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Heiderich S, Bastian B, Johannsen S, Klingler W, Rüffert H, Schuster F. [Trigger-free anesthesia : Indications and safe application]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01311-2. [PMID: 37382624 DOI: 10.1007/s00101-023-01311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
The safe anesthesiological care of patients with neuromuscular diseases poses a particular challenge for anesthetists. Only a small group of muscle diseases and syndromes are associated with an increased risk of malignant hyperthermia and therefore require trigger-free anesthetic procedures avoiding volatile anesthetics and succinylcholine. These diseases are frequently associated with mutations in the RYR1, CACNA1S or STAC-3 genes. In other neuromuscular diseases, anesthetic-induced rhabdomyolysis can occur. Therefore, volatile anesthetics should be avoided in these patients in addition to the contraindication for succinylcholine. In other neuromuscular diseases the risk of a propofol infusion syndrome or myotonic crises can be elevated or the duration of the effect of non-depolarizing muscle relaxants can be changed in an incalculable way. In every case an individual anesthetic aproach including the avoidance of potential pharmacological or non-pharmacological triggers is essential for the safety of the patients.
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Affiliation(s)
- Sebastian Heiderich
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - Börge Bastian
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Stephan Johannsen
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Werner Klingler
- Fachabteilung für Anästhesie, Intensivmedizin und Schmerztherapie, SRH Kliniken Landkreis Sigmaringen, Sigmaringen, Deutschland
| | - Henrik Rüffert
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Helios Klinikum Schkeuditz, Schkeuditz, Deutschland
| | - Frank Schuster
- Institut für Anästhesiologie, Intensivmedizin und Notfallmedizin, Donau-Isar-Klinikum Deggendorf-Dingolfing-Landau, Deggendorf, Deutschland
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2
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Matthews E, Holmes S, Fialho D. Skeletal muscle channelopathies: a guide to diagnosis and management. Pract Neurol 2021; 21:196-204. [PMID: 33563766 DOI: 10.1136/practneurol-2020-002576] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2020] [Indexed: 12/17/2022]
Abstract
Skeletal muscle channelopathies are a group of rare episodic genetic disorders comprising the periodic paralyses and the non-dystrophic myotonias. They may cause significant morbidity, limit vocational opportunities, be socially embarrassing, and sometimes are associated with sudden cardiac death. The diagnosis is often hampered by symptoms that patients may find difficult to describe, a normal examination in the absence of symptoms, and the need to interpret numerous tests that may be normal or abnormal. However, the symptoms respond very well to holistic management and pharmacological treatment, with great benefit to quality of life. Here, we review when to suspect a muscle channelopathy, how to investigate a possible case and the options for therapy once a diagnosis is made.
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Affiliation(s)
- Emma Matthews
- Atkinson-Morley Neuromuscular Centre, St George's University Hospitals NHS Foundation Trust, London, UK
- Department of Neuromuscular Diseases, UCL, Institute of Neurology, London, UK
| | - Sarah Holmes
- Queen Square Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Doreen Fialho
- Department of Neuromuscular Diseases, UCL, Institute of Neurology, London, UK
- Queen Square Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Clinical Neurophysiology, King's College Hospital NHS Foundation Trust, London, UK
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3
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Stunnenberg BC, LoRusso S, Arnold WD, Barohn RJ, Cannon SC, Fontaine B, Griggs RC, Hanna MG, Matthews E, Meola G, Sansone VA, Trivedi JR, van Engelen BG, Vicart S, Statland JM. Guidelines on clinical presentation and management of nondystrophic myotonias. Muscle Nerve 2020; 62:430-444. [PMID: 32270509 PMCID: PMC8117169 DOI: 10.1002/mus.26887] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/01/2020] [Accepted: 04/04/2020] [Indexed: 12/26/2022]
Abstract
The nondystrophic myotonias are rare muscle hyperexcitability disorders caused by gain-of-function mutations in the SCN4A gene or loss-of-function mutations in the CLCN1 gene. Clinically, they are characterized by myotonia, defined as delayed muscle relaxation after voluntary contraction, which leads to symptoms of muscle stiffness, pain, fatigue, and weakness. Diagnosis is based on history and examination findings, the presence of electrical myotonia on electromyography, and genetic confirmation. In the absence of genetic confirmation, the diagnosis is supported by detailed electrophysiological testing, exclusion of other related disorders, and analysis of a variant of uncertain significance if present. Symptomatic treatment with a sodium channel blocker, such as mexiletine, is usually the first step in management, as well as educating patients about potential anesthetic complications.
