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Malignant Hyperthermia Crisis – MH (10Cs)

This page is part of the Safetots Crisis SOPs, a framework for prevention and treatment of the most relevant crisis situations in pediatric anaesthesia.

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Summary

Malignant hyperthermia crisis occurs in response to volatile anesthetic agents and depolarizing muscle relaxants (suxamethonium). Prevention and immediate treatment with dantrolene is life-saving.

Background

  • malignant hyperthermia is a life-threatening metabolic response to volatile anesthetic agents or succinylcholine (suxamethonium). Previous uneventful exposure to these agents does not guarantee safe use
  • mortality may approach 70% if untreated, with dantrolene treatment mortality approximates 3-5%

Prevention

  • recognition of patients at risk through careful medical and family history and/ or consultation with specialist Malignant Hyperthermia reference center
  • do not use volatiles or succinylcholine (suxamethonium) in patients at risk
  • reduce preoperative anxiety
  • use a vapor free anesthetic machine if possible, if not available prepare machine according to manufacturer’s guidelines and use a new breathing circuit, rebreathing bag, and gas sampling tubes
  • consider vapor scavenging filters
  • ensure dantrolene availability

Treatment

Call for help early, initiate action plan and allocate specific tasks:

  • stop potential trigger agents immediately and give 100% oxygen
  • consider installing clean breathing system, remove inhalational agents and increase fresh gas flow to maximum, consider vapor scavenging filters
  • hyperventilate to achieve normocapnia
  • maintain anesthesia using non-volatile anesthetics and opioids as well as non-depolarizing muscle relaxants, curtail surgery if possible
  • give dantrolene (2.5mg/kg every 5 minutes until effect – max. 20mg/kg): need to assign one person to correctly reconstitute dantrolene from powder formulation
  • active cooling
  • treat or prevent hyperkalemia, acidosis, arrhythmias (no calcium channel antagonists) and prevent acute renal failure and coagulopathy
  • continuous monitoring of vital signs including peripheral and core temperature, invasive monitoring for repeated blood sampling
  • check plasma CK

Post Care

  • continue monitoring postoperatively on PICU, repeat dantrolene as required
  • repeat plasma CK
  • monitor and prevent acute renal failure and compartment syndrome
  • counsel patient and family members
  • arrange referral to Malignant Hyperthermia Unit

References

  1. Salazar JH, Yang J, Shen L, Abdullah F, Kim TW. Pediatric malignant hyperthermia: risk factors, morbidity, and mortality identified from the Nationwide Inpatient Sample and Kids’ Inpatient Database. Paediatr Anaesth. 2014; 24: 1212-6.
  2. Litman RS, Griggs SM, Dowling JJ, Riazi S. Malignant Hyperthermia Susceptibility and Related Diseases. Anesthesiology. 2018; 128: 159-67.
  3. Cummings T, Der T, Karsli C. Repeated non-anesthetic malignant hyperthermia reactions in a child. Paediatr Anaesth. 2016; 26: 1202-3.
  4. Shapiro F, Athiraman U, Clendenin DJ, Hoagland M, Sethna NF. Anesthetic management of 877 pediatric patients undergoing muscle biopsy for neuromuscular disorders: a 20-year review. Paediatr Anaesth. 2016; 26: 710-21.
  5. Wappler F. S1-Leitlinie maligne Hyperthermie. Der Anaesthesist 2018; 67: 529–32.
  6. AAGBI. Malignant Hyperthermia Crisis. AAGBI Safety Guideline. https://www.aagbi.org/publications/publications-guidelines/M/R
  7. Hopkins PM, Rüffert H, Snoeck MM, Girard T, Glahn KP, Ellis FR, Müller CR, Urwyler A; European Malignant Hyperthermia Group. European Malignant Hyperthermia Group guidelines for investigation of malignant hyperthermia susceptibility. Br J Anaesth 2015; 115: 531-9.

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