TY - THES A1 - Isbary, Susanne T1 - Evaluierung der Malignen Hyperthermie-Triggerpotenz von Succinylcholin im Tiermodell sowie durch retrospektive Analyse Maligne Hyperthermie-verdächtiger Narkosefälle T1 - Evaluation of the effect of succinylcholine on malignant hyperthermia susceptible swine and retrospective data analysis of malignant hyperthermia suspected events in humans N2 - Die Maligne Hyperthermie (MH) ist eine autosomal dominant vererbte latente metabolische Myopathie, die durch Exposition mit volatilen Anästhetika oder depolarisierenden Muskelrelaxantien vom Succinylcholin-Typ in disponierten Individuen zu einem potentiell lebensbedrohlichen hypermetabolen Syndrom der Skelettmuskulatur führen kann. Der Pathomechanismus basiert auf einer unkontrollierten sarkoplasmatischen Kalziumfreisetzung über funktionell veränderte Ryanodin- (RYR1) oder Dihydropyridinrezeptoren (DHPR) und resultiert in einer stark erhöhten Stoffwechselreaktion der Zelle. Die klinische Symptomatik umfasst Anstieg des Kohlendioxidpartialdrucks und der Körperkerntemperatur, sowie Tachykardie, Laktatazidose und erhöhte Muskelrigidität. Der Goldstandard für die Diagnostik einer MH-Veranlagung ist der Koffein-Halothan-In-vitro-Kontrakturtest (IVCT). Volatile Anästhetika sind unbestritten in der Lage eine MH-Krise auszulösen, während die Rolle von Succinylcholin bis heute kontrovers diskutiert wird. In dieser Studie wurde der Einfluß von Succinylcholin in der Entstehung einer MH-Krise an MH-veranlagten (MHS) und MH-nichtveranlagten (MHN) Schweinen untersucht. Es wurden die hämodynamischen und metabolischen Veränderungen nach Gabe von Succinylcholin, Halothan oder beider Substanzen analysiert. Hierfür wurden nach Zustimmung der lokalen Ethikkommission 27 MHS und 30 MHN Tiere narkotisiert und beatmet. Nach Narkoseeinleitung wurden CO2- Messsonden in der V. femoralis und dem M. triceps brachii platziert. Die Tiere wurden in 3 Versuchsgruppen unterteilt: Gruppe A erhielt Succinylcholin intravenös in einer Dosierung von 4mg/kg, Gruppe B Halothan in steigender Konzentration (0,5, 1.0 Vol%) und Gruppe C Succinylcholin und Halothan in Kombination. Die Vitalwerte wurden kontinuierlich überwacht. Vor Zugabe der Triggersubstanzen waren die Vitalwerte zwischen den MHS und MHN Tieren vergleichbar. In der Gruppe der MHN Tiere zeigten sich keine relevanten Änderungen der hämodynamischen und metabolischen Parameter. Succinylcholin oder Halothan induzierten signifikante metabolische und hämodynamische Veränderungen in den MHS Schweinen. In der Gruppe der MHS Tiere, die beide Substanzen in Kombination erhielten wurden diese Effekte noch potenziert. In dieser Studie konnte nachgewiesen werden, dass Succinylcholin als alleiniger Trigger eine MH auslösen kann. Im zweiten Teil der vorliegenden Arbeit wurden die Daten von 1124 Patienten, die sich aufgrund eines MH-verdächtigen Narkosezwischenfalls an der MH-Ambulanz in Würzburg zwischen 1974 und 2012 vorstellten und mittels eines IVCT untersucht wurden retrospektiv untersucht. In die Studie wurden 198 Patienten eingeschlossen. Der intraoperative Verlauf wurde anhand von Narkoseprotokollen rekonstruiert. 60 Patienten wurden als MHS, 18 als MHSh (muskuläre Kontrakturentwicklung nur nach Halothan Exposition), 3 als MHSc (muskuläre Kontrakturentwicklung nur nach Koffein Exposition) und 117 als MHN klassifiziert. Succinylcholin wurden zur Narkoseführung in 90% aller MHS Patienten und 89% aller MHN Patienten verwendet. Succinylcholin wurde in 21% der MHS Patienten als einziger MH-Trigger eingesetzt. Ausschließlich volatile Anästhetika kamen in 10% der MHS Patienten zum Einsatz. In einem Großteil der MHS und MHN-Fälle fiel nach Gabe von Succinylcholin ein Masseterspasmus auf. Herzrhythmusstörungen und erhöhte CO2 Werte waren ebenfalls häufig zu beobachten. Dantrolen wurde nur in wenigen Fällen appliziert. Zusammenfassung: Succinylcholin konnte in unserer Studie eine MH als alleiniger Trigger auszulösen. Die Kombination von Halothan und Succinylcholin verstärkt die hämodynamischen und metabolischen Veränderungen im Verlauf einer MH deutlich. Neuere Inhalationsanästhetika sind zwar weniger potent als Halothan, können aber ebenfalls eine MH auslösen. Die MH ist somit auch heute