Malignant Hyperthermia during Desflurane - Succinylcholine Anesthesia for Neurosurgery: A case report

摘要

Desflurane has been known as a weak triggering anesthetic of malignant hyperthermia (MH). It may produce a delayed onset of symptoms. In addition the use of succinylcholine may aggravate occurrence of MH. The prolonged interval after exposure may occur more than 3 h after the induction of anesthesia. Although, the treatment of MH with Dantrolene is gold standard, it is not available in most countries. Because, MH has been rarely reported all over the world. So we present the first MH suspected case in our hospital. Introduction Malignant hyperthermia (MH), an anesthetic related disorder of skeletal muscle calcium regulation, is triggered by succinylcholine and volatile anesthetics. It is characterized by hypercarbia, hyperthermia, tachycardia, acidosis, and muscle rigidity (1, 2). The common use of desflurane anesthesia all over the world has changed the clinical presentation of malignant hyperthermia.We describe a case of suspected MH in adult patient in whom succinylcholine and desflurane were the only MH triggering drugs administered. Case Description A 49-yr-old female patient, 80 kg, ASA physical status II, was scheduled for total cervical laminectomy. There was no known family history of malignant hyperthermia or muscle disease. So far, the woman was healthy and had already been anesthetized for major surgery twice (lumbar laminectomy, hepatic hydatic cyst) without any problem.One hour after premeditation with 0.07 mg midazolam intramuscularly (IM). After breathing 100% oxygen, anesthesia was induced with fentanyl (2 μg/kg), propofol (2 mg/kg), and succinylcholine (1 mg/kg) intravenously. The trachea was intubated (spirally endotracheal tube), and controlled ventilation was initiated using a circle anesthesia system with a soda lime CO2, absorber. Anesthesia was maintained with O2, air, desflurane (4.5%–6%), and intermittent boluses of fentanyl and rocuronium. In addition to standard monitoring, an arterial line (radial artery) and a central venous catheter (internal jugular vein) were inserted. A Foley catheter was introduced to measure urine output. Baseline heart rate was 68 bpm, peripheral oxygen saturation (SaO2,) 98%, end-tidal CO, (etC02,) 29 mm Hg, and skin temperature 36.4°C. The patient was then turned into prone position to perform the cervical release.Three hours after the induction, severe hypercarbia developed, with an increase in end-tidal CO2 to 79 mm Hg. Firstly we checked the tracheal tube and osculated the lungs. The patient began profusely sweating, his axillary temperature reached 39.6°C, and (we could not notice the muscle rigidity because of prone position). Twenty minutes after the first symptoms, a severe respiratory acidosis was diagnosed, with arterial pH 7.11, PaCO2 74 mm Hg, PaO2 100 mm Hg, and base excess 6.7 mEq/L. Fresh gas flow was increased to 8 L/min. We suspected the patient had malignant hyperthermia (MH).Desflurane was turned off, and hypnosis was maintained by propofol. We warned to neurosurgeon to finish (completed) the operation as soon as possible. Fresh gas flow was adjusted to 10 L/min. Soda lime and tubes of the ventilation system were replaced. Hypercarbia could not be sufficiently corrected by hyperventilation. The patient became more and more hemodynamically unstable. Tachycardia up to 150 bpm, ST segment alterations. At this time, body temperature was 40,2°C.Dantrolene is not generally available in Turkey, because MH occurs very rarely heard of in Turkish patients. Although we could not give dantrolene, we instituted the following measures: a) discontinued the triggering anesthetic (desflurane) and operation immediately; b) initiated a non-triggering anesthetic (propofol infusion at 20-30 mg/h); c) provided 100% oxygen; d) exchanged the entire anesthetic circuit; e) increased the fresh gas flow rate to 10 L/min to prevent re-breathing; f) measured the esophageal temperature; g) began aggressive cooling (ice packs and cooling); i) administered sodium bicarbonate as indicate