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Affiliation(s)
- Bas C. Stunnenberg
- Department of Neurology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Samantha LoRusso
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - W. David Arnold
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Richard J. Barohn
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas
| | - Stephen C. Cannon
- Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Bertrand Fontaine
- Assistance Publique-Hôpitaix de Paris, Sorbonne Université, INSERM, Service of Neuro-Myology and UMR 974, Institute of Myology, University Hospital Pitié-Salpêtrière, Paris, France
| | - Robert C. Griggs
- Department of Neurology, University of Rochester, Rochester, New York
| | - Michael G. Hanna
- MRC Centre for Neuromuscular Diseases, Department of Neuromuscular diseases, UCL Queen Square Institute of Neurology, United Kingdom
| | - Emma Matthews
- MRC Centre for Neuromuscular Diseases, Department of Neuromuscular diseases, UCL Queen Square Institute of Neurology, United Kingdom
| | - Giovanni Meola
- Department of Neurorehabilitation Sciences, Casa Cura Policlinico, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Valeria A. Sansone
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Neurorehabilitation Unit, University of Milan, NEuroMuscular Omnicentre (NEMO), Fondazione Serena Onlus, Milan, Italy
| | - Jaya R. Trivedi
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, Texas
| | | | - Savine Vicart
- Assistance Publique-Hôpitaix de Paris, Sorbonne Université, INSERM, Service of Neuro-Myology and UMR 974, Institute of Myology, University Hospital Pitié-Salpêtrière, Paris, France
| | - Jeffrey M. Statland
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas
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Matthews E, Balestrini S, Sisodiya SM, Hanna MG. Muscle and brain sodium channelopathies: genetic causes, clinical phenotypes, and management approaches. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:536-547. [PMID: 32142633 DOI: 10.1016/s2352-4642(19)30425-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/29/2019] [Accepted: 12/12/2019] [Indexed: 01/26/2023]
Abstract
Voltage-gated sodium channels are essential for excitability of skeletal muscle fibres and neurons. An increasing number of disabling or fatal paediatric neurological disorders linked to mutations of voltage-gated sodium channel genes are recognised. Muscle phenotypes include episodic paralysis, myotonia, neonatal hypotonia, respiratory compromise, laryngospasm or stridor, congenital myasthenia, and myopathy. Evidence suggests a possible link between sodium channel dysfunction and sudden infant death. Increasingly recognised phenotypes of brain sodium channelopathies include several epilepsy disorders and complex encephalopathies. Together, these early-onset muscle and brain phenotypes have a substantial morbidity and a considerable mortality. Important advances in understanding the pathophysiological mechanisms underlying these channelopathies have helped to identify effective targeted therapies. The availability of effective treatments underlines the importance of increasing clinical awareness and the need to achieve a precise genetic diagnosis. In this Review, we describe the expanded range of phenotypes of muscle and brain sodium channelopathies and the underlying knowledge regarding mechanisms of sodium channel dysfunction. We also outline a diagnostic approach and review the available treatment options.
