Very Rare ECT Anesthesia Complication: Malignant Hyperthermia Case Report From Japan
Out on PubMed, from authors in Japan, is this case report:
Caution for psychiatrists: malignant hyperthermia risks with the anesthetic agent succinylcholine (Suxamethonium) during electroconvulsive therapy.
BMC Psychiatry. 2024 Jun 4;24(1):411. doi: 10.1186/s12888-024-05846-5.PMID: 38834964
The abstract is copied below:
Background: Malignant hyperthermia is a potentially lethal condition triggered by specific anesthetic drugs, especially a depolarizing muscle relaxant of succinylcholine (Suxamethonium). Despite the frequent use of succinylcholine with electroconvulsive therapy (ECT), there has been no reported case of potentially lethal malignant hyperthermia following ECT. In addition, the time interval between the administration of succinylcholine and the onset of malignant hyperthermia has not been outlined in the context of ECT.
Case presentation: We present the case of a 79-year-old woman suffering from severe depression, who experienced severe malignant hyperthermia due to succinylcholine administration during an ECT session. She presented with a high fever of 40.2 °C, tachycardia of 140/min, hypertension with a blood pressure exceeding 200 mmHg, significant muscle rigidity, and impaired consciousness. These symptoms emerged two hours after ECT, which occurred in a psychiatric ward rather than an operating room, and reached their peak in less than 24 h. She was given 60 mg of dantrolene, which quickly reduced the muscular rigidity. Subsequently, she received two additional doses of 20 mg and 60 mg of dantrolene, which brought her fever down to 36.2 °C and completely eased her muscle rigidity within two days after ECT.
Conclusions: This is the first reported case of potentially lethal malignant hyperthermia after ECT. In addition, it highlights the delayed onset of malignant hyperthermia following an ECT procedure, emphasizing the necessity for psychiatrists to recognize its onset even after the treatment. In the light of potentially lethal consequences of malignant hyperthermia, it is critically important for psychiatrists to closely monitor both intraoperative and postoperative patient's vital signs and characteristic physical presentations, promptly identify any symptomatic emergence, and treat it immediately with dantrolene.
Keywords: Depression; Electroconvulsive therapy; Malignant hyperthermia; Neuroleptic malignant syndrome; Serotonin syndrome; Succinylcholine; Suxamethonium.
`The case report is here.
And from the text:
This is a well-presented case report with a good discussion of the differential diagnosis of malignant hyperthermia, NMS, and serotonin syndrome. The main point is that the onset of malignant hyperthermia may be somewhat delayed.
Interestingly, and fortunately, the patient recovered and also had resolution of her severe depression with the single ECT.
Kudos to our Japanese colleagues for the reminder about this very rare complication and its management.
This case perfectly describes a serotonin syndrome, I would be much more careful to claim a MH.
ReplyDeleteAdditionally, a massive CK rise is a necessary condition for diagnosing MH. This was not the case. Rigidity typically starts with m.masseter, which was not reported. A massive acidosis is also typical for MH, which was not the case.
Also, an interesting theory says that malignant hyperthermia, malignant catatonia and malignant neuroleptic syndrome share a common final pathway just with different triggers. This is supported by the fact that, despite the very frequent use of succinylcholine, malignant hyperthermia occurs incredibly rarely with ECT. After all, there are 1.4 million patients treated worldwide every year. It is therefore possible that malignant hyperthermia can even be treated with ECT