European Malignant Hyperthermia Group guidelines for investigation of malignant hyperthermia susceptibility.

It is 30 yr since the British Journal of Anaesthesia published the first consensus protocol for the laboratory diagnosis of malignant hyperthermia susceptibility from the European Malignant Hyperthermia Group. This has subsequently been used in more than 10 000 individuals worldwide to inform use of anaesthetic drugs in these patients with increased risk of developing malignant hyperthermia during general anaesthesia, representing an early and successful example of stratified medicine. In 2001, our group also published a guideline for the use of DNA-based screening of malignant hyperthermia susceptibility. We now present an updated and complete guideline for the diagnostic pathway for patients potentially at increased risk of developing malignant hyperthermia. We introduce the new guideline with a narrative commentary that describes its development, the changes to previously published protocols and guidelines, and new sections, including recommendations for patient referral criteria and clinical interpretation of laboratory findings.

Recognizing and managing a malignant hyperthermia crisis: guidelines from the European Malignant Hyperthermia Group.

Survival from a malignant hyperthermia (MH) crisis is highly dependent on early recognition and prompt action. MH crises are very rare and an increasing use of total i.v. anaesthesia is likely to make it even rarer, leading to the potential risk of reduced awareness of MH. In addition, dantrolene, the cornerstone of successful MH treatment, is unavailable in large areas around the world thereby increasing the risk of MH fatalities in these areas. The European Malignant Hyperthermia Group collected and reviewed all guidelines available from the various MH centres in order to provide a consensus document. The guidelines consist of two textboxes: Box 1 on recognizing MH and Box 2 on the treatment of an MH crisis.

Intracellular calcium homeostasis in human primary muscle cells from malignant hyperthermia-susceptible and normal individuals. Effect Of overexpression of recombinant wild-type and Arg163Cys mutated ryanodine receptors.

Malignant hyperthermia (MH) is a hypermetabolic disease triggered by volatile anesthetics and succinylcholine in genetically predisposed individuals. Nine point mutations in the skeletal muscle ryanodine receptor (RYR) gene have so far been identified and shown to correlate with the MH-susceptible phenotype, yet direct evidence linking abnormal Ca2+ homeostasis to mutations in the RYR1 cDNA has been obtained for few mutations. In this report, we show for the first time that cultured human skeletal muscle cells derived from MH-susceptible individuals exhibit a half-maximal halothane concentration causing an increase in intracellular Ca2+ concentration which is twofold lower than that of cells derived from MH-negative individuals. We also present evidence demonstrating that overexpression of wild-type RYR1 in cells obtained from MH-susceptible individuals does not restore the MH-negative phenotype, as far as Ca2+ transients elicited by halothane are concerned; on the other hand, overexpression of a mutated RYR1 Arg163Cys Ca2+ channel in muscle cells obtained from MH-negative individuals conveys hypersensitivity to halothane. Finally, our results show that the resting Ca2+ concentration of cultured skeletal muscle cells from MH-negative and MH-susceptible individuals is not significantly different.

Genotype-phenotype comparison of the Swiss malignant hyperthermia population.

Malignant hyperthermia (MH) is a potentially lethal pharmacogenetic disease, triggered by inhalative anesthetics or depolarizing muscle relaxants in genetically predisposed individuals. Linkage analysis have revealed MH to be a heterogenetic disease with about 50% of MH families linked to the locus of the ryanodine receptor calcium channel (RYR1). We investigated the frequency of the 23 published MH linked RYR1 gene mutations in the Swiss MH population and compared our findings to the results of the in vitro contracture test (IVCT). IVCT was performed following the protocol of the European MH Group and mutation screening was done by PCR amplification of genomic DNA followed by restriction enzyme digestion or SSCP. We identified RYR1 gene mutations in 40% of unrelated MH families (19/48) with a high incidence of the mutation V2168M (27%). IVCT results revealed a significantly stronger functional effect of mutations R614C and V2168M as compared to mutations G2434R and R2458C. This is the first time that such a high incidence of RYR1 gene mutations in an MH population has been found, supporting the use of molecular genetic testing for the diagnosis of MH susceptibility in suitable families. In addition our data show that different RYR1 gene mutations are associated with different IVCT phenotypes.

