Malignant hyperthermia is a rare condition that occurs in susceptible patients exposed to triggering anesthetic agents. It is associated with a high mortality rate if not recognized immediately and treated appropriately. A 52-year-old man presented to our clinic 2 days after an assault for management of jaw pain. A minimally displaced right parasymphyseal fracture and moderately displaced left body fracture of the mandible were diagnosed. There were no known drug allergies. The patient reported no previous difficulty with anesthesia, as well as no known prior adverse reactions to anesthesia in any relatives. The planned surgical intervention was open reduction-internal fixation of bilateral mandibular fractures. The patient received succinylcholine and desflurane during the procedure. A full 70 minutes elapsed before initial signs of hypermetabolism were noted, namely a rise in end-tidal carbon dioxide level. The patient received dantrolene sodium approximately 120 minutes after induction of anesthesia. Signs of hypermetabolism began to abate within 45 minutes of commencement of the malignant hyperthermia treatment protocol. He was subsequently transferred to the surgical intensive care unit for continued management and had a favorable postoperative course. This case underscores the importance of awareness of malignant hyperthermia and its presentation. This condition carries a potential high risk of complications after exposure to triggering anesthetic agents. Taking a complete and detailed history may help to identify potential cases. In this case, it was subsequently discovered that the patient's biological sister had a nearly fatal reaction to general anesthesia several years before this incident. Intraoperative vigilance in the monitoring of vital signs cannot be overemphasized. An increase in end-tidal carbon dioxide values, in addition to other clinical signs that cannot be easily attributed to other causes, should increase the clinical index of suspicion for a diagnosis.

There is a growing body of literature documenting the use of deep neuromuscular block (NMB) during surgery. Traditional definitions of depth of NMB rely on train-of-four assessment, which can be less reliable in retrospective studies. The goal of our study was to investigate the real-world practice pattern of dosing of neuromuscular blocking agents (NMBA), utilizing the amount of NMBA used during the course of a case, adjusted for patient weight and case duration, as a surrogate measure of depth of NMB. We also aimed to identify case factors associated with larger NMBA doses. In this retrospective observational analysis of our anesthesia information management system, we analyzed all general endotracheal anesthesia cases from 2012 to 2015 in which an intermediate-acting NMBA was used. Cases using a long-acting NMBA or only succinylcholine were excluded. The expected duration of the case was calculated based on the cumulative dose of NMB used, normalized to the patient's ideal body weight and the ED95 of the drug. If the expected duration of the case was greater than the actual case duration documented in the case record, it was classified as higher dosing (HD). If the expected duration was equal to or less than the actual duration, it was considered predicted dosing (PD). Categorical comparisons between HD and PD groups were made for various patient, procedural, and provider factors. 72,684 cases were included in the final analysis, of which 46,358, or 64% of cases, used HD. Cases with patients who were morbidly obese, younger than 65 years, and who were lower ASA Physical Status classification (I or II) used more HD as opposed to PD. Cases that were non-open, used total intravenous anesthesia, emergent cases, or used non-rapid sequence anesthesia induction had higher rates of HD than their matched counterparts. All results were statistically significant. HD was more common in cases that documented train-of-four and used the reversal agent neostigmine. Approximately two-thirds of general endotracheal anesthesia cases using an intermediate-acting NMBA used HD. Cases with higher rates of HD may be those that are traditionally technically complex or emergent, would benefit from greater paralysis, or do not use adjunctive medications for muscle relaxation. Age greater than 65 years was shown to have lower rates of HD, likely due to provider awareness of age-related changes in pharmacokinetics and pharmacodynamics. Intraoperative monitoring and NMB antagonism with neostigmine were used more frequently with HD.

Malignant hyperthermia (MH) is a life-threatening hypermetabolic state that can occur following induction with depolarizing neuromuscular blockade and volatile anesthesia gases. Because succinylcholine is a common choice for prehospital and emergency department inductions, it is important for staff to be able to recognize and effectively treat an MH crisis. This case study highlights a 20-year-old male trauma patient who presented to a Level I trauma center and was intubated for declining mental status. He developed suspected MH following his anesthetic induction with succinylcholine. The following outlines the case, clinical identification of MH, and treatment.

No information is available on the use of succinylcholine during breastfeeding. Because it is rapidly eliminated and poorly absorbed orally, it is not likely to reach the bloodstream of the infant or cause any adverse effects in breastfed infants.[1][2] A general anesthetic regimen that included succinylcholine for cesarean section caused a delay in the time to the first breastfeeding, but the part that succinylcholine played in this difference in outcome in unknown.

Myotonic dystrophy type 1 (DM1) is a multisystem disorder that affects skeletal and smooth muscle as well as the eye, heart, endocrine system, and central nervous system. The clinical findings, which span a continuum from mild to severe, have been categorized into three somewhat overlapping phenotypes: mild, classic, and congenital. Mild DM1 is characterized by cataract and mild myotonia (sustained muscle contraction); life span is normal. Classic DM1 is characterized by muscle weakness and wasting, myotonia, cataract, and often cardiac conduction abnormalities; adults may become physically disabled and may have a shortened life span. Congenital DM1 is characterized by hypotonia and severe generalized weakness at birth, often with respiratory insufficiency and early death; intellectual disability is common.

Sugammadex is a novel drug capable of reversing paralysis induced by the common steroidal nondepolarizing neuromuscular blocking drugs, rocuronium and vecuronium. Reversal is complete at any depth of blockade dependent on the dose of sugammadex administered. This allows rocuronium to be used as a rescue agent in scenarios where succinylcholine is contraindicated. Sugammadex is considered a safe drug with minimal side effects compared with traditional reversal with neostigmine and glycopyrrolate. This article features a case report where succinylcholine was undesirable and rapid reversal of paralysis with sugammadex was used during general anesthesia for dentistry.

Deciding on proper medication administration for the traumatic brain injury (TBI) patient undergoing intubation can be daunting and confusing. Pretreatment with lidocaine and/or vecuronium is no longer recommended; however, high-dose fentanyl can be utilized to help blunt the sympathetic stimulation of intubation. Induction with etomidate is recommended; however, ketamine can be considered in the proper patient population, such as those with hypotension. Paralysis can be performed with either succinylcholine or rocuronium, with the caveat that rocuronium can lead to delays in proper neurological examinations due to prolonged paralysis. Recommendations for post-intubation continuous sedation medications include a combination propofol and fentanyl in the normotensive/hypertensive patient population. A combination midazolam and fentanyl or ketamine alone can be considered in the hypotensive patient.

The prevalence of malignant hyperthermia (MH) in Germany is 1:2000-1:3000 and therefore more common than previously assumed, so that anesthesia personnel will more often be confronted with susceptible patients in the clinical setting. After the initial treatment with 2.5 mg/kg body weight dantrolene, further therapy using up to 10 mg/body weight dantrolene can be indicated for 24 h. Under these circumstances it is important to have a sufficient amount of water available for injection purposes. For outpatient anesthesia a stockage of dantrolene is not necessary as long as the use of MH trigger substances in general is strictly avoided. The introduction of Ryanodex® (Eagle Pharmaceuticals, Woodcliff Lake, NJ, USA), a preparation of dantrolene with clearly improved pharmacological properties, in the clinical practice has not yet been realized in Germany.