Presentation on theme: "Malignant Hyperthermia. History History Pathophysiology Pathophysiology Diagnosis Diagnosis Signs and Symptoms Signs and Symptoms Treatment Treatment."— Presentation transcript:
History History Pathophysiology Pathophysiology Diagnosis Diagnosis Signs and Symptoms Signs and Symptoms Treatment Treatment
Malignant Hyperthermia History History –Initially identified in Australia 1961 –Initially very high mortality –Diagnostic testing 1971 –Association with Masseter muscle rigidity 1970 –Dantrolene 1975 –Genetic component identified 1990”s –DNA testing ?
Malignant Hyperthermia Caused by mutation of the sarcolamma ryanodine receptor RyR1 which is coded on chromosome 19 Caused by mutation of the sarcolamma ryanodine receptor RyR1 which is coded on chromosome 19 Responsible for intracellular calcium metabolism Responsible for intracellular calcium metabolism RyR1 receptor RyR1 receptor
Malignant Hyperthermia Incidence Incidence 1/200000 ---- with Succinylcholine 1/65000 1/200000 ---- with Succinylcholine 1/65000 Mortality with treatment 10 % Mortality with treatment 10 % –Poor outcome related to delay in administering Dantrolene and peak temperature
Malignant Hyperthermia 1. 1. MH occurs because of an increase in metabolism due to rapid and uncontrolled increase in calcium within the sarcolema (muscle cells).
Malignant Hyperthermia 2. 2. The increase in calcium level overwhelms the capacity of the muscle cell for active calcium reuptake. 3 3.This results in muscle contraction and increased breakdown of ATP, enhanced glycolysis, uncoupling of oxidative phosphorylation, & activation of actin-myosin filaments yielding significant heat production causing cell damage, and membrane leak.
Malignant Hyperthermia Familial Dominant trait but with incomplete penetrance Familial Dominant trait but with incomplete penetrance Males more common than females Males more common than females May not trigger with first exposure to volatiles May not trigger with first exposure to volatiles Succinylcholine greatly increases risk Succinylcholine greatly increases risk
Diseases Associated with MH King Denborough syndrome Caution in children with delayed motor function Ion channel mutations Myopathic syndromes Duchenne muscular dystrophy Brody’s Disease -deficient calcium, ATP (rhabdomyolysis, not MH) McArdles Diseas -glycogen storage (rhabdomyolysis, not MH) Myotonia congenita Central Core disease
Malignant Hyperthermia Early Signs Early Signs – –Hypercarbia 40% - respiratory acidosis Innappropriate for case setting after considering opioids, ventilator settings, laparoscopic surgery etc If in doubt obtain blood gas – –Tachycardia 30% – –Masseter Spasm 20% – –Hypertension ?
Malignant Hyperthermia Differential Diagnosis Neuroleptic Malignant Syndrome Severe muscle rigidity and elevated temperature associated with the use of antipsychotic medication Thyrotoxic crisis –Thyroid Storm Cocaine toxicity Heat stroke Serotonin syndrome -excessive serotonin usually r/t combining meds Status Epilepticus Pheochromocytoma Lymphoma
Malignant Hyperthermia Treatment Call for assistance Immediately terminate trigger drugs & conclude surgery as soon as possible Hyperventilate with 100% oxygen Initiate active cooling – –Iced saline – –Gastric lavage with iced saline – –Surface cooling
Malignant Hyperthermia Treatment Dantrium®IV-2 mg/kg IV q4-8hrs repeated 24-48hrs or until symptoms resolve ( max 10 mg/Kg ) Dantrium®IV each vial contains – –1. 20 mg dantrolene sodium – –2. 3000 mg mannitol – –3. Sodium Hydroxide to yield a pH – –of approximately 9.5 when – –reconstituted with 60 mL sterile water
Malignant Hyperthermia Treatment Correct metabolic acidosis (NaHCO3 1-2mEq/kg IV based on arterial ph) Maintain urine output Hydration Furosemide ( 1mg/ kg ) Treat hyperkalemia – glucose + insulin Treatment of arrythmias Avoid Ca channel blockers – myocardial depression
Malignant Hyperthermia Key Patient Stability Indicators ETCO 2 is declining or normal ETCO 2 is declining or normal HR is stable or decreasing HR is stable or decreasing No ominous dysrhythmias No ominous dysrhythmias Temperature is declining Temperature is declining Generalized muscular rigidity is resolving (if present) Generalized muscular rigidity is resolving (if present) IV dantrolene administration has begun IV dantrolene administration has begun
Malignant Hyperthermia What is Dantrolene ? Dantium ( Dantrolene ) Dantium ( Dantrolene ) –Skeletal muscle relaxant by inhibiting sarcoplasmic release of calcium –Half life 4-8 hrs metabolized by liver –Causes generalized muscle weaknes –No cardiac effects –No effect on train of four
Management of MH Susceptible Patients Preparation of anaesthesia machine Preparation of anaesthesia machine –Fresh circuit, absorber flushed at 10 lpm x 10 min –Triggers disconnected from circuit and out of room Non triggering anaesthetic Non triggering anaesthetic –Propofol, ketamine, N2O,narcotics –Regional techniques PACU PACU –Extended stay –Observe 2-4 hours prior to discharge