Malignant Hyperthermia

[PoorInvestment]

I know there's some old threads on this but saw an honest-to-Jeebus case today. 43(!) yo male post off-pump CABG got tachy into the 140s, mottled as hell, pressure sank, and temps up to 104. Crazy stuff. Lots and lots and lots and lots of the orange stuff (Dantrolene) to even touch him. Anyone else been through this.....pretty dang cool.

Best health,
PI

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[Gern Blansten]

I know there's some old threads on this but saw an honest-to-Jeebus case today. 43(!) yo male post off-pump CABG got tachy into the 140s, mottled as hell, pressure sank, and temps up to 104. Crazy stuff. Lots and lots and lots and lots of the orange stuff (Dantrolene) to even touch him. Anyone else been through this.....pretty dang cool.

Best health,
PI

Very interesting case. Tell us more details. How far into the case were they when it was recognized? Case cancelled or was it an emergent case(ie critical left main disease etc)? Pretty sticky spot that would be if you have a pt with tight left main and now tachycardic and hyperthermic, increasing his metabolic demand. What would be the best way to proceed in that situation? If you cancel, the patient may infarct and die before the MH is controlled. If you keep going with surgery, the pt is at risk as well(even with switching to a non trig. anesthetic). I guess if he was cannulated already, the perfusionist could help with the cooling?? I will be interested to hear more details if you have them.

 

[Ferdie]

Very interesting case. Tell us more details. How far into the case were they when it was recognized? Case cancelled or was it an emergent case(ie critical left main disease etc)? Pretty sticky spot that would be if you have a pt with tight left main and now tachycardic and hyperthermic, increasing his metabolic demand. What would be the best way to proceed in that situation? If you cancel, the patient may infarct and die before the MH is controlled. If you keep going with surgery, the pt is at risk as well(even with switching to a non trig. anesthetic). I guess if he was cannulated already, the perfusionist could help with the cooling?? I will be interested to hear more details if you have them.

if you did continue, would you have to switch out the entire machine and the tubing during the case? I'm guessing you wouldn't want to switch the ET though, since there wouldn't be much volume of volatile in there anyway, and to try to re-intubate could stimulate him more - increasing metabolic demand further (and you wouldn't want to lose the airway in that situation, of course)

 

[Planktonmd]

I know there's some old threads on this but saw an honest-to-Jeebus case today. 43(!) yo male post off-pump CABG got tachy into the 140s, mottled as hell, pressure sank, and temps up to 104. Crazy stuff. Lots and lots and lots and lots of the orange stuff (Dantrolene) to even touch him. Anyone else been through this.....pretty dang cool.

Best health,
PI

So, the patient had Fever + Hypotension + Tachycardia + Mottled skin after an off pump CABG:
Any other symptoms that made people think of MH?
Could that have been a reaction to some medication?
Could it have been bacteremia secondary to unrecognized UTI?
Was any blood given? Could it have been a tranfusion reaction?
What was the CPK?
How about the blood gases?

 

[Gas]

According to MHAUS, you do not need to change the circle system or CO2 absorbent. Great case though.

 

[PoorInvestment]

Very interesting case. Tell us more details. How far into the case were they when it was recognized? Case cancelled or was it an emergent case(ie critical left main disease etc)? Pretty sticky spot that would be if you have a pt with tight left main and now tachycardic and hyperthermic, increasing his metabolic demand. What would be the best way to proceed in that situation? If you cancel, the patient may infarct and die before the MH is controlled. If you keep going with surgery, the pt is at risk as well(even with switching to a non trig. anesthetic). I guess if he was cannulated already, the perfusionist could help with the cooling?? I will be interested to hear more details if you have them.

Good questions, all. I'll tackle this group first, then I'll get plankton.
-Weird thing, it was post op so the presentation was delayed. Not 'classic' but not unheard of. Tried to sort a lot of stuff out. He came up to the ICU (small hospital, we don't have separate ICUs) looking very mottled and with poor urine output. Urine starts a-flowin and looks like cherry Kool-aid. About this same time we see the temp starting to climb from the temp probe on his Swan-Ganz. Creeping up bit by bit. EKG wouldn't read because when the guy would breathe he got these crazy tonic style jerks in his chest wall that produced messed-up artifacts.
-Plankton-good thoughts man, here's what I've got.
-No other specific symptoms I haven't mentioned but the intesivist was having to think way to hard for alternatives so we went forward with the diagnosis of MH.
-Bacteremia from UTI - UA came back clear but nitrite couldn't be measured because the urine was so funky red
-Only blood in this dude came from cell saver.
-CPK was only 350 some - one strike against MH
-Blood gas showed pH=7.2 with CO2 of 57
-We started the dantrolene and the tachycardia resolved rapidly and the urine cleared. Unfortunately, due to lab error, we couldn't get a urine myoglobin until after his urine cleared.

What do ya'll think? Was this real MH or something else? Just a med student but I thought the whole thing was fascinating.

Best health,
PI

 

[GasEmDee]

So, the patient had Fever + Hypotension + Tachycardia + Mottled skin after an off pump CABG:
Any other symptoms that made people think of MH?
Could that have been a reaction to some medication?
Could it have been bacteremia secondary to unrecognized UTI?
Was any blood given? Could it have been a tranfusion reaction?
What was the CPK?
How about the blood gases?

thyrotoxicosis can also manifest similar symptoms, but more classically appears in the post-operative setting rather than intraoperatively.

 

[urge]

I'm not convinced. What was the K? What was the bicarb? What was the highest temp? Was he stiff? What was the mixed venous? Was he well ventilated?

Are you guys recommending a biopsy?

 

[PoorInvestment]

I'm not convinced. What was the K? What was the bicarb? What was the highest temp? Was he stiff? What was the mixed venous? Was he well ventilated?

Are you guys recommending a biopsy?

-K was about 6
-Can't remember bicarb off the top of my head
-Highest temp was 104ish
-No appreciable degree of stiffness, but some muscle twitches
-Don't know mixed venous
-Ventilated like a rock star

-The trouble is his was a late onset case, which from what I've read can make diagnosis difficult. Rigidity isn't always prominent, the fevers may not go as high, etc.

 

[cfdavid]

Hey, is it understood why GA (specifically Halothane?) causes this flux of Ca2+ ions across the SR?? I'm assuming it interacts with the ryanodine receptor and it seems that there's been a ryanodine receptor mutation identified that may make certain individuals more susceptible to malignant hyperthermia.

Also, how common is propofol induced central anti-muscarinic syndrome?

I'm asking, cause we went over this in somewhat of a cursory manner in pharm recently.

 

[Gern Blansten]

Hey, is it understood why GA (specifically Halothane?) causes this flux of Ca2+ ions across the SR?? I'm assuming it interacts with the ryanodine receptor and it seems that there's been a ryanodine receptor mutation identified that may make certain individuals more susceptible to malignant hyperthermia.

Also, how common is propofol induced central anti-muscarinic syndrome?

I'm asking, cause we went over this in somewhat of a cursory manner in pharm recently.

Try this site for more info:

http://www.mhaus.org/