MALIGNANT

HYPERTHERMIA
Agung Suryana Hidayat
 Malignant Hyperthermia
• Gangguan hipermetabolik yang jarang dan sering life-
threatening, dipicu oleh inhalation agents and
succinylcholine.
• Diturunkan pada beberapa keluarga dengan pola
autosomal dominan dengan bermacam variasi
• 52% dari kasus MH terjadi dibawah usia 15 th, dengan
rerata usia 18.3 tahun.
• Incidence- 1:50,000 adults and 1:15,000 children.
MALIGNANT HYPERTHERMIA
• PATHOPHYSIOLOGY
• MH  kelainan turunan dari sistem
muskuloskeletal berupa kelainan pada
regulasi kalsium yang muncul saat
terpapar agen anestesia dan
mengakibatkan hiperkalsemia
MALIGNANT HYPERTHERMIA
• PATHOPHYSIOLOGY
• The ryanodine receptor modulate calcium
release from the channels in the
sarcoplasmic reticulum, and much
attention has been focused on this
receptor as a site of the MH defect.
• There is no evidence of primary defect in
cardiac or smooth muscle cells.
MALIGNANT HYPERTHERMIA
• PATHOPHYSIOLOGY
• When MH is initiated-the concentration of
calcium in the muscle cells increase.
• Actomysin cross-bridging, sustain muscle
contraction, and rigidity results.
MALIGNANT HYPERTHERMIA
• PATHOPHYSIOLOGY
• Increased oxygen consumption, augment
carbon dioxide and heat production,
deplete ATPstores, and generate lactic
acid.
• Resulting in acidosis, hyperthermia, ATP
depletion, marked increase of myoglobin,
creatine kinase and potassium.
MALIGNANT HYPERTHERMIA
• TRIGGERING AGENTS
• ALL VOLITILE ANESTHETICS
• SUCCINYLCHOLINE
MALIGNANT HYPERHTERMIA
• CLINICAL EVENTS OF MH:
• Takikardia
• Takipneu
• Gangguan B/P, gangguan konduksi jantung
• Peningkatan ETCO2, ABRUPT OR GRADUAL
• Rigiditas otot masseter atau generalized (75%)
• Asidosis respiratorik atau metabolik
• hiperpireksia
• Urine berwarna gelap
MALIGNANT HYPERTHERMIA
• LABORATORY FINDINGS:
• ARTERIAL BLOOD GAS:PCO2>60mmHg
BASE EXCESS MORE NEGATIVE
THAN-8mEq/L,Ph<7.25
• POTASSIUM ION >6mEq/L
CK>10,000 IU/L, AFTER ANESTHETIC
WITHOUT SUCCINYLCHOLINE
• SERUM MYOGLOBIN >170mcg/L
• URINE MYOGLOBIN >60mcg/L
MALIGNANT HYPERTHERMIA
• Hyperthermia may climb 1 degree to 2
degrees C every 5 minutes and exceed
43.3 C (110 degrees F). Often a late but
confirming sign of MH.
• Late complications: cerebral edema,
myoglobinuric renal failure, consumptive
coagulopathy, hepatic dysfunction, and
pulmonary edema.
MALIGNANT HYPERTHERMIA
• Manifestations that mimic MH
• TACHYCARDIA-hypoxia, hypercarbia,
hypovolemia, light anesthesia, anticholinergics,
sympathomimetics, cocaine,
pheochromocytoma.
• HYPERPYREXIA-heatstroke, blood transfusion
reaction, infection, drug reaction, neuroleptic
malignant syndrome, serontonin syndrome,
hypermetabolic states-sepsis, thyroid storm,
pheochromocytoma.
MALIGNANT HYPERTHERMIA
• Manifestations that mimic MH
• Tachypnea, Hypercapnia-CHF, pulmonary
edema, hypermetabolic states, intraperitoneal
CO2 insuflation, airway obstruction,
pneumothorax, excessive dead space, low
minute volume.
• Masseter Muscle Rigidity-insufficient
neuromuscular blockade, temporomandibular
joint syndrome, neuroleptic malignant syndrome,
myotonia.
MALIGNANT HYPERTHERMIA
• IN ADDITION TO BEING A TRIGGERING
AGENT FOR MH, SUCCINYLCHOLINE
MAY ALSO INDUCE A HYPERKALEMIC
–MEDIATED CARDIAC ARREST IN
CHILDREN WITH OCCULT
MYOPATHIES. PACKAGE INSERT WAS
MODIFIED TO WARN AGAINST THE
ROUTINE USE OF SUCCINYLCHOLINE
IN CHILDREN.
MALIGNANT HYPERTHERMIA
• PREOP ASSESMENT
• Family history of muscle disorders
• Unexpected intraoperative deaths
• Family or personal muscle rigidity/stiffness or high fever
under anesthesia
• Personal history of dark cola-colored urine following
surgery
• Absence of positive history does not preclude MH
susceptability
• MH is linked to Duchenne’s and Becker’s muscular
dystrophy
• 50% of patients with unexplained CK elevation test
positive for MH on biopsy
MALIGNANT HYPERTHERMIA
• TREATMENT
• CALL FOR HELP-tell surgeon to conclude
procedure
• Discontinue volitile agent and succinylcholine
• Hyperventilate 100% O2 at 10 L/min
• Dantrolene 2.5mg/kg up to 10mg/kg (175mg in
70kg up to700mg) each vial 20mg mix in 60 cc
of sterile water
• Dysrhythmias treat acidosis and hyperkalemia,
standard antiarrhythmic drugs. Avoid calcium
channel blockers
MALIGNANT HYPERTHERMIA
• FEVER- cooling lavage orogastric, bladder, open
cavities, chilled IV fluid, ice packs, hypothermia blanket

