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Bertorini TE, Finder JD, Bassam BA. Perioperative Management of Patients With Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00010-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Shafy SZ, Hakim M, Villalobos MA, Pearson GD, Veneziano G, Tobias JD. Caudal epidural block instead of general anesthesia in an adult with Duchenne muscular dystrophy. Local Reg Anesth 2018; 11:75-80. [PMID: 30410390 PMCID: PMC6197695 DOI: 10.2147/lra.s180867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Duchenne muscular dystrophy (DMD), first described in 1834, is an X-linked dystrophinopathy, leading to early onset skeletal muscle weakness. Life expectancy is reduced to early adulthood as a result of involvement of voluntary skeletal muscles with respiratory failure, orthopedic deformities, and associated cardiomyopathy. Given its multisystem involvement, surgical intervention may be required to address the sequelae of the disease process. We present a 36-year-old adult with DMD, who required anesthetic care during surgical debridement of an ischial pressure sore. Given his significant respiratory muscle involvement, ultrasound-guided caudal epidural anesthesia was used instead of general during the surgical procedure. The technique and its applications are discussed, with particular emphasis on the feasibility and safety of using regional anesthetic techniques in patients with DMD.
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Affiliation(s)
- Shabana Z Shafy
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA,
| | - Mohammed Hakim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA,
| | - Mauricio Arce Villalobos
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA,
| | - Gregory D Pearson
- Department of Plastic Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Plastic Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Giorgio Veneziano
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA,
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA, .,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, Ohio, USA
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Lahoria R, Milone M. Rhabdomyolysis featuring muscular dystrophies. J Neurol Sci 2016; 361:29-33. [DOI: 10.1016/j.jns.2015.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/09/2015] [Accepted: 12/08/2015] [Indexed: 12/13/2022]
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Hakim CH, Peters AA, Feng F, Yao G, Duan D. Night Activity Reduction is a Signature Physiological Biomarker for Duchenne Muscular Dystrophy Dogs. J Neuromuscul Dis 2015; 2:397-407. [PMID: 27812508 PMCID: PMC5089072 DOI: 10.3233/jnd-150114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is an X-linked lethal muscle disease. Dystrophic dogs are excellent models to test novel therapies for DMD. However, the use of the dog model has been hindered by the lack of an effective method to evaluate whole-body mobility. We recently showed that night activity is a good indicator of dog mobility. However, our published method relies on frame-by-frame manual processing of a 12-hour video for each dog. This labor-intensive and time-consuming approach makes it unrealistic to use this assay as a routine outcome measurement. OBJECTIVE To solve this problem, we developed an automatic video-capturing/imaging processing system. The new system reduces the data analysis time over 1,000 fold and also provides a more detailed activity profile of the dog. METHODS Using the new system, we analyzed more than 120 twelve-hour recordings from 12 normal and 22 affected dogs. RESULTS We observed similar activity profiles during repeated recording of the same dog. Throughout the night, normal dogs were in motion 10.4 ± 0.9% of the time while affected dogs were in motion 4.6 ± 0.2% of the time (p < 0.0001). Further, normal dogs made significantly more movements (p < 0.0001) while affected dogs rested significantly longer (p < 0.0001) during the period of recording (from 6 pm to 6 am next day). Importantly, statistical significance persisted irrespective of the coat color, gender and mutation type. CONCLUSIONS Our results suggest that night activity reduction is a robust, quantitative physiological biomarker for dystrophic dogs. The new system may be applicable to study mobility in other species.
