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Management of patients susceptible to malignant hyperthermia: A surgeon's perspective. Int J Pediatr Otorhinolaryngol 2022; 159:111187. [PMID: 35660936 DOI: 10.1016/j.ijporl.2022.111187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 03/28/2022] [Accepted: 05/21/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Malignant hyperthermia (MH) susceptibility caries broad implications for the care of pediatric surgical patients. While precautions must often be taken for only a vague family history, two options exist to assess MH-susceptibility. We evaluate the use of MH precautions and susceptibility testing at a freestanding children's hospital. METHODS This single institution retrospective cohort study identified patients of any age who received general anesthetics utilizing MH precautions over a five-year period. The electronic medical record was further queried for patients diagnosed with MH. The indication for MH precautions and uses of susceptibility testing are assessed. Secondary outcomes included a diagnosis of bona fide MH. RESULTS A total of 125 patients received 174 anesthetics with MH precautions at a mean age of 114 months (0-363 months). Otolaryngology was the procedural service most frequently involved in the care of the cohort (n = 45; 26%). A reported personal or family history of MH (n = 102; 59%) was the most common indication for precautions, followed by muscular dystrophy (n = 29; 17%). No MH events occurred in the cohort and further review of ICD-9 and -10 diagnosis codes found no MH diagnoses. No study subjects received muscle biopsy and contracture testing and only 5 (4%) underwent genetic testing for genomic variants known to cause MH susceptibility. A case example is given to highlight the implications of a reported MH history. CONCLUSION Otolaryngologists should maintain a familiarity with the precautions necessary to manage patients at risk for MH and MH-like reactions. Without an accessible test to rule out susceptibility, surgeons must rely on a careful history to appropriately utilize precautions. An inappropriate label of "MH-susceptible" may result in decreased access to care and treatment delays.
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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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Abstract
This review identifies disease states associated with malignant hyperthermia susceptibility based on genotypic and phenotypic findings, and a framework is established for clinicians to identify a potentially malignant hyperthermia–susceptible patient.
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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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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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Al-Takrouri H, Martin TW, Mayhew JF. Hyperkalemic cardiac arrest following succinylcholine administration: The use of extracorporeal membrane oxygenation in an emergency situation. J Clin Anesth 2005; 16:449-51. [PMID: 15567650 DOI: 10.1016/j.jclinane.2003.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2003] [Revised: 09/29/2003] [Accepted: 09/29/2003] [Indexed: 11/29/2022]
Abstract
We report an 11-year-old male with undiagnosed myopathy, who developed cardiac arrest secondary to severe rhabdomyolysis and hyperkalemia following succinylcholine administration. The patient required extracorporeal membrane oxygenation support from which he was eventually weaned successfully. He died eleven days after the cardiac arrest as a result of apparent ischemic brain injury.
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Affiliation(s)
- Hatem Al-Takrouri
- Arkansas Children's Hospital, Division of Pediatric Anesthesia and Pain Management, Little Rock, AK 72202-3591, USA
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Schmidt GN, Burmeister MA, Lilje C, Wappler F, Bischoff P. Acute heart failure during spinal surgery in a boy with Duchenne muscular dystrophy. Br J Anaesth 2003; 90:800-4. [PMID: 12765898 DOI: 10.1093/bja/aeg116] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Patients with Duchenne muscular dystrophy (DMD) are at high risk of perioperative complications. DMD may be accompanied by heart failure resulting from dystrophic involvement of the myocardium, which can be subclinical in the early stages of the disease. This case demonstrates that a normal preoperative ECG and echocardiograph cannot exclude the development of heart failure during anaesthesia in DMD patients undergoing major surgery.
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Affiliation(s)
- G N Schmidt
- Department of Anaesthesiology, University Hospital Eppendorf, Hamburg, Germany.
