Abstract: There are many issues that healthcare professionals face in the evolving world of medicine. One of these is the development of a disease process known as Malignant Hyperthermia (MH). This condition is precipitated by frequently used anesthetic agents such as volatile gases and depolarizing muscle relaxants. The onset of MH is sudden and can be life-threatening, therefore, diligent monitoring of patients is essential in early recognition and treatment of MH. The purpose of this poster is to provide in -depth knowledge about MH. This includes the pathophysiology of the disease, signs and symptoms, treatment options, and implications MH has on nursing and anesthesia staff. While no specific case studies were included in the poster, several can be found in the references provided

Smith, Alec

English

Otterbein University

Otterbein University Digital Commons @ Otterbein Nursing Student Class Projects (Formerly MSN) Student Research & Creative Work Summer 2020 Malignant Hyperthermia Alec Smith Otterbein University, smith56@otterbein.edu Follow this and additional works at: https://digitalcommons.otterbein.edu/stu_msn  Part of the Nursing Commons Recommended Citation Smith, Alec, "Malignant Hyperthermia" (2020). Nursing Student Class Projects (Formerly MSN). 439. https://digitalcommons.otterbein.edu/stu_msn/439 This Project is brought to you for free and open access by the Student Research & Creative Work at Digital Commons @ Otterbein. It has been accepted for inclusion in Nursing Student Class Projects (Formerly MSN) by an authorized administrator of Digital Commons @ Otterbein. For more information, please contact digitalcommons07@otterbein.edu. Malignant HyperthermiaAlec Smith BSN, RN, CCRN, SRNAOtterbein University, Westerville, OhioIntroduction: Malignant Hyperthermia• Malignant	Hyperthermia	(MH)	is	a	life-threatening	disease	process	that	can	be	fatal	if	untreated.	• MH	is	an	autosomal	dominant	pharmacogenetic	disorder	(Smith	et	al.,	2018).• This	disorder	is	often	precipitated	by	the	use	ofvolatile	anesthetics	and	depolarizing	muscle	relaxants.• Although	MH	is	fairly	uncommon,	it	accounts	nearly	1%	of	all	anesthesia	related	deaths	(Bamaga et	al.,	2016).Why Malignant Hyperthermia?• MH	can	be	caused	by	medications	frequently	administered	by	the	anesthesia	team.• Anesthesia	providers	and	nurses	are	tasked	with	early	detection,	treatment,	and	clinical	monitoring	for	patients	who	develop	MH.• Vigilance	along	with	proper	education	and	training	on	this	disease	process	can	help	reduce	fatalities	associated	with	MH	(Smith	et	al.,	2018).Pathophysiological ProcessesSigns & Symptoms• MH	can	present	at	any	point	during	an	anesthesia	case.	MH	can	develop	shortly	after	giving	the	triggering	medications	and	can	be	seen	up	to	one	hour	after	the	discontinuation	of	these	medications	(Rosenberg	et	al.,	2015).• Although,	MH	can	be	seen	during	an	individuals	first	exposure	to	anesthesia,	it	can	often	take	up	to	three	exposures	before	MH	is	triggered	(Rosenberg	et	al.,	2015).• One	of	the	early	signs	of	MH	is	the	unexplained	increase	in	end-tidal	CO2	(ETCO2)	with	increased	ventilation	(Smith	et	al.,	2018).• Additional	symptoms	of	MH	include	tachycardia,	dysrhythmias,	skeletal	muscle	rigidity,	rapid	rise	in	core	body	temperature,	and	rhabdomyolysis	(Smith	et	al.,	2018).• As	MH	progresses,	later	symptoms	include	metabolic	and	respiratory	acidosis,	hyperkalemia,	myoglobinuria,	and	increased	levels	of	creatine	kinase	(CK)	(Smith	et	al.,	2018).• If	the	symptoms	of	MH	are	untreated	for	long	enough,	other	pathologies	such	as	disseminated	intravascular	coagulation	and/or	acute	renal	failure	may	occur	(Smith	et	al.,	2018).• Another	symptom	of	MH	that	is	specific	to	children	is	masseter	muscle	rigidity	(Rosenberg	et	al.,	2015).Underlying Pathophysiology• MH	is	a	disease	process	that	can	be	potentiated	by	potent	inhaled	anesthetic	gases	such	as	sevoflurane,	isoflurane,	desflurane,	halothane.	