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Affiliation(s)
- Chady H Hakim
- Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Austin A Peters
- Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Feng Feng
- Department of Electrical and Computer Engineering, College of Engineering, University of Missouri, Columbia, MO, USA
| | - Gang Yao
- Department of Bioengineering, College of Engineering, University of Missouri, Columbia, MO, USA
| | - Dongsheng Duan
- Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia, MO, USA
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Rosenberg H, Pollock N, Schiemann A, Bulger T, Stowell K. Malignant hyperthermia: a review. Orphanet J Rare Dis 2015; 10:93. [PMID: 26238698 PMCID: PMC4524368 DOI: 10.1186/s13023-015-0310-1] [Citation(s) in RCA: 296] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 07/22/2015] [Indexed: 02/06/2023] Open
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, isoflurane and the depolarizing muscle relaxant succinylcholine, and rarely, in humans, to stressors such as vigorous exercise and heat. The incidence of MH reactions ranges from 1:10,000 to 1: 250,000 anesthetics. However, the prevalence of the genetic abnormalities may be as great as one in 400 individuals. MH affects humans, certain pig breeds, dogs and horses. The classic signs of MH include hyperthermia, tachycardia, tachypnea, increased carbon dioxide production, increased oxygen consumption, acidosis, hyperkalaemia, muscle rigidity, and rhabdomyolysis, all related to a hypermetabolic response. The syndrome is likely to be fatal if untreated. An increase in end-tidal carbon dioxide despite increased minute ventilation provides an early diagnostic clue. In humans the syndrome is inherited in an autosomal dominant pattern, while in pigs it is autosomal recessive. Uncontrolled rise of myoplasmic calcium, which activates biochemical processes related to muscle activation leads to the pathophysiologic changes. In most cases, the syndrome is caused by a defect in the ryanodine receptor. Over 400 variants have been identified in the RYR1 gene located on chromosome 19q13.1, and at least 34 are causal for MH. Less than 1 % of variants have been found in CACNA1S but not all of these are causal. Diagnostic testing involves the in vitro contracture response of biopsied muscle to halothane, caffeine, and in some centres ryanodine and 4-chloro-m-cresol. Elucidation of the genetic changes has led to the introduction of DNA testing for susceptibility to MH. Dantrolene sodium is a specific antagonist and should be available wherever general anesthesia is administered. Increased understanding of the clinical manifestation and pathophysiology of the syndrome, has lead to the mortality decreasing from 80 % thirty years ago to <5 % in 2006.
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Affiliation(s)
- Henry Rosenberg
- Department of Medical Education and Clinical Research, Saint Barnabas Medical Center, Livingston, NJ, 07039, USA.
| | - Neil Pollock
- Department of Anesthesia and Intensive Care, Palmerston North Hospital, Palmerston North, New Zealand.
| | - Anja Schiemann
- Institute of Fundamental Sciences, Massey University, Palmerston North, New Zealand.
| | - Terasa Bulger
- Department of Anesthesia and Intensive Care, Palmerston North Hospital, Palmerston North, New Zealand.
| | - Kathryn Stowell
- Institute of Fundamental Sciences, Massey University, Palmerston North, New Zealand.
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Brunklaus A, Parish E, Muntoni F, Scuplak S, Tucker SK, Fenton M, Hughes ML, Manzur AY. The value of cardiac MRI versus echocardiography in the pre-operative assessment of patients with Duchenne muscular dystrophy. Eur J Paediatr Neurol 2015; 19:395-401. [PMID: 25843299 DOI: 10.1016/j.ejpn.2015.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 03/02/2015] [Accepted: 03/16/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND/PURPOSE Duchenne Mmuscular Ddystrophy (DMD) related cardiomyopathy is associated with significant perioperative mortality. Cardiac MRI (CMR) has not previously been systematically evaluated as pre-operative assessment tool for heart function in DMD. Our aim was to establish whether CMR versus echocardiography contributes to pre-operative DMD assessment. METHODS Case records were retrospectively reviewed of 35 consecutive DMD boys who underwent evaluation for surgical procedures between 2010 and 2013. RESULTS Echocardiography revealed a median left ventricular (LV) shortening fraction (SF) of 29/% (range: 7-44). 37% of boys (13/35) had abnormal SF <25%, 66% (23/35) showed hypokinesia and 26% (9/35) had LV dilatation. CMR revealed a median left ventricular ejection fraction (LVEF) of 52% (range: 27-67%). 57% of boys (20/35) had abnormal LVEF <55%, 71% (25/35) had hypokinesia, and 82% late gadolinium enhancement. Extensive versus minimal late gadolinium enhancement was associated with reduced left ventricular ejection fraction (48% vs 58%; p = 0.003) suggesting more severe cardiomyopathy. Although echocardiography shortening fraction correlated with CMR ejection fraction (rs = 0.67; p < 0.001), three-quarter of echocardiography studies had suboptimal scanning windows and in 26% measurements significantly over- or underestimated left-ventricular function compared to CMR. CONCLUSION Our findings clearly demonstrate the added value of CMR versus echocardiography in assessing DMD-cardiomyopathy. Particularly when echocardiographic scanning windows are suboptimal, CMR should be considered to allow accurate pre-operative cardiac assessment.
