Quick Diagnosis: The Key for a Positive Outcome in Malignant Hyperthermia—A Case Report

João M. H. F. Moniz*, Rita Ferreira, Nuno Serrano and Ana S. Cunha

Quick Diagnosis: The Key for a Positive Outcome in Malignant Hyperthermia. The patient was admitted to the operating theatre for lower limb disarticulation. Monitoring with 3-lead electrocardiogram, non-invasive blood pressure, pulse oximetry, train of four and bispectrality index  was ensured and induction with Propofol, fentanyl, and rocuronium was achieved. Endotracheal intubation followed without complication. After confirming its correct placement, volume-controlled ventilation was started with adequate volumes, pressures and capnometry.

Sevoflurane was started for maintenance of the Five minutes later, profuse sweating was noticed. Hypoglycemia and insufficient depth of anesthesia were ruled out. Two minutes afterwards, a steady increase in end tidal carbon dioxide and heart rate were recorded, with ETCO2 values of 70-90 mmHg and heart rate between 150-190 bpm. Minute-ventilation was increased but CO2 kept scaling, reaching 100-120 mmHg. There was no evident muscle rigidity. Malignant hyperthermia was promptly suspected, and sevoflurane discontinued.

High-flow ventilation with FiO2 100% was started and the anesthetic technique was changed to a total intravenous anesthesia with Propofol. The CO2 absorbent was replaced. Dantrolene was swiftly prepared by the anesthesia nurse, with the help of another anesthesiologist to confirm the correct dosing and to help dilute it in sterile water. One hundred mg were prepared  and were administered as soon as they were ready, within the first 10-minutes. An arterial blood gas analysis  was done, revealing a significant respiratory acidosis.

An arterial line, central line and urinary catheter were placed, and cooling was started with ice packages. Central temperature monitoring was achieved with an esophageal probe. Maximum temperature registered was 36.3 °C, already during the cooling phase. Additional treatment comprised of sodium bicarbonate, insulin+hypertonicglucose and calcium gluconate for impending hyperkalemia. Venous blood samples were obtained and were later found to be within normal references.
Res Pract Anesthesiol Open J. 2023; 7(1): 1-4. doi: 10.17140/RPAOJ-7-133