DEATH BY ANESTHESIA---MALIGNANT HYPERTHERMIA

By Dr. Stephen Juan

At least ten Australians die each year as a direct result of anesthesia. Another twenty deaths are partly due to an anesthetic. This is according figures from the National Health and Medical Research Council (NHMRC). The NHMRC claims that “as many States did not have adequate reporting procedures for such deaths, the actual number of deaths was probably much higher.” Sudden and unexpected deaths of a healthy individual undergoing minor surgery such as liposuction or undergoing a caesarean-section delivery under general anesthesia should never happen in this age of high tech medical care. But occasionally this can and does still happen.

Why?

Sometimes the cause is a strange syndrome known as malignant hyperthermia (MH).

MH is a chain reaction of symptoms triggered by commonly used general anesthetics and perhaps a few other drugs. According to Dr. Harold Rosenberg of the Department of Anesthesiology at the Thomas Jefferson University in Philadelphia, writing in the online “Mortality Associated With Anesthesia” (2009), when MH was first recognized in 1960 (two Australian doctors, Michael Denborough and Richard Lovell first described it), 80 per cent of those who suffered from it died. Survivors were often left with severe brain damage, failed kidneys, or other impaired organs.
The symptoms include a greatly increased body metabolism, muscle rigidity, and a fever of 43 degrees C. (110 degrees F.) or more. Death may result from cardiac arrest, brain damage, internal hemorrhaging, or failure of other body systems.

Susceptibility to MH runs in families. It is genetically inherited. We have known this since 1992 with the work of Dr. F. Richard Ellis of the St. James Hospital in Leeds published in the BRITISH MEDICAL JOURNAL. It is also believed that the gene responsible is dominant and resides on the long arm of chromosome 19. Dr. Ellis stresses that family members communicate with each other if any member of the family ever experiences a terrible reaction to an anesthetic. It could be that the family is prone to MH.

Those who are susceptible may be completely unaware of the risk until they are exposed to the anesthetic---but by then it may be too late. And it should be noted that not everyone who has the MH gene develops an MH episode during every anesthetic exposure. Even those who have had a prior uneventful operation cannot be certain that they are not at risk. Dr. R.S. Litman and four colleagues from the Department of Anesthesiology and Critical Care at the Children’s Hospital in Philadelphia note in the November 2008 issues of ANESTHESIOLOGY that MH occurs within 40 minutes after the anesthetic is administered.

Although the cause of MH reactions is still unknown, research suggests that a “derangement” occurs involving the processes which regulate muscle contraction. A dangerous chain reaction is set into motion in the body, rather like a meltdown in a nuclear power plant. Certain commonly used anesthetic agents and surgical muscle relaxants induce increased concentrations of calcium in the muscle cells. These high calcium levels cause the muscles to contract and become rigid. This in turn leads to a greatly increased metabolism. And this results in an extremely high fever and eventually muscle cell breakdown.

Early treatment consisted only of cooling the patient and treating the specific symptoms, but not the underlying cause. However, since 1979 and the use of dantrolene sodium as an antidote, there has been a dramatic decline in MH mortality. The Malignant Hyperthermia Association of the United States (MHAUS) recommends that at least 36 vials of dantrolene sodium be on hand at hospitals.
Although there is currently no simple test available for screening the general population for MH, the most accurate diagnostic test involves a biopsy of skeletal muscle from the thigh. This test is usually reserved for families where an MH episode has occurred or where a patient has had a previous suspicious reaction to an anesthetic.
Despite this, surgery can be safe for a known MH-susceptible patient. Anesthetics that do not trigger MH can be used. Other special precautions and techniques can be employed as well, including the very close monitoring of all vital signs in the patient for at least 24 hours after they receive an anesthetic.
Interestingly, some experts believe that potent drugs used in treating some psychiatric conditions may also bring about a reaction in MH-susceptible people. Furthermore, other experts believe that several muscle diseases may predispose people to MH. These diseases include muscular dystrophy, central core disease (failure of muscles), and some forms of myotonia (toxic muscle spasms).

The NHMRC has called on State and territory governments to introduce uniform laws requiring the reporting of all anesthesia-related deaths so they may be investigated.

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Anesthesia administered during liposuction and during a caesarean-section delivery are two medical procedures where an anesthesia death is most likely to occur. Dr. R. Boni of the Center for Liposuction in Zurich, Switzerland writes in the 4 July 2007 issue of PRAXIS that the death rate in liposuction from a general anesthetic is 2.6 to 19.1 per 100,000 patients. Dr. M.F. Haque and three colleagues from the Mymensingh Medical College in Bangladesh write in the July 2007 MYMENSINGH MEDICAL JOURNAL that “anesthetic mishaps are considered as the sixth most frequent cause of maternal mortality.”

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The medical field of anesthesiology in the modern sense began in 1846 when William Thomas Green Morton demonstrated that chemical compounds could produce insensitivity to pain in predictable ways and could be controlled by medical personnel. The first anesthetic was diethyl ether which was originally known as Letheon. This vastly improved the situation for patients although many still died from ether. Chloroform was then introduced as an alternative and the situation further improved. According to Dr. Rosenberg, when mortality from anesthesia was first studied in the 1950, there was approximately one death for every 10,000 anesthesia administrations in an otherwise generally healthy individual.

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Anesthesia is the lack of awareness of surrounding events.

Akinesia is the keeping of the patient still to allow surgery to take place.

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