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Affiliation(s)
- A Brunklaus
- Dubowitz Neuromuscular Centre, UCL Institute of Child Health & Great Ormond Street Hospital, London WC1N 3JH, UK
| | - E Parish
- Dubowitz Neuromuscular Centre, UCL Institute of Child Health & Great Ormond Street Hospital, London WC1N 3JH, UK
| | - F Muntoni
- Dubowitz Neuromuscular Centre, UCL Institute of Child Health & Great Ormond Street Hospital, London WC1N 3JH, UK
| | - S Scuplak
- Department of Paediatric Anaesthesia, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - S K Tucker
- Department of Orthopaedics, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - M Fenton
- Department of Paediatric Cardiology, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - M L Hughes
- Department of Paediatric Cardiology, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - A Y Manzur
- Dubowitz Neuromuscular Centre, UCL Institute of Child Health & Great Ormond Street Hospital, London WC1N 3JH, UK.
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Segura LG, Lorenz JD, Weingarten TN, Scavonetto F, Bojanić K, Selcen D, Sprung J. Anesthesia and Duchenne or Becker muscular dystrophy: review of 117 anesthetic exposures. Paediatr Anaesth 2013; 23:855-64. [PMID: 23919455 DOI: 10.1111/pan.12248] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are associated with life-threatening perioperative complications, including rhabdomyolysis, hyperkalemia, and hyperthermia. Current recommendations contraindicate use of succinylcholine and volatile anesthetics; however, the latter recommendation remains controversial. OBJECTIVE To review the perioperative outcomes of patients with DMD and BMD. METHODS We reviewed records of patients with DMD or BMD who underwent anesthetic management at our institution from January 1990 through December 2011. RESULTS We identified 47 patients (DMD, 37; BMD, 10) who underwent 117 anesthetic exposures (DMD, 101; BMD, 16). Volatile anesthetic agents were used 66 times (DMD, 59; BMD, 7). One patient with undiagnosed BMD received succinylcholine and developed acute rhabdomyolysis and hyperkalemic cardiac arrest. All other major complications were attributed to the procedure (i.e., large bleeding), to preexisting comorbidities (i.e., respiratory failure, cardiac disease), or to both. CONCLUSIONS Use of succinylcholine in children with dystrophinopathy is contraindicated. These patients have significant comorbidities and are frequently undergoing extensive operations; complications related to these factors can develop, as evidenced by our series. These complications may occur with use of volatile and nonvolatile anesthetics. However, because most of our patients were older than 8 years at the time of surgery, our observation cannot be generalized to younger dystrophin-deficient children.
