Saw a case of Malignant Hyperthermia

[Analyzethis]

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So I am doing an anesthesia elective right now as a 4th year student-not going into the field but I had a case of malignant hyperthermia today and even the attending said in 7 years he had never seen one and had to call in 2 other attendings-it was quite the big deal. It was crazy-it was during a pretty long gyn-onc case and they had to tell the surgeons to close in the middle of theprocedure

WHat was odd-is it happened about 3 hours into the surgery and I know about 90 percent occur within the first 45 minutes or so. But was very interesting to see it managed. Anyway thought it was kind of a cool thing to see since it is quite rare-something like 1/4000 or something isnt it?

 

[Noyac]

So why don't you give us your best recollection of how they managed it.👍

 

[jetproppilot]

So why don't you give us your best recollection of how they managed it.👍

Yes.

I've had one MH (kid) in ten years.

 

[militarymd]

I must not be living right.....3 cases that triggered in the OR.

 

[jwk]

27 years - nada.

 

[Noyac]

9yrs and not one case.

 

[TIVA]

3 years, zip.

 

[Lizard1]

3 years, zip.

well that's because all you do are TIVA's! 😀

 

[deleted87051]

13 years, no cases.

These folks are not so lucky...

http://www.apsf.org/resource_center/newsletter/2006/summer/malignant.html

 

[VolatileAgent]

good resource:

http://www.mhaus.org/

we (fairly) routinely get "mh precautions" cases here at penn state. i've had 5-6 already in my short career, but never a trigger. they have run the gamut from peds with known family members, ortho trauma, to ob cases.

marilyn larach, one of our attendings, is a world opinion leader and actually established mhaus. she is still actively involved in research and patient/physician education.

 

[cchoukal]

Had a patient with history of neuroleptic malignant syndrome for B/L staged THA. There's some discussion in the literature whether MH and NMS share a common pathophysiology and, therefore whether a h/o one increases the risk for the other. We managed her with spinal and propofol, but went through the MH risk protocol of changing out the machine, removing vaporizers, changing the CO2 absorber and running high flow O2 for 30 minutes. She did fine, but, again, this may all have been unnecessary as no one really knows if pts with NMS are at risk for MH. I'd be curious to hear how the OPs case was managed.

 

[VolatileAgent]

There's some discussion in the literature whether MH and NMS share a common pathophysiology and, therefore whether a h/o one increases the risk for the other.

they don't and there isn't. and there are no longer any questions/controversy about whether there is.

http://neuro.psychiatryonline.org/c...ndrome"+"malignant hyperthermia" correlation"

She did fine, but, again, this may all have been unnecessary as no one really knows if pts with NMS are at risk for MH.

it was unnecessary because they aren't.

 

[cchoukal]

they don't and there isn't. and there are no longer any questions/controversy about whether there is.

http://neuro.psychiatryonline.org/c...ndrome"+"malignant hyperthermia" correlation"



it was unnecessary because they aren't.

I'm not in the habit of making such bold pronouncements based on single articles, even though the decade-old review you cite is authored by folks who have published extensively in the area. The epidemiological work cited by these authors does not find an increased risk of MH among sufferers of NMS. A more recent review discussed small case series of NMS patients undergoing muscle fiber testing for susceptibility to MH, and some of these series showed an association.

You may be correct, but I don't think it's as open and shut as your curt post implied.

Adnet et al, Neuroleptic Malignant Syndrom, BJA 2000 vol 85:1 129-135.

I'm less interested in high-jacking this post than in hearing how the OPs case turned out, so let's have it, OP!

 

[VolatileAgent]

well, i only quoted one study, but there is a body of information that refutes your premise. but, if you are suggesting that because the data i cited shows they are distinct disease entities is older than what you referenced (which also is not readily available online for comment) it is therefore inferior, i would subsequently suggest you peruse the following abstracts.

this study, from 2001, states that dantrolene - the mainstay of effective treatment in MH - is "meritless" in nms.

http://www.ncbi.nlm.nih.gov/entrez/...uids=11525080&query_hl=15&itool=pubmed_DocSum

this, from 2002, clearly states that - although they appear to be similar clinical entities - they do not possess the same pathophysiology:

http://www.ncbi.nlm.nih.gov/entrez/..._uids=12151905&query_hl=8&itool=pubmed_DocSum

not a hijack or sidetrack, but an important concept to understand. i hope this more-than-curt response satisfies you.

 

[VolatileAgent]

p.s. the only thing you need to be SURE to do if you have an NMS patient coming to the O.R. is avoid most of the triggering anti-emetic drugs. if you give an nms patient a volatile and then follow that up with phenergan, you're going to mistakenly believe that your volatile triggered that event.

 

[Noyac]

I agree, its been well documented that there is no relation. It is a totally different pathway of triggering the NMS as opposed to MH.

If there are cases of pts with NMS who have triggered MH then I would wager that it is really bad luck on the pts part since they have both although, still unrelated. However, i am not aware of any cases of of pts or family members of pt with NMS having MH as well.

MH is a Ca+ release problem in the terminal cisternae.

NMS is believed to be due to a dopamine depletion in the CNS. THerefore, treated with dopamine agonists.

 

[Noyac]

p.s. the only thing you need to be SURE to do if you have an NMS patient coming to the O.R. is avoid most of the triggering anti-emetic drugs. if you give an nms patient a volatile and then follow that up with phenergan, you're going to mistakenly believe that your volatile triggered that event.

While this may be true, Volatile. NMS has a slow onset usually over 2 weeks. I find it hard to believe that one dose of droperidol or phenergan can cause NMS but I guess anything is possible depending on the when it is given.

 

[VentdependenT]

While this may be true, Volatile. NMS has a slow onset usually over 2 weeks. I find it hard to believe that one dose of droperidol or phenergan can cause NMS but I guess anything is possible depending on the when it is given.

Happened to my Fiance's patient. SHes an obgyn and had ordered compazine for a patient during the morning. That night (maybe after the patients 3rd dose or something like that) pt became febrile and had mental status changes. Took em a little while to figure it out but everything worked out ok.

No hx of allergies.

 

[supahfresh]

15 months and no MH!

 

[Noyac]

Happened to my Fiance's patient. SHes an obgyn and had ordered compazine for a patient during the morning. That night (maybe after the patients 3rd dose or something like that) pt became febrile and had mental status changes. Took em a little while to figure it out but everything worked out ok.

No hx of allergies.

Yeah, thats what I mean. It takes more than one dose as far as I can tell. I'll bet it took the OB service a while to figure out what was going on. Did the pt have torticollis(?)? How sure are they that it was NMS?

 

[Noyac]

Happened to my Fiance's patient. SHes an obgyn and had ordered compazine for a patient during the morning. That night (maybe after the patients 3rd dose or something like that) pt became febrile and had mental status changes. Took em a little while to figure it out but everything worked out ok.

No hx of allergies.

Yeah, thats what I mean. It takes more than one dose as far as I can tell. I'll bet it took the OB service a while to figure out what was going on. Did the pt have torticollis(?)? How sure are they that it was NMS?