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Affiliation(s)
- Emma Matthews
- Department of Neuromuscular Diseases, Medical Research Council Centre for Neuromuscular Diseases, University College London Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, University College London Hospitals National Health Service Foundation Trust, London, UK.
| | - Simona Balestrini
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK; Chalfont Centre for Epilepsy, Buckinghamshire, UK; National Hospital for Neurology and Neurosurgery, University College London Hospitals National Health Service Foundation Trust, London, UK
| | - Sanjay M Sisodiya
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, London, UK; Chalfont Centre for Epilepsy, Buckinghamshire, UK; National Hospital for Neurology and Neurosurgery, University College London Hospitals National Health Service Foundation Trust, London, UK
| | - Michael G Hanna
- Department of Neuromuscular Diseases, Medical Research Council Centre for Neuromuscular Diseases, University College London Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, University College London Hospitals National Health Service Foundation Trust, London, UK
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5
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Cea G, Andreu D, Fletcher E, Ramdas S, Sud R, Hanna MG, Matthews E. Sodium channel myotonia may be associated with high-risk brief resolved unexplained events. Wellcome Open Res 2020; 5:57. [PMID: 32509969 PMCID: PMC7241273 DOI: 10.12688/wellcomeopenres.15798.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2020] [Indexed: 11/20/2022] Open
Abstract
Brief resolved unexplained events (BRUEs) have numerous and varied causes posing a challenge to investigation and management. A subset of infants with the neuromuscular disorder sodium channel myotonia, due to mutations in the SCN4A gene, experience apnoeic events due to laryngospasm (myotonia) of the upper airway muscles that may present as a BRUE. We sought to ascertain the frequency, severity and outcome of infants carrying the G1306E SCN4A mutation commonly associated with this presentation. We report 12 new cases of individuals with the G1306E mutation from three unrelated families and perform a literature review of all published cases. Infants with the G1306E mutation almost universally experience laryngospasm and apnoeic events. The severity varies significantly, spans both low and high-risk BRUE categories or can be more severe than criteria for a BRUE would allow. At least a third of cases require intensive care unit (ICU) care. Seizure disorder is a common erroneous diagnosis. Apnoeas are effectively reduced or abolished by appropriate treatment with anti-myotonic agents. Probands with the G1306E mutation who are family planning need to be counselled for the likelihood of post-natal complications. There is readily available and extremely effective treatment for the episodic laryngospasm and apnoea caused by this mutation. Proactively seeking clinical evidence of myotonia or muscle hypertrophy with consideration of CK and EMG in high risk BRUEs or more complex apnoeic events may reduce avoidable and prolonged ICU admissions, patient morbidity and potentially mortality.
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Affiliation(s)
- Gabriel Cea
- Departamento de Ciencias Neurológicas, Universidad de Chile, Santiago, Chile
- Servicio de Neurología, Hospital Salvador, Santiago, Chile
| | - Daniel Andreu
- Departamento de Ciencias Neurológicas, Universidad de Chile, Santiago, Chile
| | - Elaine Fletcher
- Department of Clinical Genetics, Centre for Genomic and Experimental Medicine, Western General Hospital, Edinburgh, EH5 2GL, UK
| | - Sithara Ramdas
- Department of Paediatric Neurology, John Radcliffe Hospital NHS Foundation Trust, Oxford, UK
| | - Richa Sud
- Neurogenetics Unit, UCL Queen Square Institute of Neurology, London, UK
| | - Michael G. Hanna
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Emma Matthews
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
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6
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Cea G, Andreu D, Fletcher E, Ramdas S, Sud R, Hanna MG, Matthews E. Sodium channel myotonia may be associated with high-risk brief resolved unexplained events. Wellcome Open Res 2020; 5:57. [PMID: 32509969 PMCID: PMC7241273 DOI: 10.12688/wellcomeopenres.15798.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2020] [Indexed: 12/02/2022] Open
Abstract
Brief resolved unexplained events (BRUEs) have numerous and varied causes posing a challenge to investigation and management. A subset of infants with the neuromuscular disorder sodium channel myotonia, due to mutations in the SCN4A gene, experience apnoeic events due to laryngospasm (myotonia) of the upper airway muscles that may present as a BRUE. We sought to ascertain the frequency, severity and outcome of infants carrying the G1306E SCN4A mutation commonly associated with this presentation. We report 14 new cases of individuals with the G1306E mutation from three unrelated families and perform a literature review of all published cases. Infants with the G1306E mutation almost universally experience laryngospasm and apnoeic events. The severity varies significantly, spans both low and high-risk BRUE categories or can be more severe than criteria for a BRUE would allow. At least a third of cases require intensive care unit (ICU) care. Seizure disorder is a common erroneous diagnosis. Apnoeas are effectively reduced or abolished by appropriate treatment with anti-myotonic agents. Probands with the G1306E mutation who are family planning need to be counselled for the likelihood of post-natal complications. There is readily available and extremely effective treatment for the episodic laryngospasm and apnoea caused by this mutation. Proactively seeking clinical evidence of myotonia or muscle hypertrophy with consideration of CK,EMG and genetic testing in high risk BRUEs or more complex apnoeic events may reduce avoidable and prolonged ICU admissions, patient morbidity and potentially mortality.