A dual microtiter plate (192 sample) luminometer employing computer-aided single-photon imaging applicable to cellular luminescence and luminescence immunoassay.

In spite of the increasing applications of luminescence measurements, no instrumentation is yet commercially available that permits sensitive luminescence measurements to be performed simultaneously on a large number of samples. Based on the principle of single-photon imaging, we describe here the performance of a computer-aided image luminometer with a capacity for two microtiter plates. Applications to the study of chemiluminescence by a B lymphocyte cell line, and to an IgE luminescence immunoassay are used to exemplify the capabilities of the system, which we have termed 'chemiluminescence multiwell analyser'.

Are laboratory values in bone marrow aspirate predictable for venous blood in paediatric patients?

In an emergency situation, early laboratory results are important, but often difficult to obtain. If venous access cannot be established, the intraosseous route may be used as an alternative. This study investigated the predictive value of bone marrow aspirate in performing laboratory studies. Thirty children underwent general anaesthesia for bone marrow aspiration (iliac crest) for oncologic or haematologic reasons. The aspirate and a peripheral venous blood sample, which was obtained simultaneously, were subjected to different laboratory tests and the results were compared by means of confidence interval analyses of the individual ratios of venous/bone marrow values. Based on these analyses, a high predictability of bone marrow values were found for haemoglobin, sodium, chloride, glucose, bilirubin, urea, creatinine, pH, and standard bicarbonate. Moderate, but clinically useful predictability was found for haematocrit, potassium, and total protein, while bone marrow values of alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, PCO2, PO2, thrombocytes and leukocytes were systematically different from values in venous blood. Our data suggest that the intraosseous route is not only an important emergency alternative to intravenous access for administering fluids and drugs but may also serve as a reliable alternative for obtaining initial diagnostic laboratory studies when intravascular access is not obtainable.

Sulfidoleukotriene generation from peripheral blood leukocytes of horses affected with insect bite dermal hypersensitivity.

Sulfidoleukotrienes (sLT) generated in vitro after incubation of equine peripheral blood leukocytes (PBL) with different inducing agents were determined in 18 healthy and 16 insect bite dermal hypersensitivity (IDH)-affected horses. PBL from these 32 horses were stimulated with Concanavalin A, Parascaris equorum, Culicoides nubeculosus and Simulium extracts, and with a six-Grass mix. The cells of all but four horses generated sLT after incubation with Concanavalin A; these four horses did also not produce sLT with the other inducing agents. Of the 28 remaining horses (12 affected with IDH and 16 healthy), all but three generated sLT with the P. equorum extract. The six-Grass mix did not induce sLT production in any of the tested horses. sLT generation with Concanavalin A and Parascaris was statistically not different between IDH-affected and healthy horses. PBL of the diseased horses, however, produced significantly more sLT with the Culicoides (p < 0.01) and Simulium (p < 0.05) extracts than those of the healthy animals. Additionally, sLT generation with the Culicoides extract was measured at different times of the year in one IDH-affected animal and remained high even in winter, when the horse was asymptomatic. sLT and histamine release were determined in 10 horses in parallel. Positive correlations of 0.81 and 0.82 for Concanavalin A and Parascaris (p < 0.01 and p < 0.05, respectively), and of 0.95 and 0.94 for Culicoides and Simulium (p < 0.01) were found between sLT and histamine release. These results indicate that, alike in humans, sLT are released in vitro from equine basophils along with histamine in response to various stimuli and that immediate type hypersensitivity reactions to Culicoides and Simulium are often involved in the pathogenesis of IDH. Thus, sLT generation from equine basophils offers an in vitro diagnostic tool for IDH even in sensitised but asymptomatic horses.

Muscle biopsy for malignant hyperthermia screening in children.