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Affiliation(s)
- Leal G Segura
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA
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Poole T, Lim T, Buck J, Kong A. Perioperative cardiac arrest in a patient with previously undiagnosed Becker's muscular dystrophy after isoflurane anaesthesia for elective surgery †. Br J Anaesth 2010; 104:487-9. [DOI: 10.1093/bja/aeq035] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Kocabas S, Yedicocuklu D, Askar F, Atay Y. Anesthetic management of a child with Duchenne muscular dystrophy undergoing correction of Fallot's Tetralogy. Paediatr Anaesth 2008; 18:448-50. [PMID: 18312525 DOI: 10.1111/j.1460-9592.2008.02456.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ortiz Gómez JR. [Anesthesia in malignant hyperthermia]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2008; 55:165-174. [PMID: 18401991 DOI: 10.1016/s0034-9356(08)70535-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Malignant hyperthermia is a condition for which the anesthesiologist must be prepared to take specific measures. Associated mortality is high despite correct diagnosis and, occasionally, the right treatment. Malignant hyperthermia is rare in Spain, however, and perhaps for this reason the Spanish public health authorities have not made an effort to respond to persistent calls for a national reference center for study and diagnosis, such as can be found in other European countries. The problem of malignant hyperthermia may become worse in the near future due to changes in the population brought about by immigration. It is therefore necessary to establish appropriately revised protocols and action plans to cope with this possibility. A reference center cannot be created by individuals, but we can become more aware of the need to establish up-to-date protocols in our departments in order to be prepared for this situation.
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Affiliation(s)
- J R Ortiz Gómez
- Servicio de Anestesiología y Reanimación, Hospital García Orcoyen, Estella, Navarra.
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Abstract
Patients with Duchenne and Becker muscular dystrophy suffer from a progressive deterioration in muscle secondary to a defect in the dystrophin gene. As such, they are susceptible to perioperative respiratory, cardiac and other complications, such as rhabdomyolysis. Inhalational anesthetic agents have been implicated as a cause of acute rhabdomyolysis that can resemble malignant hyperthermia (MH). This article reviews perioperative 'MH-like' reactions reported in muscular dystrophy patients and groups them into three categories according to clinical presentation. The etiology and underlying pathophysiological process responsible for these reactions is discussed and recommendations are proposed for the safe anesthetic management of these patients.
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Affiliation(s)
- Jason Hayes
- The Hospital for Sick Children, Toronto, ON, Canada.
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Phadke A, Broadman LM, Brandom BW, Ozolek J, Davis PJ. Postoperative hyperthermia, rhabdomyolysis, critical temperature, and death in a former premature infant after his ninth general anesthetic. Anesth Analg 2007; 105:977-80, table of contents. [PMID: 17898376 DOI: 10.1213/01.ane.0000280935.90260.d0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An 8-mo-old infant born at 24-wk of gestation died unexpectedly 12 h after his ninth uneventful general anesthetic. Preoperatively, he required low-flow nasal oxygen due to bronchopulmonary dysplasia, chronic diuretic therapy, and IV alimentation. As planned preoperatively, the infant remained tracheally intubated after his elective surgery and went to the Neonatal Intensive Care Unit in stable condition. However, over the next 6 h, he developed fever. The diagnosis of postoperative sepsis was considered. One hour before his death his temperature reached 43 degrees C. Autopsy documented Duchenne's muscular dystrophy and renal tubules containing myoglobin.
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Affiliation(s)
- Aparna Phadke
- Department of Anesthesiology, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Brambrink AM, Kirsch JR. Perioperative care of patients with neuromuscular disease and dysfunction. Anesthesiol Clin 2007; 25:483-509, viii-ix. [PMID: 17884705 DOI: 10.1016/j.anclin.2007.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
A variety of different pathologies result in disease phenotypes that are summarized as neuromuscular diseases because they share commonalty in their clinical consequences for the patient: a progressive weakening of the skeletal muscles. Distinct caution and appropriate changes to the anesthetic plan are advised when care is provided during the perioperative period. The choice of anesthetic technique, anesthetic drugs, and neuromuscular blockade always depends on the type of neuromuscular disease and the surgical procedure planned. A clear diagnosis of the underlying disease and sufficient knowledge and understanding of the pathophysiology are of paramount importance to the practitioner and guide optimal perioperative management of affected patients.