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Affiliation(s)
- Gabriel Cea
- Departamento de Ciencias Neurológicas, Universidad de Chile, Santiago, Chile
- Servicio de Neurología, Hospital Salvador, Santiago, Chile
| | - Daniel Andreu
- Departamento de Ciencias Neurológicas, Universidad de Chile, Santiago, Chile
| | - Elaine Fletcher
- Department of Clinical Genetics, Centre for Genomic and Experimental Medicine, Western General Hospital, Edinburgh, EH5 2GL, UK
| | - Sithara Ramdas
- Department of Paediatric Neurology, John Radcliffe Hospital NHS Foundation Trust, Oxford, UK
| | - Richa Sud
- Neurogenetics Unit, UCL Queen Square Institute of Neurology, London, UK
| | - Michael G. Hanna
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Emma Matthews
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
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7
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Anesthetic management of a patient with sodium-channel myotonia: a case report. JA Clin Rep 2019; 5:77. [PMID: 32026975 PMCID: PMC6967029 DOI: 10.1186/s40981-019-0300-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 11/15/2019] [Indexed: 02/08/2023] Open
Abstract
Background Sodium-channel myotonia (SCM) is a nondystrophic myotonia, characterized by pure myotonia without muscle weakness or paramyotonia. The prevalence of skeletal muscle channelopathies is approximately 1 in 100,000, and the prevalence of SCM is much lower. To our knowledge, this is the first report on anesthetic management of a patient with SCM. Case presentation A 23-year-old woman with congenital nasal dysplasia and SCM was scheduled to undergo rhinoplasty with autologous costal cartilage. Total intravenous anesthesia without muscle relaxants was administered followed by continuous intercostal nerve block. Although transient elevation of potassium level in the blood was observed during surgery, the patient did not show exacerbation of myotonic or paralytic symptoms in the postoperative period. Conclusion Total intravenous anesthesia and peripheral nerve block can be administered safely to a patient with SCM. However, careful monitoring of the symptoms and electrolytes is recommended.
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8
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Litman RS, Smith VI, Larach MG, Mayes L, Shukry M, Theroux MC, Watt S, Wong CA. Consensus Statement of the Malignant Hyperthermia Association of the United States on Unresolved Clinical Questions Concerning the Management of Patients With Malignant Hyperthermia. Anesth Analg 2019; 128:652-659. [DOI: 10.1213/ane.0000000000004039] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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9
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Lai EA, Nesrsta EA, Bodiford JM, Jain RR. Medical alert tattoos-A pinch of style along with patient safety. Paediatr Anaesth 2018; 28:1154-1155. [PMID: 30511798 DOI: 10.1111/pan.13493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 08/14/2018] [Accepted: 08/19/2018] [Indexed: 11/28/2022]
Abstract
The use of medical tattoos can potentially be life-saving. We present a 16-year-old patient who chose to tattoo a medical condition on her forearm. Her tattoo is more extensive than most medical tattoos and shows the measures a mother will take to ensure her daughter's safety. To our knowledge, there are no published guidelines recommending an ideal location or symbology for a medical tattoo. Such guidelines would be useful to artists, as well as to medical personnel in emergencies if the patient has a tattoo.