Malignant Hyperthermia (MH) remains a life-threatening event in anaesthetic practice. In paediatric patients, triggering agents such as volatile anaesthetics and other succinylcholine are widely used. For children with a positive family history or previous clinical signs of MH, muscle biopsy for the halothane and caffeine in vitro muscle contracture tests is the only reliable procedure for diagnosis of MH susceptibility. Here we investigated outcome and compliance of patients and parents involved in the test. Twenty-four children between 6 and 14 yrs of age were admitted to hospital for biopsy. Muscle withdrawal was performed at the upper leg from lateral vastus muscle using regional or trigger-free general anaesthesia. Outcome and compliance were controlled by a telephone interview or direct physical re-evaluation. Seventeen patients out of 24 were diagnosed as clinically MH-susceptible according to the protocol of the European MH Group. Seven children were excluded as MH-negative by the test. Twenty-one children were evaluated postoperatively. Minor side effects of wound healing occurred, but none of the patients showed any abnormalities of muscle contracture or movement performance. Considering the high risk of fatal complications in the presence of MH-susceptibility, muscle biopsy of the upper leg for in-vitro diagnosis is a justified procedure that is acceptable to children and their parents.

Effects of intravenous lidocaine and/or esmolol on hemodynamic responses to laryngoscopy and intubation: a double-blind, controlled clinical trial.

STUDY OBJECTIVES: To evaluate the efficacy of intravenous lidocaine and two doses of esmolol for attenuating the cardiovascular responses to laryngoscopy and intubation, and to assess whether a combination of both drugs is more effective than either drug alone. DESIGN: Randomized, prospective, double-blind, placebo-controlled study. SETTING: University hospital. PATIENTS: 90 ASA status I and II normotensive women scheduled for elective gynecologic procedures with general anesthesia. INTERVENTIONS: Induction of anesthesia was standardized for all patients. The first group received lidocaine 1.5 mg/kg (Group LID); the second and third groups received esmolol 1 mg/kg and 2 mg/kg, respectively (Groups E1 and E2, respectively); the fourth group received lidocaine 1.5 mg/kg and esmolol 1 mg/kg (Group LID-E1); the fifth group received lidocaine 1.5 mg/kg and esmolol 2 mg/kg (Group LID-E2); the sixth group received saline as a placebo (Group PLAC). MEASUREMENTS AND MAIN RESULTS: Systolic blood pressure and heart rate (HR) were recorded before induction, before injection of the first test drug, immediately before laryngoscopy, and 1, 2, and 5 minutes following intubation. Duration of laryngoscopy was recorded. Only patients receiving placebo had increased HR values after intubation compared with baseline values (p < 0.05). The proportion of patients with a maximum HR exceeding 90 beats/min was significantly higher in the placebo group (8 of 15 patients) than in both esmolol groups (E1 2 of 15; E2 2 of 15) (p < 0.05). Systolic blood pressure values after tracheal intubation did not differ among groups except for those receiving the combinations of lidocaine and esmolol, and they had significantly lower blood pressure (BP) values compared with placebo (p < 0.05). CONCLUSIONS: Esmolol 1 to 2 mg/kg is reliably effective in attenuating HR response to tracheal intubation. Neither of the two doses of esmolol tested nor that of lidocaine affected the BP response. Only the combination of lidocaine and esmolol attenuated both HR and BP responses to tracheal intubation.

Effect of maca supplementation on bovine sperm quantity and quality followed over two spermatogenic cycles.

Maca (Lepidium meyenii Walpers), is an Andean crop that grows between 3,800 and 4,500 m a.s.l. The persistent interest in this plant is based on its assumed effects on fertility of male mammals due to the prevalence of certain, partially specific, secondary compounds. The present study aimed at evaluating the effect of maca supplementation on quality and quantity of semen, mating behavior, and clinical status of peripubertal breeding bulls. The experiment followed a cross-over design lasting for 23 wk with 3 wk of adaptation and baseline measurements, and 2 x 10 wk of treatment feeding thus covering two times the complete 8-wk spermatogenic cycle. Seventy-eight 55 wk to 84 wk old breeding bulls received either no maca (control) or maca (233 mg dried hypocotyls/kg body weight/day) for 10 wk followed by 10 wk without maca (maca early) or maca only in the last 10 wk (maca late). Measurements were always made in the last 2 wk of each period. Apart from standard analyses, ejaculates were analyzed by flow cytometry. Data was evaluated by analysis of variance considering the repeated measurement structure of the data. Significant treatment by measurement period indicated direct or carry-over effects of maca. Maca supplementation had no direct effect on body weight, testes circumference, rectal temperature, mating behavior, and ejaculate volume. However, supplementing maca in the first 10 wk period increased the number of sperms in the second 10 wk period, i.e., when the animals no longer received maca. The DNA fragmentation index and the visually assessed motility of the sperms of bulls, that initially showed a borderline sperm quality, were significantly improved with early maca supplementation, while no such effect was observed in the two other groups. No effects occurred in the proportion of intact sperm plasma membranes or acrosomes or both. In conclusion, maca supplementation seems to improve sperm quantity and quality of bulls to a certain degree, while mating behavior appears unaffected.

