This page is part of the Safetots Crisis SOPs, a framework for prevention and treatment of the most relevant crisis situations in pediatric anaesthesia.
Malignant hyperthermia crisis occurs in response to volatile anesthetic agents and depolarizing muscle relaxants (suxamethonium). Prevention and immediate treatment with dantrolene is life-saving.
- 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%
- 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
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
- 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
- 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.
- Litman RS, Griggs SM, Dowling JJ, Riazi S. Malignant Hyperthermia Susceptibility and Related Diseases. Anesthesiology. 2018; 128: 159-67.
- Cummings T, Der T, Karsli C. Repeated non-anesthetic malignant hyperthermia reactions in a child. Paediatr Anaesth. 2016; 26: 1202-3.
- 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.
- Wappler F. S1-Leitlinie maligne Hyperthermie. Der Anaesthesist 2018; 67: 529–32.
- AAGBI. Malignant Hyperthermia Crisis. AAGBI Safety Guideline. https://www.aagbi.org/publications/publications-guidelines/M/R
- 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.
See all Cs:
- Can´t Oxygenate – Can´t Ventilate
- Can´t Intubate
- Can Intubate – Can’t Oxygenate
- Can´t Cannulate – Failed Venous Access
- Major Hemorrhage
- Perioperative Pulmonary Aspiration
- Tonsillar Bleeding
- Local Anesthetic Systemic Toxicity – LAST
- Malignant Hyperthermia Crisis – MH
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