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Affiliation(s)
| | - Eric A Nesrsta
- Department of Anesthesiology, McGovern Medical School, Houston, Texas
| | - Jason M Bodiford
- Department of Anesthesiology, McGovern Medical School, Houston, Texas
| | - Ranu R Jain
- Department of Anesthesiology, McGovern Medical School, Houston, Texas
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Anaesthesia and orphan disease: rocuronium and sugammadex in the anaesthetic management of a parturient with Becker's myotonia congenita. Eur J Anaesthesiol 2018; 33:545-7. [PMID: 26950083 DOI: 10.1097/eja.0000000000000442] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Statland JM, Barohn RJ. Muscle channelopathies: the nondystrophic myotonias and periodic paralyses. Continuum (Minneap Minn) 2014; 19:1598-614. [PMID: 24305449 DOI: 10.1212/01.con.0000440661.49298.c8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW The muscle channelopathies are a group of rare inherited diseases caused by mutations in muscle ion channels. Mutations cause an increase or decrease in muscle membrane excitability, leading to a spectrum of related clinical disorders: the nondystrophic myotonias are characterized by delayed relaxation after muscle contraction, causing muscle stiffness and pain; the periodic paralyses are characterized by episodes of flaccid muscle paralysis. This review describes the clinical characteristics, molecular pathogenesis, and treatments of the nondystrophic myotonias and periodic paralyses. RECENT FINDINGS Advances have been made in both the treatment and our understanding of the molecular pathophysiology of muscle channelopathies: (1) a recent controlled trial showed that mexiletine was effective for reducing symptoms and signs of myotonia in nondystrophic myotonia; (2) the mechanisms by which hypokalemic periodic paralysis leads to a depolarized but unexcitable sarcolemma membrane have been traced to a novel gating pore current; and (3) an association was demonstrated between mutations in a potassium inward rectifier and patients with thyrotoxic periodic paralysis. SUMMARY The muscle channelopathies are an expanding group of muscle diseases caused by mutations in sodium, chloride, potassium, and calcium ion channels that result in increased or decreased muscle membrane excitability. Recognizing patients with channelopathies and confirming the diagnosis is important, as treatment and management strategies differ based on mutation and clinical phenotype.
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Bandschapp O, Iaizzo PA. Pathophysiologic and anesthetic considerations for patients with myotonia congenita or periodic paralyses. Paediatr Anaesth 2013; 23:824-33. [PMID: 23802937 DOI: 10.1111/pan.12217] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2013] [Indexed: 12/13/2022]
Abstract
Myotonia congenita and periodic paralyses are hereditary skeletal muscle channelopathies. In these disorders, various channel defects in the sarcolemma lead to a severely disturbed membrane excitability of the affected skeletal muscles. The clinical picture can range from severe myotonic reactions (e.g., masseter spasm, opisthotonus) to attacks of weakness and paralysis. Provided here is a short overview of the pathomechanisms behind such wide-ranging phenotypic presentations in these patients, followed by recommendations concerning the management of anesthesia in such populations.
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Affiliation(s)
- Oliver Bandschapp
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
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13
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HOPPE K, LEHMANN-HORN F, CHAIKLIENG S, JURKAT-ROTT K, ADOLPH O, KLINGLER W. In vitro muscle contracture investigations on the malignant hyperthermia like episodes in myotonia congenita. Acta Anaesthesiol Scand 2013; 57:1017-23. [PMID: 23639175 DOI: 10.1111/aas.12126] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND A common form of congenital myotonia, myotonia congenita (MC), is caused by mutations in the skeletal muscle Cl(-) channel gene type 1 (CLCN1). Due to the reduced Cl(-) conductance of the mutated channels, the patients may develop generalized muscle rigidity and hypermetabolism during general anaesthesia. The clinical symptoms resemble malignant hyperthermia (MH), which may lead to mistreatment of the patient. METHODS Muscle specimens of ADR mice (an animal model of MC) as well as of human individuals were used and exposed to potent ryanodine receptor type 1 (RyR1) activators and increasing K(+) concentration. Muscle force was monitored by a standardized diagnostic method for MH, the so-called in vitro contracture test. RESULTS Neither muscle of ADR mice nor MC muscle (murine and human myotonic muscle) showed pathological contractures after exposure to the potent RyR1 agonists caffeine and halothane. Increasing concentrations of K(+) had a dose-dependent preventive effect on myotonic stiffness. CONCLUSION We conclude that the adverse anaesthetic MH-like episodes observed in MC patients do not primarily originate from an altered Ca(2+) release in skeletal muscle. In MC muscle, this hypermetabolism is facilitated by a (pharmacologically induced) sustained depolarization due to an instable membrane potential. The in vitro results suggest that these patients benefit from tight K(+) monitoring because of the membrane potential stabilizing effect of K(+) .
