Case Disussions

From: drtahbildar@rediffmail.com>Date: Jul 3, 2007 8:14

name: Dr. Utpal Tahbildar.address:

Institute of Child and Woman Health Care, Mother Teresa Road city: Guwahati.

query

I am sending the following case record for finding out the cause

:HYPERPYREXIAA two years male patient, weight 10 kgs, of complete bilateral cleft lip and palate with ASA-I , no history of previous anaesthetic exposure, no allergy, no family history of any anaesthetic complications was posted for lip repair under General Anaesthesia. Minimal laboratory investigations were done and all were within normal limit. Patient was fasting for four hours preoperative and then premeditated with Glycopyrolate 0.1 mg I.V. and Ketorolac 10 mg I.V. Induced with Ketamine 20 mg I.V. and Succinylcholine 20 mg I.V. Patient was intubated with 4.5mm RAE ETT, IPPV done with oxygen and nitrous oxide and maintaining relaxation with Atracurium 4mg and 2 mg I.V. Duration of operation was 65 minutes. Injection Cefotaxime 500 mg I.V. given. Patient was reversed with Neostigmine 0.5 mg and Glycopyrolate 0.1 mg I.V. and extubated. Patient was crying and maintaining the vitals without any supplementation. Patient was shifted to recovery room and observed. Intravenous maintenance fluid was continued. During the intraoperative period also everything was normal including Heart rate, SPO2, ETCO2 etc. After one hour in the recovery room patients Heart rate was 112/min. and SPO2 was 99% without supplementation, no bleeding from the wound. Patient was shifted to the ward. His temperature was 98 F and after two and half hours it became 99F and heart rate became 134/min. After three hours of operation patients temperature suddenly shot up to 108F ,heart rate to 198/min. and respiratory rate to 78/min and patient was restless. Initial measures were taken in the ward to control the temperature and the patient was shifted to ICU where he was managed accordingly. For temperature control we used the surface cooling measures and Injection Paracetamol. The patient had squint and small phallus with bilateral complete cleft lip and palate. There was no muscle rigidity at any point of time. But he developed seizure in the ICU which was controlled. I gave Lasix and Mannitol to prevent cerebral oedema. His urine was clear. His S. Creatinine level was 1.5 mg/dL, S. Sodium was 134 mEq/L, S. Potassium was 4.5 mEq/L, S. Calcium was 6.7 mg/dL, Albumin was 3.6 gm/dL, LDH was 8970 U/L, Creatine Kinase was 13080 U/LAfter various resuscitative measures the patient developed respiratory failure and was put on ventilator. In course of time all measures failed and patient had Cardiac arrest and he unfortunately died after 21 hours of surgery.

query

Now what may be the cause of the hyperpyrexia which led to the death of the patient?

Can we think it a case of Malignant Hyperthermia?

Dr. Utpal Tahbildar

AnaesthesiologistInstitute of Child and Woman Health Care A unit of Dr. Kuntal Goswami Memorial Public Charitable TrustMother Teresa Road, Guwahati, PIN- 781024, Assam, IndiaEmail: drtahbildar@rediffmail.com, Phone: +919864010359