A Fulminant Malignant Hyperthermia Episode in a Patient with Ryanodine Receptor Gene Mutation p.Tyr522Ser

Application of Advanced Technologies-Nanotechnology, Genomics Technology, and 3D Printing Technology-In Precision Anesthesia: A Comprehensive Narrative Review

There has been increasing interest and rapid developments in precision medicine, which is a new medical concept and model based on individualized medicine with the joint application of genomics, bioinformatics engineering, and big data science. By applying numerous emerging medical frontier technologies, precision medicine could allow individualized and precise treatment for specific diseases and patients. This article reviews the application and progress of advanced technologies in the anesthesiology field, in which nanotechnology and genomics can provide more personalized anesthesia protocols, while 3D printing can yield more patient-friendly anesthesia supplies and technical training materials to improve the accuracy and efficiency of decision-making in anesthesiology. The objective of this manuscript is to analyze the recent scientific evidence on the application of nanotechnology in anesthesiology. It specifically focuses on nanomedicine, precision medicine, and clinical anesthesia. In addition, it also includes genomics and 3D printing. By studying the current research and advancements in these advanced technologies, this review aims to provide a deeper understanding of the potential impact of these advanced technologies on improving anesthesia techniques, personalized pain management, and advancing precision medicine in the field of anesthesia.

Rhabdomyolysis associated acute renal failure - Report of two fatal cases and a brief review of literature

BACKGROUND

Rhabdomyolysis is a potentially fatal condition which occurs due to skeletal muscle injury and classically presents with myalgia and red-brown coloured urine. Presence of excess myoglobin in the glomerular filtrate forms myoglobin casts which causes severe obstruction and necrosis of the tubules leading to acute renal failure.

METHODS

We report two fatal cases of rhabdomyolysis associated acute renal failure. The first victim died in police custody and the second victim died due to severe physical exertion.

RESULTS

In both the cases, creatine kinase levels were elevated and myoglobin was detected in urine in the second case. Myoglobin immunohistochemistry detected the presence of myoglobin cast in the glomerular tubules of kidney in both the cases.

CONCLUSIONS

Myoglobin immunohistochemistry of renal tissues, serum creatine kinase, urine myoglobin analysis and muscle histopathology are the laboratory tests that should be considered at autopsy where rhabdomyolysis is suspected.

Kyphoscoliosis associated with congenital neuromuscular disease with uniform type 1 fibers

OBJECTIVE

To report the first case of surgical treatment for severe kyphoscoliosis associated with respiratory disorder in a patient with congenital neuromuscular disease with uniform type 1 fibers (CNMDU1), including management of the possible onset of malignant hyperthermia (MH) in general anesthesia. CNMDU1 is rare among congenital neuromuscular diseases, and surgery for spinal deformity in CNMDU1 has not been described. Onset of MH in general anesthesia is a concern in this disease.

METHODS

A 13-year-old female with motor retardation, suspected myopathy, and severe spinal deformity was followed at another pediatric hospital before referral to Meijo Hospital. Symptoms at the initial consultation were mild general muscular weakness and muscular atrophy. The rib hump was 60° and trunk balance was poor. The tendon reflex showed hyporeflexia, and blood tests were normal. Vital capacity was 0.69 L and forced expiratory volume percentage in 1 s was 75.5%, showing a restrictive and obstructive ventilatory defect. A plain radiograph showed severe kyphoscoliosis with thoracic scoliosis of 130° (T5-L1) and thoracic kyphosis of 110° (T2-T12) with almost no flexibility in bending or traction film.

RESULTS

After preoperative halo traction for 2 months, one-stage anterior and posterior correction and fusion from T2 to L3 was conducted. MH did not occur, but recovery of respiratory function required 8 days by intubation after surgery. Postoperatively, thoracic kyphosis improved to 25° and thoracic scoliosis was 66° (correction rate: 49%). Pathological results of an intraoperative muscle biopsy from the paraspinal muscles confirmed the diagnosis of CNMDU1. At 6 years after surgery, the patient has no problems in daily life and no respiratory difficulty.

CONCLUSION

Spinal deformity in CNMDU1 has a risk of severe progression, which makes early diagnosis by biopsy important. The surgery may be recommended before severe progression of spinal deformity and respiratory disorder. Perioperative MH is a concern, but can be managed by appropriate procedures.

Anesthesia for patients with a history of malignant hyperthermia

PURPOSE OF REVIEW

Malignant hyperthermia-susceptible patients have an increased risk during anaesthesia. The aim of this review is to present current knowledge about pathophysiology and triggers of malignant hyperthermia as well as concepts for safe anaesthesiological management of these patients.

RECENT FINDINGS

Trigger substances and mechanisms have been well defined to date. Anaesthesia can be safely performed with i.v. anaesthetics, nitrous oxide, nondepolarizing muscle relaxants, local anaesthetics as well as xenon. Attention must be directed to the preparation of the anaesthetic machine because modern workstations need longer cleansing times than their predecessors. Alternatively, activated charcoal might be beneficial for elimination of volatile anaesthetics. Day case surgery can be performed in malignant hyperthermia-susceptible patients, if all safety aspects are regarded. Whether there is an association between malignant hyperthermia susceptibility and other disorders is still a matter of debate.

SUMMARY

The incidence of malignant hyperthermia is low, but the prevalence can be estimated as up to 1: 3000. Because malignant hyperthermia is potentially lethal, it is relevant to establish management concepts for perioperative care in susceptible patients. This includes preoperative genetic and in-vitro contracture testing, preparation of the anaesthetic workstation, use of nontriggering anaesthetics, adequate monitoring, availability of sufficient quantities of dantrolene and appropriate postoperative care. Taking these items into account, anaesthesia can be safely performed in susceptible patients.

Anesthetic case in a child with congenital neuromuscular disease with uniform type 1 fibers (CNMDU1)

Congenital neuromuscular disease with uniform type 1 fibers (CNMDU1) is an extremely rare, non-progressive, congenital neuromuscular disorder. Although the etiology is unknown, ryanodine receptor gene mutation is reportedly involved. No descriptions of anesthetic practice in patients with this disease have been reported around the world. We report a case of safe perioperative management with general anesthesia, using total intravenous anesthesia, propofol, fentanyl and a non-depolarizing muscle relaxant but avoiding the use of any inhaled anesthetics or depolarizing muscle relaxants to prevent malignant hyperthermia and postoperative respiratory failure, during anesthetic management for cranioplasty for premature synostosis of the cranial sutures in a pediatric patient of CNMDU1.