MH	can	also	be	caused	by	non-depolarizing	muscle	relaxants	like	succinylcholine	(Abdulrahman,	2020).• In	MH,	a	defect	or	mutation	exists	in	the	calcium	channel	termed	the	ryanodine	receptor	(RyR1).	This	channel	is	responsible	for	the	regulation	and	release	of	calcium	from	the	sarcoplasmic	reticulum	(SR)	into	the	cell	Rosenberg	et	al.,	2015).• By	introducing	these	anesthetic	agents	into	individuals	with	this	defect,	an	uncontrolled	release	of	calcium	from	the	SR	into	the	cell	can	result.	This	then	causes	a	hypermetabolic	state	with	sustained	muscle	contraction,	rigidity,	and	hyperthermia.	(Dagestad &	Hermann,	2017).• This	hypermetabolic	state	results	in	excessive	consumption	and	depletion	of	adenosine-tri	phosphate	(ATP)	which	then	leads	to	the	failure	of	membrane	integrity	and	the	release	of	CK	and	potassium.	(Rosenberg	et	al.,	2015).Retrieved	from	https://smw.ch/article/doi/smw.2012.13652Significance of Physiology• MH	is	a	rare	genetic	disorder	and	because	of	this	it	is	not	often	diagnosed	until	symptoms	develop.• The	“gold	standard”	test	for	the	diagnosis	of	MH	is	the	in	vitro	contracture	test	(IVCT).	This	test	is	based	the	contracture	of	muscle	fibers	when	introduced	to	caffeine	of	halothane.	An	individual	is	considered	susceptible	to	MH	when	muscle	fiber	contracture	results	from	both	caffeine	and	halothane.	However,	IVCT	is	expensive,	requires	surgical	intervention,	and	is	only	done	at	specialized	testing	centers	(Rosenberg	et	al.,	2015).• Another	option	to	determine	susceptibility	to	MH	is	genetic	testing.	While	this	can	provide	useful	data,	it	may	also	have	ramifications	for	the	future	health	of	individuals	and	their	immediate	family	members.	Genetic	testing	can	also	be	disadvantageous	regarding	the	ability	of	a	individuals	to	gain	employment	or	access	health	and/or	life	insurance,	therefore,	the	previously	mentioned	IVCT	is	preferred	(Rosenberg	et	al.,	2015).Retrieved	from	https://www.sciencedirect.com/science/article/pii/B9780323429740000410Treatment• Rapid	treatment	of	MH	is	essential	in	preventing	adverse	outcomes	pertaining	to	MH.	It	is	suggested	that	treatment	be	initiated	within	3-7	minutes	from	the	time	of	onset	(Dagestad &	Hermann,	2017).• After	the	discontinuation	of	provoking	anesthetic	agents,	dantrolene	can	be	administered	to	treat	MH.	Dantrolene	is	a	direct-acting	skeletal	muscle	relaxant	that	interferes	with	calcium	release	to	help	stop	skeletal	muscle	contraction	(Dagestad &	Hermann,	2017).	• Dantrolene	is	administered	intravenously	with	a	maximum	dose	of	10mg/kg.	A	maintenance	dose	then	recommended	48	hours	from	the	time	of	the	last	MH	related	symptom	(Dagestad &	Hermann,	2017).• Other	treatments	for	MH	are	symptomatic	and	include	ensuring	the	patient	is	normothermic.• In	addition	to	the	initial	treatments	listed	above,	other	therapies	such	as	extracorporeal	membrane	oxygenation	(ECMO)	and	continuous	renal-replacement	therapy	(CRRT)	may	be	beneficial	in	more	severe	cases	(Huh	et	al.,	2017).Implications for Nursing Care• A	large	part	of	the	prevention	of	MH	comes	in	the	preoperative	assessment.	It	is	vital	that	all	members	of	the	healthcare	team	ensure	a	thorough	assessment	is	completed	(Rosenberg	et	al.,	2015).• In	order	to	optimize	outcomes	from	patients	diagnosed	with	MH	it	is	imperative	that	nursing	staff	in	the	OR	and	PACU	be	diligent	in	monitoring	the	patient’s	condition.• Nursing	must	be	knowledgeable	in	the	presentation	of	MH	so	subtle	changes	in	patient	condition	can	be	identified	and	reported.	This	includes	familiarity	with	monitoring	devices	such	as	ETCO2,	pulse	oximetry	saturation	(SpO2),	and	core	temperature	monitoring	systems.	Nursing	must	not	only	know	how	to	use	this	equipment,	but	know	what	values	are	expected	in	different	situations	(Xu	et	al.,	2019).	