In this scenario, there is a 35 twelvemonth old female patient who develops malignant hyperthermy during surgery. Malignant hyperthermy is an uncommon pharmacogeneric upset that leads to the hypermetabolic reactions of the skeletal musculus. [ Ben Abraham, et Al, 1998, Britt, 1985, Hopkins 2008 ] . Age, type of anaesthetic, environmental temperature, extenuating drugs administered at the same time and grade of emphasis play an of import function in triping malignant hyperthermy. [ Ording, 1985 ] . Primarily, powerful inspiration anaesthetic agents and depolarising musculus relaxants such as succinylcholine are the major triping factor amongst all the triping factors. Malignant hyperthermy can go on at any clip during surgery particularly after the initiation of the anaesthetic and in the early postoperative period. Besides that, there is a inclination of the recurrent of malignant hyperthermy every bit good.
Even though hypermetabolic reaction of skeletal musculus will do hyperthermy and rhabdomyolysis but febrility is non the earliest symptom of malignant hyperthermy. The earliest marks and symptoms of malignant hyperthermy are addition in the end-expired C dioxide concentration ( EtCO2 ) , tachycardia and musculus rigidness ( particularly when succinylcholine is given ) . [ Britt, 1985 ] . Furthermore, the late mark of malignant hyperthermy is lift of the organic structure temperature. [ Ali et Al, 2003 ; Britt,1985 ] .The other marks and symptoms are unstable blood force per unit area, tachypnea, hyperkalemia and arrhythmia.
Harmonizing to Hogan, 1998 the estimated incidence of malignant hyperthermy during anaesthesia in North America and Europe is 1:15000 anaesthetics for kids and striplings and 1:50000- 1:150000 anaesthetics for grownups. [ Hogan, 1998 ] .All cultural groups are affected with malignant hyperthermy and males are more prone to be affected compared to female. [ Britt, 1976 ; Hopkins, 2008 ] . The mortality was about 80 % thirty old ages ago and has been reduced to less than 10 % with the debut of the musculus relaxant dantrolene Na, widespread instruction and clinical and research probe. [ Ali, 2003 ; MacLennan, 1990 ]
Malignant hyperthermy is an familial upset where the Ca channel that mediates the excitement contraction matching in skeletal musculus is mutated. As a consequence, the Ca channel is really sensitive to the anaesthetic agents [ Hopkins, 2008 ] . This will take to the uncontrolled release of cytoplasmatic Ca from the sarcroplasmic Reticulum upon the initiation of anaesthetic agents [ Hopkins, 2008 ; Rosenberg et Al. 2004 ] . As a affair of fact, there is a continued interaction between actin and myosin with sustained musculus contraction [ Hopkins, 2008 ; Rosenberg et Al. 2004 ] . The manifestation of the marks and symptoms of malignant hyperthermy can be explained by the increased release of the Ca. At first, this mechanism is compensated by the resequestion of Ca, which has lead to the dislocation of the adenosine trisphosphate ( ATP ) [ Hopkins, 2008 ; Rosenberg et Al. 2004 ] . This will do the stimulation of the metamorphosis and consequences in increased O ingestion, heat and C dioxide production. The dislocation of the ATP causes the release of the K into the extracellular fluid consequences in hyperkalemia and this will take to the development of cardiac arrhythmias. Besides that, the uninterrupted contraction of the skeletal musculus due to the dislocation of the ATP will take to the farther production of heat. As a consequence, there will be a farther addition of O ingestion, C dioxide and lactic acid production, which, will take to metabolic acidosis [ Britt, 1985 ; Hopkins, 2008 ; Rosenberg et Al. 2004 ] . In add-on, the addition of the production of heat will besides increase the contractility of the skeletal musculus hence further declining the rhabdomyolysis procedure. If malignant hyperthermy is untreated, it might take to critical organ disfunction, acute nephritic failure, disseminated intravascular curdling, congestive bosom failure and even decease.
In this scenario, since the patient developed malignant hyperthermy during surgery, thereby the direction of malignant hyperthermy can be divided into exigency intervention and postoperative intervention. When there is an acute development of malignant hyperthermy during surgery, all triping agents have to be discontinued and the patient has to be hyperventilated with 100 % O to take down the terminal tidal CO2 instantly. This is followed by disposal of 2.5mg/kg dantrolene Na intravenously every 5 minute until the marks and symptoms of malignant hyperthermy are under controlled. [ Morgan et Al. 2006 ] . The dosage of dantrolene can be titrated up to 10mg/kg. [ Gronert et al. , 1976 ; Harrison, 1988 ] . The monitoring of blood gases, all serum electrolytes, musculus enzyme such as cretine kinase, coagulating profile, blood and piss for myoglobin, blood glucose, lactate and urea N must be carried out often during the surgery. Sodium hydrogen carbonate should be given to rectify the metabolic acidosis to the normal degree. In add-on, patient has to be closed monitored and anti-arrhythmic except Ca channel blocker can be given for arrhythmias. Cooling steps have to be initiated if there is the present of hyperthermy. Ice battalions to groin, armpit, and cervix, chilling cover, and nasogastric lavage with iced solution can be used to chilling down the patient. The chilling steps have to be stop if the organic structure temperature is at 38.5oC. In order to handle myoglobinaemia and therefore acute prevent nephritic failure urine end product and urine pH should be greater than 3ml/kg/h and pH7 severally. [ Hopkins, 2008 ] . This diuresis can be achieved by hydrating the patient with crystalloid solutions together with Osmitrol ( 0.3g/kg ) and furosemide ( 0.5-1.0mg/kg ) . [ Hopkins, 2008 ; Mary, 1998 ] . Hyperkalaemia which is life endangering can be treated with glucose, insulin, endovenous Ca and endovenous K chloride. [ Britt, 1979 ; Hopkins, 2008 ] .
