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calcium, potassium, and serum enzymes (creatine phosphokinase [CPK], glutamic oxalic transaminase, glutamate pyruvate transaminase); and elevated concentrations serum myoglobin. 1 Dantrolene sodium is the drug of choice for the treatment of MH because of its ability to stop this catabolic process and lower body temperature. We experienced a patient who developed postoperative hyperthermia after receiving propofol anesthesia during an alveolar cleft bone grafting procedure with a graft from the iliac crest. The patient's condition was characterized by myoglobinuria

EtCO 2 quickly rose to over 80 mmHg. The SpO 2 had also decreased gradually to its lowest point of 95%. At this point the skin temperature was only 34–35°C. A presumptive diagnosis of malignant hyperthermia was made, and the emergency cart containing a malignant hyperthermia kit was obtained. EMS was activated and the clinic nurse apprised Columbus Children's Hospital (CCH) of the situation. A second 20 g IV was obtained at the left hand, and 0.9 normal saline was administered through both IV lines. Dantrolene was reconstituted with sterile water as quickly

surgery, which were managed successfully by administration of continuous veno-venous hemofiltration (CVVH) in the absence of availability of dantrolene. CASE REPORT Case 1 A 25-year-old man with dentofacial deformities, weighing 60 kg, was scheduled for a maxillary osteotomy. His initial axillary temperature was 36.5°C. He had not been diagnosed with any muscular disorder, nor had he experienced chronic muscle pain previously, and his family's medical history was noncontributory. The patient was premedicated with 100 mg of

Prior to 1979, the mortality rate for fulminant malignant hyperthermia (MH) was 64%. 1 , 2 The approval of dantrolene sodium by the US Food and Drug Administration in that year enabled health care providers to successfully treat the symptoms of MH and reverse the deadly effects of the disease. Today, the mortality rate of MH has dropped dramatically; a patient who develops an acute case of MH has a 95% chance of survival if treated appropriately. 3 , 4 MH is an extremely rare, hypermetabolic disease state associated with impaired

Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment. Larach MG, Klumpner TT, Brandon BW, Vaughn MT, et al. on behalf of the Multicenter Perioperative Outcomes Group. Anesthesiol . 2019;130:41–54. Dantrolene is an effective treatment for malignant hyperthermia (MH). Succinylcholine and volatile anesthetic agents are potential triggers for inducing MH; however, discrepant recommendations for emergency preparedness exist regarding the availability of dantrolene during general anesthesia. The Malignant

) How much dantrolene should be available in facilities where volatile agents are not available or administered, and succinylcholine is stocked on site only for emergency purposes? (2) What defines masseter muscle rigidity? What is its relationship to MH, and how should it be managed when it occurs? (3) What is the relationship between MH susceptibility and heat- or exercise-related rhabdomyolysis? (4) What evidence-based interventions should be recommended to alleviate hyperthermia associated with MH? (5) After treatment of acute MH, how much dantrolene should be

developing MH with a nontriggering agent, MH-susceptible patients may safely undergo procedures using a nontriggering anesthetic technique in a free-standing ASC. Based on a lack of supporting evidence, pretreatment of MH-susceptible patients with dantrolene is not recommended. Anesthetic plans for MH-susceptible patients should avoid MH triggering agents, and additional core temperature monitoring beyond that recommended in basic intraoperative standards should be implemented. Preparations need to ensure that dantrolene can be administered within 10 minutes from the first

facilities are performed exclusively with oral or intravenous sedative-hypnotics and/or analgesics. These facilities typically do not stock dantrolene because no known triggers of malignant hyperthermia (ie, inhaled anesthetics and succinylcholine) are available. This article argues that, in the absence of succinylcholine, the morbidity and mortality from laryngospasm can be significant, indeed, higher than the unlikely scenario of succinylcholine-triggered malignant hyperthermia. The Society for Ambulatory Anesthesia (SAMBA) position statement for the use of

replacing Sch as an emergency drug with rocuronium and sugammadex in practice, these practitioners can avoid using any MH-triggering agents. Avoidance of all MH-triggering agents would enable these providers to no longer carry dantrolene and all the other medications and ancillary equipment necessary to manage an MH crisis. 23 This results in the elimination of the excessive cost associated with dantrolene, but more importantly, it also eliminates the rare complication of MH, which can be fatal or lead to renal failure even with prompt and appropriate management. The

to be rationed nor how long the shortage will exist, the wise practitioner should consider having perhaps a 6-month supply of each drug that is considered invaluable to his/her practice. A review of the year’s previous purchase records could be a reasonable guide to determine how many packages of each critical drug should be the 6-month minimum in stock before reordering. Drugs such as propofol, midazolam, ketamine, fentanyl, remifentanil, esmolol, ephedrine, epinephrine, phenylephrine, atropine, lidocaine, sevoflurane, dantrolene, and succinylcholine are fairly