Spinal cord injury-related thermoregulatory impairment masks a fatal malignant hyperthermia crisis: a case report.

PURPOSE: Malignant hyperthermia (MH) is a hypermetabolic disorder that can occur in genetically susceptible individuals exposed to halogenated anesthetics and succinylcholine. Spinal cord injury (SCI) above the sixth thoracic vertebra is associated with dysfunction of the sympathetic/parasympathetic nervous pathways, including thermoregulatory dysfunction, presenting as hypothermia in cold environments because of vasodilation and heat loss. This effect could mitigate or obscure an MH episode. Here, we describe development of a fatal MH crisis in a patient with SCI. CLINICAL FEATURES: A 27-yr-old male patient with an SCI after fracture of the sixth cervical vertebra was admitted for spinal arthrodesis. Anesthetic medications included remifentanil, propofol, succinylcholine, rocuronium, and isoflurane. After the start of the surgery, muscular contractures resembling myoclonus were noted, which resolved with pancuronium administration. Four hours after the start of anesthesia, the patient presented with hyperthermia, hypercarbia, hypotension, muscle rigidity, arrhythmia, and cardiogenic shock, with metabolic/respiratory acidosis. Malignant hyperthermia was suspected and the treatment was started, but he developed cardiopulmonary arrest and died an hour and a half after the first cardiac arrest. Both parents were investigated and were found to have normal creatine kinase levels and positive in vitro contracture tests. His mother carried a variant in the ryanodine receptor type 1 (RYR1) gene (c.14918C>T), which is associated with MH. CONCLUSION: Spinal cord injury-induced thermoregulatory dysfunction may obscure the early diagnosis of MH and lead to fatal outcome.

RéSUMé: OBJECTIF: L'hyperthermie maligne est un trouble hypermétabolique qui peut survenir chez les personnes génétiquement susceptibles exposées à des anesthésiques volatils et à la succinylcholine. Les lésions médullaires situées au-dessus de la sixième vertèbre thoracique sont associées à un dysfonctionnement des voies nerveuses sympathiques / parasympathiques, y compris un trouble de la thermorégulation, et se présentent sous forme d'hypothermie dans des environnements froids en raison de la vasodilatation et de la perte de chaleur. Cet effet pourrait atténuer ou occulter un épisode d'hyperthermie maligne. Nous décrivons ici l'apparition d'une crise mortelle d'hyperthermie maligne chez un patient atteint de lésion médullaire. CARACTéRISTIQUES CLINIQUES: Un patient de 27 ans atteint d'une lésion médullaire après une fracture de la sixième vertèbre cervicale a été admis pour une arthrodèse rachidienne. Les médicaments anesthésiques comprenaient du rémifentanil, du propofol, de la succinylcholine, du rocuronium et de l'isoflurane. Après le début de la chirurgie, des contractures musculaires ressemblant à une myoclonie ont été notées, lesquelles se sont résolues avec l'administration de pancuronium. Quatre heures après l'induction d'anesthésie, le patient a présenté une hyperthermie, une hypercarbie, une hypotension, une rigidité musculaire, une arythmie et un choc cardiogénique, avec acidose métabolique / respiratoire. Une hyperthermie maligne a été suspectée et le traitement a été amorcé, mais le patient a subi un arrêt cardiorespiratoire et est décédé une heure et demie après le premier arrêt cardiaque. Les deux parents ont passés des tests et se sont avérés avoir des taux normaux de créatine kinase et des tests de contracture in vitro positifs. La mère du patient était porteuse d'un variant du gène récepteur de ryanodine de type 1 (RYR1) (c.14918C>T), lequel est associé à l'hyperthermie maligne. CONCLUSION: Un trouble de la thermorégulation induit par une lésion médullaire peut masquer un diagnostic précoce d'hyperthermie maligne et entraîner une issue fatale.

Estudo clínico prospectivo aleatório sobre o uso da máscara laríngea Supreme® em pacientes submetidos a anestesia geral / Prospective, randomized clinical trial of laryngeal mask airway Supreme® used in patients undergoing general anesthesia / Estudio clínico prospectivo aleatorio sobre el uso de la mascarilla laríngea Supreme® en pacientes sometidos a la anestesia general

JUSTIFICATIVA E OBJETIVOS: Dispositivos supraglóticos são cada vez mais usados como opção à intubação traqueal durante procedimentos eletivos de complexidade variável. O objetivo deste estudo foi avaliar prospectivamente o uso clínico da máscara laríngea Supreme® (MLS) em pacientes submetidas a procedimentos cirúrgicos eletivos na mama e compará-la ao tubo endotraqueal (TE). MÉTODO: 60 pacientes submetidas a procedimentos cirúrgicos da mama sob anestesia geral foram distribuídas aleatoriamente em dois grupos de acordo com o dispositivo usado (MLS ou TE). Foram avaliados: tempo de inserção, número de tentativas para inserção, resposta hemodinâmica à inserção, presença de sangue no dispositivo usado e incidência de dor de garganta, disfagia, náuseas e vômitos no pós-operatório. RESULTADOS: Não houve diferença entre os grupos com relação ao tempo de inserção, ao número de tentativas para inserção bem-sucedida e à presença de sangue no dispositivo. A frequência cardíaca e a pressão arterial após a inserção foram maiores no grupo TE. A incidência de dor de garganta e disfagia após duas horas de pós-operatório também foi maior no grupo TE. Não houve diferença na incidência e na intensidade das complicações avaliadas após seis horas de pós-operatório. CONCLUSÕES: O uso da MLS como técnica de acesso à via aérea durante a anestesia geral em procedimentos cirúrgicos eletivos na mama é tão seguro e eficiente quanto a intubação traqueal, com a vantagem de desencadear menor resposta hemodinâmica durante a sua execução e menor incidência de dor de garganta e disfagia nas primeiras horas de pós-operatório.