noch eine ernst zu nehmende Komplikation in der Anästhesie, die zum Tode des Patienten führen kann. Jeder Anästhesist und Intensivmediziner muss in der Lage sein dieses Krankheitsbild zu erkennen und zu therapieren. Bei Anwendung von MH-Triggersubstanzen in der Narkoseführung muss Dantrolen als Mittel der Wahl für eine Therapie zur Verfügung stehen. N2 - Malignant hyperthermia (MH) is an autosomal dominant potentially lethal metabolic myopathie, which develops in predisposed individuals after exposure to trigger substances: depolarizing neuromuscular blocking agents and volatile anesthetics. In skeletal muscles of MH susceptible (MHS) individuals, mutated ryanodine receptors (RYR1) or dihydropyridin receptors (DHPR) lead to a massive intracellular Ca2+-release with an enhanced mitochondrial energy consumption. Besides an overwhelming production of carbon dioxide, clinical signs of MH include heat production, tachykardia, lactat acidosis and an increase of muscle rigidity. The standard procedure for diagnosing MH-susceptibility is the halothane-caffeine-contracture test (IVCT), which requires an invasive muscle biopsy. The impact of volatile anaesthetics to induce MH is abundantly clear, while the role of succinylcholine still remains controversial. To evaluate the influence of succinylcholine on porcine MH events, the hemodynamic and metabolic responses in MH susceptible (MHS) and non-susceptible (MHN) swine following either succinylcholine or halothane application alone or a combination of both substances were analyzed. 27 MHS and 30 MHN pigs were anaesthetized and mechanically ventilated after the approval of the local animal care committee. Fiberoptic probes for continuous pCO2 -measurement were inserted into the femoral vein and the triceps muscle. Group A received succinylcholine 4 mg/kg, group B incremental doses of halothane (0.5, 1.0, 2.0 vol%) and group C succinylcholine and halothane simultaneously. Vital signs were recorded continuously. Prior to drug application measured values did not differ between MHS and MHN. Succinylcholine and halothane lead to significant hemodynamic and metabolic changes in MHS swine. The combination of both pharmacological agents potentiated the observed effects. Consequently succinylcholine acted as an independent and supportive factor during onset of an MH episode. In the second part of the study, patients data of a suspected MH episodes during general anesthesia were analyzed, referred to the Wuerzburg MH unit between 1974 and 2012. Only patients with a suspected MH episode during general anesthesia and patients who underwent an IVCT were included in the investigation. The incidents were evaluated retrospectively using anesthetic documentation and medical records. Between 1974 and 2012 a total of 198 patients were tested. 60 patients were diagnosed MH-susceptible, 18 MHSh (pathological muscle contracture only after halothane exposure), 3 MHSc (pathological muscle contracture only after coffein exposure) and 117 MH-non-susceptible by IVCT. 90% of the MHS patients and 89% of the MHN patients unterwent a general anaesthesia with the use of succinylcholin. 21% of the MHS patients received only succinylcholine and in 10% of the MHS patients only volatile anaesthetics were applied. In the majority of the cases masseter spasm after succinylcholine had been the primary symptom. Cardiac arrhythmias and hypercapnia frequently occurred in the early course of the events. Interestingly, dantrolene treatment was initiated in a few cases only. Conclusion: Succinylcholine was able to induce an MH crisis in our study as a sole trigger. The combination of succinylcholine and a volatile anaesthetic amplified the hemodynamic and metabolic changes. Modern inhalation anesthetics are less potent trigger substances, but were also able to induce a fulminant MH. MH is still an important anesthetic complication. Every anesthesist must be aware of this life-threatening syndrome at any time. Dantrolene must be readily available wherever MH triggering agents are used for anesthesia. KW - Maligne Hyperthermie KW - Tiermodell KW - Narkosezwischenfall KW - Succinylcholin KW - Succinylcholine KW - In Vitro Kontrakturtest KW - in vitro contracture test KW - Volatile Anästhetika KW - volatile anesthetics Y1 - 2016 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-146337 ER - TY - JOUR A1 - Schuster, Frank A1 - Johannsen, Stephan A1 - Moegele, Susanne A1 - Metterlein, Thomas A1 - Roewer, Norbert A1 - Anetseder, Martin T1 - The effect of succinylcholine on malignant hyperthermia events in susceptible swine N2 - Background While the impact of volatile anaesthetics to induce malignant hyperthermia (MH) is abundantly clear, the role of succinylcholine still remains controversial. To evaluate the influence of succinylcholine on porcine MH events, the authors investigated the hemodynamic and metabolic responses in MH susceptible (MHS) and non-susceptible (MHN) swine following either succinylcholine or halothane application alone or a combination of both substances. Methods With approval of the local animal care committee 27 MHS and 30 MHN pigs were anaesthetized and mechanically ventilated. Fiberoptic probes for continuous PCO2 measurement were inserted into the femoral vein and the triceps muscle. Group A received succinylcholine 4 mg/kg, group B incremental doses of halothane (0.5, 1.0 vol%) and group C succinylcholine and halothane simultaneously. Vital signs were recorded continuously. Results Prior to drug application measured values did not differ between MHS and MHN. While MHN pigs did not show relevant alterations, succinylcholine, halothane and the combination of both lead to significant hemodynamic and metabolic changes in MHS swine. Conclusions Hemodynamic and metabolic alterations following succinylcholine were similar to halothane in MHS pigs. The combination of both pharmacological agents potentiated the observed effects. According to these results succinylcholine acted as an independent and supportive factor during onset of an MH episode. KW - Malignant hyperthermia KW - Succinylcholine KW - Halothane KW - Swine Y1 - 2014 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-110302 ER - TY - JOUR A1 - Schuster, Frank A1 - Johannsen, Stephan A1 - Schneiderbanger, Daniel A1 - Roewer, Norbert T1 - Evaluation of suspected malignant hyperthermia events during anesthesia JF - BMC Anesthesiology N2 - Background Malignant hyperthermia (MH), a metabolic myopathy triggered by volatile anesthetics and depolarizing muscle relaxants, is a potentially lethal complication of general anesthesia in susceptible patients. The implementation of modern inhalation anesthetics that research indicates as less potent trigger substances and the recommended limitations of succinylcholine use, suggests there may be considerable decline of fulminant MH cases. In the presented study, the authors analyzed suspected MH episodes during general anesthesia of patients that were referred to the Wuerzburg MH unit between 2007 and 2011, assuming that MH is still a relevant anesthetic problem in our days. Methods With approval of the local ethics committee data of patients that underwent muscle biopsy and in vitro contracture test (IVCT) between 2007 and 2011 were analyzed. Only patients with a history of suspected MH crisis were included in the study. The incidents were evaluated retrospectively using anesthetic documentation and medical records. Results Between 2007 and 2011 a total of 124 patients were tested. 19 of them were referred because of suspected MH events; 7 patients were diagnosed MH-susceptible, 4 MH-equivocal and 8 MH-non-susceptible by IVCT. In a majority of cases masseter spasm after succinylcholine had been the primary symptom. Cardiac arrhythmias and hypercapnia frequently occurred early in the course of events. Interestingly, dantrolene treatment was initiated in a few cases only. Conclusions MH is still an important anesthetic complication. Every anesthetist must be aware of this life-threatening syndrome at any time. The rapid onset of adequate therapy is crucial to avoid major harm and possibly lethal outcome. Dantrolene must be readily available wherever MH triggering agents are used for anesthesia. KW - Malignant hyperthermia KW - In vitro contracture test KW - Succinylcholine KW - Volatile anesthetics Y1 - 2013 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-96231 UR - http://www.biomedcentral.com/1471-2253/13/24 ER -