• ACIDOSIS- NA bicarbonate, send ABG’s, lytes, glucose

every 15minutes. Base line coagulation studies, CK,
myoglobin, liver enzymes
• HYPRERKALEMA-hyperventilation, 10 units regular
insulin in 50 ml 50% glucose titrated to potassium level
• Maintain urine output 2ml/kg/hr by hydration and
mannitol (300mg/kg) and/or furosemide (.5 to 1.0mg/kg)
• Consider CVP/PA arterial monitoring
 MALIGNANT HYPERTHERMIA
• Anesthesia for the MH-susceptible patient
• Standard monitoring equipment
• Cooling blanket under patient at start of procedure
• Preop anxiolytic
• Local or regional if possible
• Triggering agents removed from OR
• Anesthesia machine- change soda lime, circuit, removing or
inactivating vaporizers, flush 10L O2 for 20 minutes
• 3000 ml cold IV solution available
• Ice available
• ABG analysis available
• 36 VIAL OF DANTROLENE AVAILABLE
MALIGNANT HYPERTHERMIA
• DIAGNOSTIC TESTING
• CAFFEINE HALOTHANE TEST
• THIGH MUSCLE BIOPSY MEASURES
THE CONTRACTILE RESPONSE TO
CAFFEINE, HALOTHANE, OR BOTH.
THIS IS AUGMENT IN THE PATIENT
WITH MH.
• 92% SENSITIVITY AND
78%SPECIFICITY
MALIGNANT HYPERTHERMIA
• POSTOP CARE
• DANTROLENE TREATMENT NEEDS TO BE
CONTINUED FOR A MINIMUM OF 24 HOURS
AFTER CONTROL OF THE EPISODE.
• MASSETER MUSCLE RIGIDITY-STUDIES
INDICATE IF THE CK IS GREATER THAN
20,000 IU AND A CONCOMITANT MYOPATHY
IS NOT PRESENT THE DIAGNOSIS OF MH IS
LIKELY