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Affiliation(s)
| | | | | | - K. JURKAT-ROTT
- Division of Neurophysiology; Ulm University; Ulm; Germany
| | - O. ADOLPH
- Department of Anaesthesiology; Ulm University; Ulm; Germany
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14
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Management of pregnancy with Thomsen's disease. Eur J Obstet Gynecol Reprod Biol 2013; 170:293-4. [PMID: 23806446 DOI: 10.1016/j.ejogrb.2013.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 03/07/2013] [Accepted: 05/19/2013] [Indexed: 11/20/2022]
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Frossard B, Combret C, Benhamou D. [Analgesia for labour and delivery in a parturient with paramytonia congenita]. ACTA ACUST UNITED AC 2013; 32:372-4. [PMID: 23648013 DOI: 10.1016/j.annfar.2013.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 03/25/2013] [Indexed: 11/15/2022]
Abstract
A patient presenting with paramyotonia congenita (Eulenburg's paramyotonia) was seen at the preanaesthetic visit during pregnancy. The underlying disease was known for years. Analysis of the literature and advice taken from specialists emphasized the safe use of regional anaesthesia and analgesia which was indeed used for labour and delivery without any complication. By contrast, the limited information available on the use of general anaesthesia suggests the risks associated with the use of succinylcholine and possibly with halogenated agents. Additional and useful factors that may limit the occurrence of myotonic crises such as maintenance of normal temperature and plasma potassium concentration, should be undertaken simultaneously.
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Affiliation(s)
- B Frossard
- Département d'anesthésie-réanimation, hôpital Bicêtre, hôpitaux universitaires Paris-Sud, 78 rue du Général-Leclerc, Le Kremlin-Bicêtre cedex, France
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Conravey A, Santana-Gould L. Myotonia congenita and myotonic dystrophy: surveillance and management. Curr Treat Options Neurol 2011; 12:16-28. [PMID: 20842486 DOI: 10.1007/s11940-009-0055-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OPINION STATEMENT Myotonia can be treated both pharmacologically and by lifestyle modifications. Cell membrane stabilizers are the medications most commonly used for symptomatic treatment of myotonia. Most patients do not require treatment for the myotonia itself, unless it is severe, but physicians must be aware of anesthesia risks in both myotonia congenita and myotonic dystrophy. A mainstay of management of myotonic dystrophy is the surveillance and treatment of its various systemic complications.
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Affiliation(s)
- Allison Conravey
- Department of Pediatrics, Tulane University, 1430 Tulane Avenue, SL-37, New Orleans, LA, 70112, USA,
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Abstract
PURPOSE OF REVIEW Anaesthesia for a child with a muscle disease is always challenging because there is a risk of malignant hyperthermia, rhabdomyolysis or hypermetabolic reaction if a halogenated agent is used. Ongoing progress in genetics helps in clarifying the link between malignant hyperthermia (a calcium channelopathy) and muscle diseases. RECENT FINDINGS We provide a summary of the most recent clinical, pathophysiological and genetic information on those risks when the diagnosis is known or suspected preoperatively. Some simple clues are also given to help make a decision in the presence of an infant or child with hypotonia or motor delay but no diagnosis. SUMMARY Only a few muscle diseases are really associated with a risk of malignant hyperthermia. The risk of rhabdomyolysis is more difficult to clarify and a multicentric database would be useful to evaluate the risk/benefit ratio of all anaesthetic drugs in patients with muscle diseases.