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12
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Obata R, Yasumi Y, Suzuki A, Nakajima Y, Sato S. Rhabdomyolysis in association with Duchenne's muscular dystrophy. Can J Anaesth 1999; 46:564-6. [PMID: 10391604 DOI: 10.1007/bf03013547] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To present a case of rhabdomyolysis which developed in a child with a known history of Duchenne's muscular dystrophy, following an anesthetic which included sevoflurane. CLINICAL FEATURES An 11 yr old boy with a known history of Duchenne's muscular dystrophy underwent anesthesia for strabismus repair. The anesthetic consisted of sevoflurane and nitrous oxide without the use of a muscle relaxant. His postoperative course was complicated by a complaint of heel pain and the development of myoglobinuria. He was treated with dantrolene sodium and discharged home after two days, without further complication. CONCLUSION Sevoflurane anesthesia has not been shown previously to be associated with the development of acute rhabdomyolysis in a child with a history of Duchenne's muscular dystrophy. As with halothane and isoflurane, the continued use of sevoflurane in the presence of Duchenne's muscular dystrophy should be questioned.
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Affiliation(s)
- R Obata
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Japan
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Affiliation(s)
- K A Medina
- Department of Anesthesiology, University of Texas Medical Branch, Galveston 77555-0591, USA
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Warner LO, Reiner CB, Beach TP. Cardiac arrest on the day following surgery in children with unrecognized rhabdomyolysis. J Clin Anesth 1997; 9:501-6. [PMID: 9278841 DOI: 10.1016/s0952-8180(97)00109-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We present tow male children who experienced cardiac arrest secondary to unrecognized rhabdomyolysis on the day following an uneventful general anesthetic and recovery room course for adenotonsillectomy. Neither child exhibited hypermetabolism typical of malignant hyperthermia or appeared to have a dystrophinophy, prompting the authors to search for other etiologies of childhood rhabdomyolysis infrequently associated with anesthesia. In this report, we review the heritable metabolic myopathies caused by enzyme deficiencies (enzymopathies) that can lead to life-threatening rhabdomyolysis following certain triggering conditions, and we offer suggestions for avoiding these triggers in the perianesthetic period. We also describe key symptoms an signs that postanesthetic caregivers should be aware of, and briefly comment on follow-up diagnostic studies.
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Affiliation(s)
- L O Warner
- Department of Anesthesiology, Columbus Children's Hospital, OH, USA
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Pedrozzi NE, Ramelli GP, Tomasetti R, Nobile-Buetti L, Bianchetti MG. Rhabdomyolysis and anesthesia: a report of two cases and review of the literature. Pediatr Neurol 1996; 15:254-7. [PMID: 8916167 DOI: 10.1016/s0887-8994(96)00171-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Rhabdomyolysis occurred in two apparently healthy boys aged 9.5 and 5.5 years after general anesthesia with suxamethonium. Mild hyperkalemia and renal failure were observed in the first patient, who was subsequently diagnosed with Becker dystrophy. In the second patient, the clinical presentation was not classic for malignant hyperthermia and a muscle biopsy failed to disclose any pathological finding. A review of the literature revealed 66 pediatric cases (56 boys and 10 girls) of anesthesia-associated rhabdomyolysis. Forty-nine (74%) cases were caused by an underlying, mostly unrecognized congenital muscle disease, and 14 (21%) cases were caused by malignant hyperthermia susceptibility. Hyperkalemia (23 patients), cardiac arrhythmias (38 patients), renal failure (4 patients), and death (11 patients) were the most serious complications of anesthesia-associated rhabdomyolysis. The neuromuscular blocking agent suxamethonium had been used in at least 43 of the patients reported in the literature.
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Affiliation(s)
- N E Pedrozzi
- Department of Pediatrics, Ospedale San Giovanni, Bellinzona, Switzerland
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Affiliation(s)
- A M Cone
- Department of Anaesthesia, Southampton General Hospital, United Kingdom
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Friedman S, Baker T, Gatti M, Simon G, Paskin S. Probable succinylcholine-induced rhabdomyolysis in a male athlete. Anesth Analg 1995; 81:422-3. [PMID: 7618742 DOI: 10.1097/00000539-199508000-00040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- S Friedman
- Department of Anesthesiology, Monmouth Medical Center, Long Branch, NJ 07740-6395, USA
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Friedman S, Baker T, Gatti M, Simon G, Paskin S. Probable Succinylcholine-Induced Rhabdomyolysis in a Male Athlete. Anesth Analg 1995. [DOI: 10.1213/00000539-199508000-00040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Farrell PT. Anaesthesia-induced rhabdomyolysis causing cardiac arrest: case report and review of anaesthesia and the dystrophinopathies. Anaesth Intensive Care 1994; 22:597-601. [PMID: 7818067 DOI: 10.1177/0310057x9402200518] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Gronert GA, Fowler W, Cardinet GH, Grix A, Ellis WG, Schwartz MZ. Absence of malignant hyperthermia contractures in Becker-Duchenne dystrophy at age 2. Muscle Nerve 1992; 15:52-6. [PMID: 1732762 DOI: 10.1002/mus.880150110] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Two 2-year-old males underwent muscle biopsy that established the histopathologic diagnosis of Becker dystrophy in one, and Duchenne dystrophy in the other. Concomitant contracture testing with caffeine or halothane was normal for malignant hyperthermia (MH). The results suggest that acute hypermetabolism or acute rhabdomyolysis during anesthesia, in patients with these disorders, is related to the X-linked myopathy and its associated muscle deterioration, rather than to the autosomal dominant MH.