Adult behavioral and pharmacological dysfunctions following disruption of the fetal brain balance between pro-inflammatory and IL-10-mediated anti-inflammatory signaling.

Maternal infections during pregnancy increase the risk for schizophrenia and related disorders of putative neurodevelopmental origin in the offspring. This association has been attributed to enhanced expression of pro-inflammatory cytokines in the fetal environment in response to maternal immunological stimulation. In contrast, the specific roles of anti-inflammatory cytokines are virtually unknown in this context. Here, we demonstrate that genetically enforced expression of the anti-inflammatory cytokine interleukin (IL)-10 by macrophages attenuates the long-term behavioral and pharmacological consequences of prenatal immune activation in a mouse model of prenatal viral-like infection by polyriboinosinic-polyribocytidilic acid (PolyI:C; 2 mg/kg, intravenously). In the absence of a discrete prenatal inflammatory stimulus, however, enhanced levels of IL-10 at the maternal-fetal interface by itself also precipitates specific behavioral abnormalities in the grown offspring. This highlights that in addition to the disruptive effects of excess pro-inflammatory molecules, a shift toward enhanced anti-inflammatory signaling in prenatal life can similarly affect cognitive and behavioral development. Hence, shifts of the balance between pro- and anti-inflammatory cytokine classes may be a critical determinant of the final impact on neurodevelopment following early life infection or innate immune imbalances.

[Malignant hyperthermia]. / Die Maligne Hyperthermie.

Malignant hyperthermia (MH) is a rare, life-threatening pharmacogenetic disease. The genetic incidence is estimated to be 1:10,000. In predisposed individuals, MH is triggered by volatile anaesthetics and/or depolarizing muscle relaxants by an abnormal increase of intracellular calcium concentration in skeletal muscle cells. The clinical presentation may vary from abortive MH to the fulminant MH crisis. Early diagnosis, the use of electrocardiography and capnography for anaesthetic monitoring, immediate cessation of trigger agents and dantrolene treatment are essential components of an effective MH therapy. In some MH families, a genetic alteration of the ryanodine receptor gene (a calcium channel of the sarcoplasmic reticulum) on chromosome 19 has been identified as the potential cause of MH susceptibility. Recent molecular biological findings support the view of MH being a heterogenetic disease. At present, the diagnosis in potentially MH-susceptible individuals is still made using the in vitro halothane and caffeine muscle contracture test.

[Neonatal resuscitation in the delivery room. What role does the anesthetist play?]. / Neugeborenenreanimation im Kreissaal. Welche Rolle spielt der Anästhesist?