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Parness J, Bandschapp O, Girard T. The Myotonias and Susceptibility to Malignant Hyperthermia. Anesth Analg 2009; 109:1054-64. [DOI: 10.1213/ane.0b013e3181a7c8e5] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Wakeman B, Babu D, Tarleton J, Macdonald IM. Extraocular muscle hypertrophy in myotonia congenita. J AAPOS 2008; 12:294-6. [PMID: 18313341 DOI: 10.1016/j.jaapos.2007.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Revised: 11/30/2007] [Accepted: 12/06/2007] [Indexed: 11/19/2022]
Abstract
Myotonia congenita (MC) is a rare disorder of skeletal muscle caused by mutations in the CLCN1 gene,(1,2) which encodes the chloride ion channel found in the t-tubule of skeletal muscle. MC is characterized by impaired relaxation of voluntary muscle after sudden contraction that diminishes with muscle activity, known as the "warm-up effect." Individuals with MC can develop muscular hypertrophy despite little physical activity. Esotropia and reduced saccadic velocities have been reported in the dominant form of MC. We report two cases in which orbital magnetic resonance imaging (MRI) imaging showed extraocular muscle hypertrophy.
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Affiliation(s)
- Bradley Wakeman
- Department of Ophthalmology, University of Alberta, Edmonton, Alberta, Canada.
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Wieser T, Kraft B, Kress HG. No carnitine palmitoyltransferase deficiency in skeletal muscle in 18 malignant hyperthermia susceptible individuals. Neuromuscul Disord 2008; 18:471-4. [PMID: 18430572 DOI: 10.1016/j.nmd.2008.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 02/10/2008] [Accepted: 03/14/2008] [Indexed: 11/15/2022]
Abstract
Malignant hyperthermia is a rare, potentially life threatening pharmacogenetic disorder triggered by volatile anaesthetics and depolarizing muscle relaxants. The clinical picture comprises rhabdomyolysis, metabolic and respiratory acidosis, and hyperthermia. Carnitine palmitoyltransferase II deficiency is a metabolic myopathy affecting the transport of fatty acids into the mitochondria, leading to impaired energy supply under stressful conditions resulting in muscle weakness and rhabdomyolysis. It was postulated in a previous study that some patients with the MH phenotype have a carnitine palmitoyltransferase deficiency. To investigate a potential association, we tested 18 individuals with proven MH susceptibility for impairment of carnitine palmitoyltransferase enzyme activity in muscle. Enzyme activity was normal in all individuals tested indicating no impairment of the CPT system in this sample of malignant hyperthermia susceptible individuals. Thus our data do not support the hypothesis that susceptibility to malignant hyperthermia has an effect on the carnitine palmitoyltransferase enzyme system.
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Affiliation(s)
- Thomas Wieser
- Department of Anaesthesia and Pain Management, Medical University of Vienna, Allgemeines Krankenhaus, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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Abstract
Myotonia is a symptom of many different acquired and genetic muscular conditions that impair the relaxation phase of muscular contraction. Myotonia congenita is a specific inherited disorder of muscle membrane hyperexcitability caused by reduced sarcolemmal chloride conductance due to mutations in CLCN1, the gene coding for the main skeletal muscle chloride channel ClC-1. The disorder may be transmitted as either an autosomal-dominant or recessive trait with close to 130 currently known mutations. Although this is a rare disorder, elucidation of the pathophysiology underlying myotonia congenita established the importance of sarcolemmal chloride conductance in the control of muscle excitability and demonstrated the first example of human disease associated with the ClC family of chloride transporting proteins.
