Leadership

Abstract

A 12-year-old boy sustains a bicycle accident resulting in an open fracture of the mandible. Because the patient has a full stomach and mouth opening is reduced due to pain, the anesthesia resident decides to perform a rapid sequence induction with thiopental and succinylcholine. The intubation is successful and uneventful and anesthesia is maintained as a total intravenous anesthesia (TIVA) with propofol and remifentanil. After 30 min of uneventful anesthesia, the saturation begins to drop slowly and sinus tachycardia developes. Under the assumption of insufficient anesthetic depth, the resident increases the concentration of propofol and remifentanil. This intervention, however, does not affect the tachycardia. The anesthesia resident checks the i.v. line to rule out soft tissue infiltration and auscultates both lungs. Breath sounds are equal bilaterally. Meanwhile the patient requires 70% oxygen to maintain saturations above 95%. Because the resident is unable to find any apparent cause for the clinical deterioration and because of the danger of the situation, he calls for help from his attending physician. When the attending physician enters the operating room a few minutes later, the patient is receiving a minute volume of 9.5 l/min to maintain the end-expiratory CO₂ at 45 mmHg. Infrequent monomorphic premature ventricular contractions are noted on the ECG. The attending tells the resident to insert an arterial pressure line into the radial artery and to obtain an arterial blood gas. The lab results show a combined respiratory and metabolic acidosis with a mild alveolo-arterial difference in the partial pressure of oxygen and a potassium concentration of 5.6 mmol/l. Based on the induction of anesthesia with succinylcholine in conjunction with the current clinical picture and the lab findings, the attending physician decides to interpret the clinical deterioration as symptoms of malignant hyperthermia and to treat it accordingly. The patient’s body temperature is 37.2°C (99°F). He informs the maxillofacial surgeons about the seriousness of the condition and asks them to interrupt the operation. Dantrolene is dissolved in solution and administered to the patient. The arterial blood gas is monitored closely and the appropriate treatments for pH abnormalities, hyperkalemia, and renal protection are initiated. Cardiovascular stability is maintained by catecholamine support. Due to an increase in the patient’s temperature to 39.7°C (103.4°F) over 20 min, the attending anesthesiologist initiates externalcooling procedures, which are accomplished by the surgeons and OR technicians. Twenty minutes after the administration of dantrolene, the heart rate begins to drop slowly and the acid–base status begins to improve. Minute ventilation and FiO₂ are gradually reduced. Once the treatment begins to indicate a reassuring response by the patient, the attending physician contacts the pediatric intensive care unit (PICU) and requests a bed for his patient. He informs the pediatric intensivist about the clinical course, the measures taken, and current clinical status. An hour later, the patient is further stabilized and is transferred to the PICU. Over the course of the next day, the patient develops a compartment syndrome of the left lower leg requiring reoperation. The anesthetic is trigger free for malignant hyperthermia and proceeds uneventfully. The patient is extubated postoperatively and is transferred from the PICU to the general ward on the following day. He is discharged from the hospital without any residual symptoms. The patient and his family are tested for their susceptibility to malignant hyperthermia and both the patient and his younger brother have positive results.