• Knowledge	of	treatment	as	well	as		how	to	rapidly	access	different	treatments	such	as	dantrolene	is	essential	for	nursing	staff.• Specific	for	anesthesia	providers	– a	knowledge	of	alternative	treatment	and	medications	for	MH	susceptible	patients	is	imperative.	Retrieved	from	https://www.semanticscholar.org/paper/Malignant-hyperthermia%3A-a-pharmacogenetic-disorder.-Stratman-Flynn/e1a359fb44b3b163b5ffbfc29cf2653440a3591fConclusions• MH	is	a	rare	genetic	disorder	and	a	complications	of	anesthesia	with	an	incidence	of	only	1:10,000	cases.	However,	once	MH	begins	its	rapid	progression	can	cause	multiple	organ	failure	leading	to	death	(Pan	et	al.,	2016).• MH	is	a	serious	complication	that	healthcare	providers	must	have	a	thorough	understanding	of.	• Hyperthermia	in	MH	can	measured with	a	core	temperature	increase	of	1-2	degrees	Celsius	every	5	minutes	(Rosenberg	et	al.,	2015).• Rapid	detection	and	treatment	is	the	key	to	decreasing	mortality	related	to	MH.	• Children,	younger	adults,	and	males	are	at	an	increased	risk	for	MH	(Rosenberg	et	al.,	2015).• Dantrolene	works	by	decreasing	RyR1	channel	activity	and	is	imperative	in	treating	MH	(Rosenberg	et	al.,	2015).ReferencesAbdulrahman,	A.	(2020).	Perioperative	Considerations	for	Suspected	Malignant	Hyperthermia.	Bahrain	Medical	Bulletin,	42(2),	140–141.Bamaga,	A.	K.,	Riazi,	S.,	Amburgey,	K.,	Ong,	S.,	Halliday,	W.,	Diamandis,	P.,	Guerguerian,	A.-M.,	Dowling,	J.	J.,	&	Yoon,	G.	(2016).	Neuromuscular	conditions	associated	with	malignant	hyperthermia	in	paediatric patients:	A	25-year	retrospective	study.	Neuromuscular	Disorders,	26(3),	201–206.	https://doi.org/10.1016/j.nmd.2016.02.007	Dagestad,	A.,	&	Hermann,	M.	(2017).	Keeping	cool	when	things	heat	up	during	a	malignant	hyperthermia	crisis.	Nursing	for	Women's	Health,	21(5),	338–347.	https://doi.org/10.1016/j.nwh.2017.07.001Huh,	H.,	Jung,	J.,	Park,	S.,	Park,	M.,	Lim,	C.,	&	Yoon,	S.	(2017).	Successful	early	application	of	extracorporeal	membrane	oxygenation	to	support	cardiopulmonary	resuscitation	for	a	patient	suffering	from	severe	malignant	hyperthermia	and	cardiac	arrest:	A	case	report.	Korean	Journal	of	Anesthesiology,	70(3),	345.	https://doi.org/10.4097/kjae.2017.70.3.345	Malignant	hyperthermia:	A	pharmacogenetic	disorder.	|	semantic	scholar.	(n.d.).	https://www.semanticscholar.org/paper/Malignant-hyperthermia:-a-pharmacogenetic-disorder.-Stratman-Flynn/e1a359fb44b3b163b5ffbfc29cf2653440a3591fMalignant	hyperthermia.	(n.d.).	Swiss	Medical	Weekly.	https://smw.ch/article/doi/smw.2012.13652Malignant	hyperthermia.	(2018,	February	9).	ScienceDirect.	https://www.sciencedirect.com/science/article/pii/B9780323429740000410Pan,	T.,	Ji,	W.,	Nie,	M.,	&	Li,	Y.	(2016).	Clinical	treatment	of	malignant	hyperthermia	in	three	cases.	Experimental	and	Therapeutic	Medicine,	12(5),	2881–2884.	https://doi.org/10.3892/etm.2016.3712	Rosenberg,	H.,	Pollock,	N.,	Schiemann,	A.,	Bulger,	T.,	&	Stowell,	K.	(2015).	Malignant	hyperthermia:	A	review.	Orphanet Journal	of	Rare	Diseases,	10(1).	https://doi.org/10.1186/s13023-015-0310-1Smith,	J.	L.,	Tranovich,	M.	A.,	&	Ebraheim,	N.	A.	(2018).	A	comprehensive	review	of	malignant	hyperthermia:	Preventing	further	fatalities	in	orthopedic	surgery.	Journal	of	Orthopaedics,	15(2),	578–580.	https://doi.org/10.1016/j.jor.2018.05.016Xu,	Z.,	Jiang,	Y.,	St.	Jacques,	P.,	Scharfman,	K.,	&	Wanderer,	J.	P.	(2019).	Increase	in	carbon	dioxide	removal	for	early	diagnosis	of	malignant	hyperthermia:	A	retrospective	study	from	a	large	medical	center	in	north	america.	Journal	of	Clinical	Anesthesia,	58,	73–74.	https://doi.org/10.1016/j.jclinane.2019.05.016

Malignant Hyperthermia

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Malignant Hyperthermia

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