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Affiliation(s)
- Christoph Lossin
- Department of Neurology, UC Davis School of Medicine, Sacramento, California 95817
| | - Alfred L George
- Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232
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Farrow C, Carling A. Successful spinal blockade in a parturient with myotonia congenita. Int J Obstet Anesth 2007; 16:89-90. [PMID: 17126000 DOI: 10.1016/j.ijoa.2006.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2006] [Indexed: 11/27/2022]
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Scala D, Di Martino A, Cozzolino S, Mancini A, Bracco A, Andria B, Tammaro A, Savoia G. Follow-up of patients tested for malignant hyperthermia susceptibility. Eur J Anaesthesiol 2006; 23:801-5. [PMID: 16780615 DOI: 10.1017/s0265021506000858] [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] [Accepted: 05/01/2006] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVE Malignant hyperthermia is an inherited disorder of skeletal muscle characterized by muscle contracture and hypermetabolic crisis following exposure to halogenated anaesthetics and depolarizing muscle relaxants. We planned this follow-up to get more information about the safety of non-triggering anaesthesia in susceptible patients; the safety of the use of trigger agents in non-susceptible patients and any minor sequelae following the biopsy. METHODS A questionnaire was sent to 244 patients tested for susceptibility between 1998 and 2004 enquiring about sequelae from the biopsy, subsequent experience with anaesthesia and difficulties encountered because of the investigation. RESULTS Replies were received from 129 patients. Thirty-four complained about sequelae from the biopsy: 10 reported headache and nausea; 16 experienced pain and a lack of strength in the biopsed leg and 8 found the scar less than satisfactory. Ten patients found it difficult to find a diagnostic centre. Eighteen reported problems and/or delay when they had needed a subsequent anaesthetic. Fourteen patients found the anaesthesiologist reluctant to anaesthetize them and four experienced a delay. Forty-three patients received anaesthesia since their biopsy. Complete medical records were available for 24 anaesthetic exposures in 23 patients. No documented perioperative complications occurred. Only three non-susceptible patients received one trigger agent. CONCLUSIONS It is safe to use trigger-free anaesthesia in susceptible patients. The difficulties encountered by patients to be anaesthetized and the management of the majority of non-susceptible patients during general anaesthesia show the need of more accurate educational programmes and methods for promoting patient-centred care.
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Affiliation(s)
- D Scala
- Cardarelli Hospital, Biotechnology Centre, Naples, Italy.
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Chrestian N, Puymirat J, Bouchard JP, Dupré N. Myotonia congenita--a cause of muscle weakness and stiffness. ACTA ACUST UNITED AC 2006; 2:393-9; quiz following 399. [PMID: 16932590 DOI: 10.1038/ncpneuro0239] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Accepted: 04/25/2006] [Indexed: 11/08/2022]
Abstract
BACKGROUND A 56-year-old woman was referred to a neurogenetic clinic with a history of stiffness and transient weakness. A previous needle electromyogram had confirmed the presence of myotonia, but a muscle biopsy had revealed no evidence of dystrophy. INVESTIGATIONS Neurological examination, electrophysiological studies and genetic testing. DIAGNOSIS Recessive myotonia congenita (Becker's disease). MANAGEMENT Explanation of the nature of the disease and treatment with mexiletine 200 mg twice daily.
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Stevens MF, Golla E, Lipfert P. [Intraoperative and postoperative analgesia with a caudal catheter in a child suffering from Schwartz-Jampel syndrome]. Anaesthesist 2006; 55:555-60. [PMID: 16389541 DOI: 10.1007/s00101-005-0967-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The Schwartz-Jampel syndrome, also known as myotonia chondrodystrophica, is a rare autosomal recessive disorder characterized by bone dysplasia, growth retardation and generalized myotonia. Laryngoscopy and intubation may be difficult because of micrognathia and limited mouth opening due to myotonia of the masseter muscles. As regional anaesthesia reduces myotonic contractions and avoids administration of opioids causing respiratory depression, it appears to be the ideal method for postoperative analgesia. We report on a 5-year-old girl who underwent osteotomy of both hips and received intraoperative and postoperative analgesia via a caudal catheter. Excellent analgesia without myoclonic episodes could be achieved by continuous infusion of ropivacaine.
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Affiliation(s)
- M F Stevens
- Klinik für Anästhesiologie, Universitätsklinikum, Düsseldorf, Germany.
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