Neonatal resuscitation in the delivery room of small obstetric units is problematic because of the lack of on-site personnel with adequate training and experience. In large university hospitals this task is usually fulfilled by neonatologists who are present 24 h/day. However, in medium-sized and small obstetric units neonatal resuscitation is performed by a variety of professionals: paediatricians, obstetricians, anaesthetists, midwives, nurses, and nurse anaesthetists. The degree of responsibility and involvement of the anaesthesia specialist in the resuscitation of the newborn in Switzerland is unknown, and therefore an investigation was conducted. METHOD. After a telephone inquiry at all the hospitals in Switzerland, a total of 175 obstetric units were identified. A questionnaire with items regarding organisation, responsibilities, and the extent of involvement of the anaesthesia department of the particular hospital was sent to each of the appropriate anaesthetists. RESULTS. Of the 175 questionnaires, 163 (93%) were returned; 14 could not be analysed (5 were sent to hospitals where there was in fact no obstetric unit and 9 were sent to anaesthetists who shared responsibilities for one unit). In 1988, 76,505 babies were born in Switzerland; two-thirds of these were delivered in hospitals with an annual birth rate of less than 600 births per year. Of the 149 questionnaires that were eligible for further analysis, 118 (79%) documented participation of the anaesthetic team in the resuscitation of the newborn. However, only 22% of these departments had an official contract with the hospital administration. Ninety-nine per cent of all responders agreed that every anaesthetist should have the knowledge--both theoretical and practical--to resuscitate a newborn infant. However, reservations were expressed on how to acquire and how to maintain this competence. The initial evaluation of the newborn was done by an anaesthetist in 3% (2250/76,505) of all deliveries in Switzerland in 1988; 1.2% (882/76,505) of these babies needed bag-and-mask ventilation and in 0.4% (308/76,505) endotracheal intubation was performed by the anaesthetist. Proceeding on the assumption that 5% of all newborns need some sort of resuscitation immediately after birth, it is estimated that in 1988 approximately one-third of resuscitations were performed by anaesthetists. It is therefore concluded that anaesthetists play an important role in the resuscitation of newborns in Switzerland.

Lumbovertebral syndrome after extradural blood patch.

We describe a patient who developed an immobilizing lumbovertebral syndrome after an extradural blood patch and who was hospitalized with a suspected extradural abscess. An infectious aetiology of the persistent backache could be excluded and the patient recovered with analgesics and physiotherapy. The probable aetiology is discussed.

Paravascular lumbar plexus block: block extension after femoral nerve stimulation and injection of 20 vs. 40 ml mepivacaine 10 mg/ml.

The goal of this prospective randomized study was to assess the extension of the "three-in-one" paravascular lumbar plexus block after femoral nerve stimulation and injection of 20 vs. 40 ml mepivacaine 10 mg/ml. Three-in-one blocks were achieved in 12 of 39 (31%) patients given 20 ml of 1% mepivacine (group 1), and 17 of 41 (41%) patients given 40 ml (Group 2) of the same solution (n.s.). The level of successful blockade at each nerve did not differ between groups. The femoral nerve was blocked in 92% vs. 93% of patients in groups 1 and 2, respectively; the obturator nerve in 62% vs. 78%; and the lateral cutaneous femoral nerve in 41% vs. 44%. We conclude that femoral nerve stimulation is effective in faciliating blockade in the femoral nerve but not the obturator or lateral cutaneous femoral nerve with the tested solution and volumes, and therefore not particularly effective for achieving complete 3-in-1 blockade. Within the clinically relevant range of 20-40 ml, the volume of mepivacaine 10 mg/ml does not appear to influence the extent of blockade.

Effects of three different types of management on the elimination kinetics of volatile anaesthetics. Implications for malignant hyperthermia treatment.

The effectiveness of three types of management on the elimination kinetics of volatile anaesthetics was studied prospectively in 45 patients randomised to one of three groups. Patients were anaesthetised using isoflurane. Inspiratory and expiratory isoflurane concentrations were measured. After reaching a steady-state isoflurane concentration, the vaporizer was turned off. In group 1, only the fresh gas flow was increased from 40 to 120 ml.kg-1 x min-1. Patients in group 2, in addition to the increase in the fresh gas flow, had a charcoal filter connected in the inspiratory limb of the circuit. Patients in group 3 had the fresh gas flow increased and the anaesthetic machine and breathing system changed. There was a statistically significant difference in the isoflurane washout from the anaesthetic machines between group 1 (90% elimination time 39 [10] s) and group 2 (90% elimination time 25 [5] s) (p < 0.01). However, there was no significant difference in the isoflurane washout from the patients in any of the groups. Thus the use of a charcoal filter or a change of the anaesthetic machine and breathing system proved to be of no clinical advantage.