BACKGROUND AND OBJECTIVES: Supraglottic airway devices are increasingly used as an option to tracheal intubation for elective procedures of varying complexity. The aim of this study was to prospectively evaluate the clinical use of the laryngeal mask airway Supreme® (LMAS) in patients undergoing elective breast surgery and compare it with endotracheal tube (ETT). METHODS: Sixty patients undergoing breast procedures under general anesthesia were randomly divided into two groups according to the device used (LMAS or ETT). Time of insertion, number of insertion attempts, hemodynamic response to insertion, presence of blood on the device used; and incidence of sore throat, dysphagia, nausea and vomiting were assessed postoperatively. RESULTS: There was no difference between groups regarding time of insertion, number of attempts for successful insertion, and presence of blood on the device. Heart rate and blood pressure after insertion were higher in ETT group. Incidence of sore throat and dysphagia was also higher in ETT group after two hours in the postoperative period. There was no difference regarding incidence and severity of complications evaluated after six hours postoperatively. CONCLUSIONS: The use of the LMAS technique to access airway during general anesthesia for elective breast surgery is as safe and effective as tracheal intubation, with the advantage of promoting smaller hemodynamic response during its management and lower incidence of sore throat and dysphagia in the first hours after surgery.

JUSTIFICATIVA Y OBJETIVOS: Los dispositivos supraglóticos son cada vez más usados como una opción a la intubación traqueal durante los procedimientos electivos de complejidad variable. El objetivo de este estudio, fue evaluar prospectivamente el uso clínico de la mascarilla laríngea Supreme® (MLS) en pacientes sometidas a procedimientos quirúrgicos electivos en la mama y compararlo con el tubo endotraqueal (TE). MÉTODO: Sesenta pacientes fueron sometidas a procedimientos quirúrgicos de la mama bajo anestesia general, y distribuidas aleatoriamente en dos grupos de acuerdo con el dispositivo usado (MLS o TE). Se evaluaron: tiempo de inserción, número de intentos para la inserción, respuesta hemodinámica a la inserción, presencia de sangre en el dispositivo usado, e incidencia de dolor de garganta, disfagia, náuseas y vómitos en el postoperatorio. RESULTADOS: No hubo diferencia entre los grupos con relación al tiempo de inserción, al número de intentos para la inserción exitosa y a la presencia de sangre en el dispositivo. La frecuencia cardíaca y la presión arterial después de la inserción fueron más elevadas en el grupo TE. La incidencia de dolor de garganta y disfagia después de dos horas de postoperatorio, también fue mayor en el grupo TE. No hubo diferencia en la incidencia y en la intensidad de las complicaciones evaluadas después de seis horas del postoperatorio. CONCLUSIONES: El uso de la MLS como técnica de acceso a la vía aérea durante la anestesia general en procedimientos quirúrgicos electivos en la mama, es tan seguro y eficiente como la intubación traqueal, con la ventaja de que desencadena una menor respuesta hemodinámica durante su ejecución y una menor incidencia de dolor de garganta y disfagia en las primeras horas del postoperatorio.

Prospective, randomized clinical trial of laryngeal mask airway Supreme(®) used in patients undergoing general anesthesia.

BACKGROUND AND OBJECTIVES: Supraglottic airway devices are increasingly used as an option to tracheal intubation for elective procedures of varying complexity. The aim of this study was to prospectively evaluate the clinical use of the laryngeal mask airway Supreme(®) (LMAS) in patients undergoing elective breast surgery and compare it with endotracheal tube (ETT). METHODS: Sixty patients undergoing breast procedures under general anesthesia were randomly divided into two groups according to the device used (LMAS or ETT). Time of insertion, number of insertion attempts, hemodynamic response to insertion, presence of blood on the device used; and incidence of sore throat, dysphagia, nausea and vomiting were assessed postoperatively. RESULTS: There was no difference between groups regarding time of insertion, number of attempts for successful insertion, and presence of blood on the device. Heart rate and blood pressure after insertion were higher in ETT group. Incidence of sore throat and dysphagia was also higher in ETT group after two hours in the postoperative period. There was no difference regarding incidence and severity of complications evaluated after six hours postoperatively. CONCLUSIONS: The use of the LMAS technique to access airway during general anesthesia for elective breast surgery is as safe and effective as tracheal intubation, with the advantage of promoting smaller hemodynamic response during its management and lower incidence of sore throat and dysphagia in the first hours after surgery.