Successful treatment of an episode of malignant hyperthermia using a large dose of dantrolene

doi:10.1016/0952-8180(93)90092-S

Journal of Clinical Anesthesia

Volume 5, Issue 1, January–February 1993, Pages 69-72

https://doi.org/10.1016/0952-8180(93)90092-S Get rights and content

Abstract

This clinical case report describes the use of extremely high doses of dantrolene in the management of an episode of malignant hyperthermia (MH). A 6-year-old, 25 kg girl underwent anesthetic induction with halothane for an elective inguinal herniorrhaphy. Tachydysrhythmias, laryngospasm, opisthotonos, rhabdomyolysis, and profound metabolic acidosis ensued as features of an MH crisis. Initial dantrolene administration did not alleviate the symptoms. Increasing doses of dantrolene eventually totaling 42 mglkg, along with symptomatic supportive care, were administered successfully to treat the event. It is postulated that the severe muscle rigidity may have precluded the circulation of dantrolene to its site of action. The role of the Malignant Hyperthermia Association of the United States (MHAUS) Hotline as a 24-hour consultative service is noted.

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Cited by (16)

Clinical protocol for the management of malignant hyperthermia
2017, Revista Espanola de Anestesiologia y Reanimacion
La hipertermia maligna es un síndrome hipermetabólico que ocurre en pacientes susceptibles, tras la exposición a un fármaco anestésico desencadenante (succinilcolina, anestésicos inhalatorios). En España, se presenta en uno de cada 40.000 en adultos, con una mortalidad estimada del 10%. Está inducido por una regulación anormal de los receptores de rianodina, que produce una liberación masiva del calcio del retículo sarcoplasmático del músculo. Las manifestaciones clínicas son variadas y consisten en: elevación del CO₂, taquicardia e inestabilidad hemodinámica, acidosis metabólica y respiratoria, sudoración profusa, hiperpirexia, elevación de CPK, mioglobinuria, fallo renal, CID y finalmente parada cardiorrespiratoria. El tratamiento con dantroleno sódico inhibe la liberación de calcio al antagonizar los receptores de rianodina. El diagnóstico definitivo se realiza con el test de contracción de fibra muscular expuesta a cafeína y halotano.
Ante este grave evento la protocolización del manejo ayuda a garantizar que el paciente reciba una atención fiable y segura.
Malignant hyperthermia is a hypermetabolic syndrome that appears in susceptible patients after exposure to certain anaesthetic drugs (succinylcholine, inhalation anaesthetics). Its incidence in Spain is 1 in 40,000 adults, with a 10% mortality rate. It is induced by an abnormal regulation of the ryanodine receptors, producing a massive release of calcium from the sarcoplasmic reticulum in the striate muscle. Clinical manifestations include: CO₂ increase, tachycardia, haemodynamic instability, metabolic and respiratory acidosis, profuse sweating, hyperpyrexia, CPK increase, myoglobinuria, kidney failure, disseminated intravascular coagulation (DIC), and ending in cardiac arrest. Dantrolene sodium is a ryanodine receptor antagonist, and inhibits the release of intracellular calcium. Definitive diagnosis is achieved by the exposure of muscle fibres to caffeine and halothane.
Protocols can help guarantee a reliable and secure management when this severe event occurs.
Is There an Ideal Approach to the Patient Susceptible to Malignant Hyperthermia?
2013, Evidence-Based Practice of Anesthesiology
Emergencies in parkinsonism: akinetic crisis, life-threatening dyskinesias, and polyneuropathy during L-Dopa gel treatment
2009, Parkinsonism and Related Disorders
Citation Excerpt :
A 15% death rate was observed in patients treated with apomorphine, and similar rates are described in NMLS or in NMS [2,19]. For all these critical conditions there is not any validated evidence that treatments (bromocriptine [20], dantriolene [20,21], steroids [22], apomorphine [23], amantadine [9–11,14]) are suggested to modify the critical course. The reader is invited to access the original cohort study [4] as detailed descriptions of single cases are available from the web site of the journal, and further information can be obtained on L-Dopa kinetics during the crisis, occurrence of disseminated intravascular coagulation, disappearance of dyskinesias during the crisis despite vigorous dopaminomimetic treatment.
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Akinetic crisis is also known as Parkinsonian hyperpyrexia, Neuroleptic-like malignant syndrome, Acute akinesia, and Malignant syndrome in parkinsonism. It appears in 0.3% of PD patients/year, and is characterized in the most severe cases by total akinesia with dysphagia, hyperthermia, dysautonomia, increment of muscle enzymes and alterations of mental status, but it may also appear in less severe forms (“forme frusta”). At difference with the continuum of motor hypokinesias observed in PD it is characterized by transient (in cases with favorable outcome) unresponsiveness to rescue drugs. Life-supporting measures are mandatory in patients affected by this emergency.
Severe dyskinesia, or life-threatening dyskinesia, is due to increased dopaminergic stimulation (either by the patient or by the prescriber): when it appears the level of dopaminomimetic stimulation should be reduced.
Polyneuropathy during duodenal L-Dopa gel infusion is a recently described complication, attributed to the onset of Guillain–Barré syndromes. However, hemapheresis was not effective in some reported cases, and recent evidence suggests that Vitamin B12 deficiency or direct high-dose chronic L-Dopa toxicity might play a role in its origin.
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2009, Evidence-Based Practice of Anesthesiology
Malignant syndrome in Parkinson's disease: Concept and review of the literature
2003, Parkinsonism and Related Disorders
We reviewed literature on malignant syndrome occurring in patients with Parkinson's disease (PD) during the course of drug therapy. Clinical features were high fever, marked rigidity, consciousness disturbance, autonomic dysfunction, and elevation of serum creatine kinase. The clinical features were essentially similar to those of neuroleptic malignant syndrome. The immediate triggering event was, most often, discontinuation or reduction of anti-parkinsonian drugs, particularly of levodopa. But no anti-parkinsonian drug was the exception to the induction of malignant syndrome. Serious complications were severe pneumonia, disseminated intravascular coagulation, and acute renal failure. Early treatment with intravenous fluid infusion and external body cooling are essential for good recovery. Bromocriptine and dantrolene sodium were used frequently. It has been claimed that they are effective; however, randomized controlled studies are needed to explicitly prove the efficacy of these drugs in malignant syndrome associated with PD.
Malignant hyperthermia and myotonic disorders
2002, Anesthesiology Clinics of North America

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^☆: The opinions and assertions contained herein are the views of the authors and are not to be construed as official or reflecting the views of the Department of Defense or the Department of the Air Force.

^∗: Assistant Professor

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Case reportSuccessful treatment of an episode of malignant hyperthermia using a large dose of dantrolene☆

Abstract

Br J Anaesth

J. Pharm Sci

Clin Chim Acta

Dantrolene—an update

Dantrolene dose response in malignant hyperthermia-susceptible (MHS) swine: method to obtain prophylaxis and therapeusis

Anesthesiology

Dantrolene dose response in awake man: implications for management of malignant hyperthermia

Anesthesiology

Dantrolene

Can Anaesth Soc J

Case report
Successful treatment of an episode of malignant hyperthermia using a large dose of dantrolene☆