Malignant hyperthermia (MH) is a subclinical myopathy in which general anesthesia triggers an uncontrollable contraction of skeletal muscle that leads to a life-threatening hypercatabolic state and an increase in body temperature. The disease is primarily autosomal dominant; mutations in receptors (especially ryanodine receptor type 1) predispose to volatile anesthetic agents or succinylcholine causing an accumulation of intracellular calcium in skeletal muscle that leads to its overactivation and hypermetabolism. In the acute setting, diagnosis is based mainly on clinical presentation and end-tidal capnography, which reveals an increase in end-tidal CO2. Immediate treatment measures involve stopping the triggering agent and administration of dantrolene. In nonacute settings, there are specific diagnostic tools (e.g., caffeine-halothane contracture test) to confirm suspected cases. MH is a lethal disease and has a high mortality rate if left untreated.
- Inherited susceptibility: primarily autosomal dominant with reduced penetrance
- Triggering agents
Administration of triggering substances → calcium release from intracellular compartments or delay in its reuptake → ↑ calcium in muscle cells → ↑ contractility of the skeletal muscle → ↑ metabolism → ↑ oxygen consumption in addition to ↑ CO2 production, heat, and lactate (malignant hyperthermia) → mixed respiratory and metabolic acidosis → uncoupled oxidative phosphorylation → breakdown of the cell's energy supply → cell death
- Early signs
- Late signs
Although the rise in body temperature is usually a late sign in malignant hyperthermia, it may occur as an early sign in severe cases.
Diagnosis is generally clinical, based on intraoperative signs and symptoms (e.g., muscle and jaw rigidity, hyperthermia) in connection with increased end-tidal CO2 and signs of muscle breakdown. Patients with a positive family history, suspicious clinical history, or masseter muscle rigidity should receive confirmatory preoperative testing to rule out the risk of MH.
Gold standard: caffeine-halothane contracture test (CHCT)
- A muscle sample is obtained under regional anesthesia.
- The muscle sample is divided with the grain of the fibers into six strips.
- After tissue viability testing via electrical stimulation, the muscle strips are mounted into a bath.
- Three strips are exposed to 3% halothane, and the remaining three other strips are exposed to caffeine.
- The test is considered positive if any of the strips contract.
- Disadvantages: only available at select testing centers, which will likely require the patient to travel.
- Molecular genetic testing: low sensitivity, but highly specific and less expensive and invasive than CHCT
- Clinical features: See “Clinical features” above.
- Respiratory parameters: continuous increase in end-tidal CO2
- Blood tests
- Urine: myoglobinuria
- Discontinuation of potential triggering agents
Immediate administration of dantrolene (ryanodine receptor antagonist)
- Mechanism of action
- Adverse effects
- Cooling measures (e.g., ice packs, cool water blankets, ice-water immersion, IV iced saline, forced air cooling) 
- Increase respiratory minute volume by at least 3-fold.
- Ventilation with 100% O2
- Expedited completion of surgery
Dantrolene directly deals with distressed muscle.