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Affiliation(s)
- Ansgar M Brambrink
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Sciences University, 3181 Sam Jackson Park Road, Portland, OR 97239-3098, USA.
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Rosenberg H, Davis M, James D, Pollock N, Stowell K. Malignant hyperthermia. Orphanet J Rare Dis 2007; 2:21. [PMID: 17456235 PMCID: PMC1867813 DOI: 10.1186/1750-1172-2-21] [Citation(s) in RCA: 264] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Accepted: 04/24/2007] [Indexed: 11/10/2022] Open
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 and the depolarizing muscle relaxant succinylcholine, and rarely, in humans, to stresses such as vigorous exercise and heat. The incidence of MH reactions ranges from 1:5,000 to 1:50,000-100,000 anesthesias. However, the prevalence of the genetic abnormalities may be as great as one in 3,000 individuals. MH affects humans, certain pig breeds, dogs, horses, and probably other animals. The classic signs of MH include hyperthermia to marked degree, tachycardia, tachypnea, increased carbon dioxide production, increased oxygen consumption, acidosis, muscle rigidity, and rhabdomyolysis, all related to a hypermetabolic response. The syndrome is likely to be fatal if untreated. Early recognition of the signs of MH, specifically elevation of end-expired carbon dioxide, provides the clinical diagnostic clues. In humans the syndrome is inherited in autosomal dominant pattern, while in pigs in autosomal recessive. The pathophysiologic changes of MH are due to uncontrolled rise of myoplasmic calcium, which activates biochemical processes related to muscle activation. Due to ATP depletion, the muscle membrane integrity is compromised leading to hyperkalemia and rhabdomyolysis. In most cases, the syndrome is caused by a defect in the ryanodine receptor. Over 90 mutations have been identified in the RYR-1 gene located on chromosome 19q13.1, and at least 25 are causal for MH. Diagnostic testing relies on assessing the in vitro contracture response of biopsied muscle to halothane, caffeine, and other drugs. Elucidation of the genetic changes has led to the introduction, on a limited basis so far, of genetic testing for susceptibility to MH. As the sensitivity of genetic testing increases, molecular genetics will be used for identifying those at risk with greater frequency. Dantrolene sodium is a specific antagonist of the pathophysiologic changes of MH and should be available wherever general anesthesia is administered. Thanks to the dramatic progress in understanding the clinical manifestation and pathophysiology of the syndrome, the mortality from MH has dropped from over 80% thirty years ago to less than 5%.
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Affiliation(s)
- Henry Rosenberg
- Department of Medical Education and Clinical Research, Saint Barnabas Medical Center, Livingston, NJ 07039, USA
| | - Mark Davis
- Department of Medical Education and Clinical Research, Saint Barnabas Medical Center, Livingston, NJ 07039, USA
| | - Danielle James
- Department of Medical Education and Clinical Research, Saint Barnabas Medical Center, Livingston, NJ 07039, USA
| | - Neil Pollock
- Department of Medical Education and Clinical Research, Saint Barnabas Medical Center, Livingston, NJ 07039, USA
| | - Kathryn Stowell
- Department of Medical Education and Clinical Research, Saint Barnabas Medical Center, Livingston, NJ 07039, USA
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Hyperkalemic Cardiac Arrest After Cardiopulmonary Bypass in a Child with Duchenne Muscular Dystrophy. Anesth Analg 2005. [DOI: 10.1097/00000539-200511000-00069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Al-Takrouri H, Mayhew JF. Hyperkalemic cardiac arrest after cardiopulmonary bypass in a child with Duchenne muscular dystrophy. Anesth Analg 2005; 101:1561-1562. [PMID: 16244038 DOI: 10.1213/01.ane.0000180242.35595.32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Hetam Al-Takrouri
- Arkansas Childrens' Hospital; University of Arkansas Medical Center; Little Rock, AR (Al-Takrouri) Batson Childrens' Hospital; University of Mississippi Medical Center; Jackson, MS; (Mayhew)
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