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Affiliation(s)
- G A Gronert
- Department of Anesthesiology, University of California, Davis 95616
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Abstract
Rhabdomyolysis during routine surgery was studied in three groups of patients who had surgery, with limited trauma to muscle, in the lateral and supine positions, and prone on the spinal frame. A range of blood tests was performed (before surgery, and on the first, third and seventh day after operation). These showed that a creatine kinase increase in the 24 hours and the early appearance of myoglobin in the serum were the best indicators. Rhabdomyolysis was associated with the lateral position and long lasting surgery. No blood test before surgery was of any predictive value.
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Affiliation(s)
- L Targa
- Servizio Anestesia-Analgesia-Rianimazione U.S.L. 31-Ferrara, Università degli Studi di Ferrara, Italy
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Bush A, Dubowitz V. Fatal rhabdomyolysis complicating general anaesthesia in a child with Becker muscular dystrophy. Neuromuscul Disord 1991; 1:201-4. [PMID: 1822795 DOI: 10.1016/0960-8966(91)90025-n] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A 6-yr-old boy who presented with brown urine due to myoglobinuria and who was otherwise virtually asymptomatic was diagnosed as having Becker muscular dystrophy on the basis of a greatly elevated creatine kinase, muscle biopsy, dystrophin analysis, and a deletion of exons 3-7 in the dystrophin gene. Fifteen months later, during a general anaesthetic for dental treatment, he had a cardiac arrest associated with acute rhabdomyolysis, hyperkalaemia and hypocalcaemia. He died 4 days later. This case is reported to highlight this rare but potentially fatal complication of anaesthesia in muscular dystrophy, and to discuss possible ways of preventing such a catastrophe.
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Affiliation(s)
- A Bush
- Department of Paediatrics and Neonatal Medicine, Royal Postgraduate Medical School, London, U.K
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Tanigaki T, Kondo T, Ohta Y, Yamabayashi H. Transient neuromuscular impairment resulting from prolonged inhalation of halothane and enflurane. Chest 1990; 98:1012-3. [PMID: 2145134 DOI: 10.1378/chest.98.4.1012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Inhalation anesthesia first with halothane followed by enflurane relieved a patient with status asthmaticus who was refractory to conventional therapy including mechanical ventilation. After 13 days of anesthesia while on mechanical ventilation and employing nondepolarizing muscle relaxants, significant neuromuscular impairment, manifested by tetraplegia and sensory disturbance, developed. Anesthesia was discontinued on day 14, and the patient was weaned from mechanical ventilation on day 16. Over the next two months, the neuromuscular impairment markedly improved. Halothane was associated with cardiac arrhythmias and hepatitis necessitating replacement by enflurane. Enflurane appeared to be as effective a treatment for refractory asthma as halothane. The most probable cause of the neuromuscular impairment in our patient was the long-term use of inhalation anesthetics or nondepolarizing muscle relaxants.
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Affiliation(s)
- T Tanigaki
- Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
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Abstract
Severe rhabdomyolysis complicated by respiratory and renal failure developed three weeks after initiation of low dose lovastatin therapy in a 79 year old, non-immunocompromised patient. The concomitant use of gemfibrozil may increase the risk of this complication.
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Affiliation(s)
- A D Kogan
- Department of Medicine, Loyola University, Evanston 60202
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