysis will assess the incidence of MH according to age, gender, geographical region, race, and the provoking agent if possible. The review will benefit patients, healthcare providers, and policymakers. ETHICS AND DISSEMINATION Ethical approval and informed consent are not required, as the study will be a literature review and will not involve direct contact with patients or alterations to patient care. TRIAL REGISTRATION NUMBER The protocol for this review has been registered in the PROSPERO network (registration number: CRD42017076628).
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Affiliation(s)
- Junyong In
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Gyeonggido
| | - Eun Jin Ahn
- Department of Anesthesiology and Pain Medicine, Inje University Seoul Paik Hospital
| | - Dong Kyu Lee
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University School of Medicine
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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Dantrolenbevorratung in Anästhesie und Intensivmedizin in Deutschland. Anaesthesist 2017; 66:773-781. [DOI: 10.1007/s00101-017-0335-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 06/05/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
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Joshi GP, Desai MS, Gayer S, Vila H. Succinylcholine for Emergency Airway Rescue in Class B Ambulatory Facilities. Anesth Analg 2017; 124:1447-1449. [DOI: 10.1213/ane.0000000000001682] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pan T, Ji W, Nie M, Li Y. Clinical treatment of malignant hyperthermia in three cases. Exp Ther Med 2016; 12:2881-2884. [PMID: 27882090 PMCID: PMC5103719 DOI: 10.3892/etm.2016.3712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 09/01/2016] [Indexed: 12/16/2022] Open
Abstract
Malignant hyperthermia (MH) is a rare life threatening inherited disorder that is triggered by drugs used for general anesthesia in susceptible persons. The symptoms include rapid increase of body temperature and severe muscle contractions. The present study includes 3 cases of MH and highlights the timely identification of symptoms for rescuing the patient. In case I, a 7-year-old male child underwent surgery with ketamine at a dose of 250 mg. After 4 h of operation, the child went through convulsions, high fever and succumbed within a few hours. High fever was not detected in a timely manner, which is one of the main symptoms of MH. In case II, a 12-year-old male child had convulsions and high fever after simple surgery caused by MH. Once confirmed, immediate measures were taken to lower the body temperature and the child was rescued. In case III, a male 57-year-old was admitted to hospital due to paraplegia. The patient underwent more critical conditions once symptoms of MH appeared. Additionally, antidote dantrolene was unavailable in the first and third case; thus, the progression of disease was not alleviated although active symptomatic and supportive treatment were employed.
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Affiliation(s)
- Tao Pan
- Department of Intensive Care Medicine, Xiangyang Hospital Affiliated to Hubei University of Medicine, Wuhan, Hubei 441000, P.R. China
| | - Wenli Ji
- Department of Intensive Care Medicine, Xiangyang Hospital Affiliated to Hubei University of Medicine, Wuhan, Hubei 441000, P.R. China
| | - Mengqi Nie
- Department of Intensive Care Medicine, Xiangyang Hospital Affiliated to Hubei University of Medicine, Wuhan, Hubei 441000, P.R. China
| | - Yang Li
- Department of Intensive Care Medicine, Xiangyang Hospital Affiliated to Hubei University of Medicine, Wuhan, Hubei 441000, P.R. China
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