Once the surgery is finished, the patient has to be moved to intensive attention unit or recovery room until malignant hyperthermy is under controlled and the patient should be monitored closely. Since it is possible for the recrudescence of malignant hyperthermy, dantrolene should be continued giving to patient for at least 48 hours. [ Flewellen, 1983 ; Rosenberg, 2004 ] . Several laboratory trials such as blood gases, electrolytes, curdling profile, musculus enzyme, blood and piss for myoglobin should be assessed more often. [ Hopkin, 2008 ] .
At first, besides dantrolene, procainamide/ Ethocaine was recommended to handle malignant hyperthermy. The usage of procainamide/ Ethocaine was due to the successful surveies carried out by Harrison, 1971, Denborough, 1972 and Noble, 1973. The survey carried out by Harrison, 1971 showed a successful intervention of malignant hyperthermy with big dosage of endovenous Ethocaine in 2 out of 5 Landrace hogs. However, the survey from Gronert, 1976 showed that the recommendation dosage of procaine/ procainamide was uneffective in forestalling malignant hyperthermy of the 20 susceptible hogs. Study compared the effectivity of dantrolene and procainamide conducted by Nelson, 1979 showed that procainamide did non barricade the contracture response to halothane and it is uneffective for curative and as prophylaxis of malignant hyperthermy. Procainamide or Ethocaine was non been used after all.
Harrison, 1975 demonstrated that dantrolene can loosen up musculus asperity in hogs with malignant hyperthermy and ceased the inordinate heat and acerb production. The survey showed 100 % survival rate in the last seven of eight experiments. Besides that, based on Britt, 1984 that 79 patients who received dantrolene therapy showed a important 16.56 % decrease in mortally ( P & lt ; 0.05 ) . In add-on, there was a important decrease ( P & lt ; 0.01 ) in the chilling rate in dantrolene group in the survey conducted by Channa et al. , 1990. Harmonizing to the survey of the principle for dantrolene versus procainamide for the intervention of malignant hyperthermy carried out by Nelson, 1979 illustrated that 0.8mg/kg dantrolene in vivo reversed the contracture response of malignant hyperthermy musculus strip that induced by halothane and they concluded that dantrolene is effectual in forestalling malignant hyperthermy during general anaesthesia.
Dantrolene is now the lone known curative agent used to handle malignant hyperthermy. Dantrolene is a diphenylhydantoin derived function that is extremely lipid soluble but ailing H2O soluble. [ PMJ & A ; GG Harrison ] . Dantrolene can be administered by unwritten path or endovenous path. Roughly, 70 % of dantrolene is absorbed with the extremum plasma concentration reached in 6 hours following the consumption of dantrolene by oral cavity. From the experiment performed by Harrison 1975, unwritten dantrolene was effectual in handling Ethocaine malignant hyperthermy. However, there is a great fluctuation in the plasma concentration for the unwritten dantrolene particularly in kids. Dantrolene is formulated as lyophilised orange pulverization, which comprises of dantrolene Na, Osmitrol and Na chloride. These contents are dissolved in H2O to give a solution with the pH of 9.5 for endovenous injection. Furthermore, the extra of the Osmitrol is to better the solubility since dantrolene is ailing H2O soluble and Osmitrol besides acts as diuresis, which prevent the hurtful effects of myoglobinaemia. The biological riddance half life of dantrolene is 12 hours. As a consequence, after 12 hours the plasma concentration of dantrolene will be 4.2AAµg/ml with the disposal of 2.4mg/kg organic structure weight of dantrolene intravenously. [ Allen et Al, 1988 ; Muehlschlegel & A ; Sims, 2009 ] . Dantrolene is chiefly metabolized in the liver through oxidization and decrease reaction. Oxidation and decrease of the dantrolene consequence in the production 5-hydroxydantrolene and aminodantrolene severally. Aminodantrolene will so undergo acetylation leads to the formation of reduced acetylated derived function of dantrolene. The metabolites of the dantrolene are excreted in urine and bile with 79 % of 5-hydroxydantrolene, 17 % reduced acetylated derived function of dantrolene and 4 % of the dosage is excreted unchanged in the piss. [ Dykes, 1975 ; Lietman et al, 1974 ] . Furthermore, it has been stated that the metabolites of dantrolene particularly 5-hydroxydantrolene has some musculus relaxant activity. [ Ellis & A ; Wessels, 1978 ; Ali et Al, 2003 ] .
Harmonizing to Malignant Hyperthermia Association ( MHAUS ) the recommended dose of dantrolene is about 2-3mg/kg. [ Schulte-Sasse ] . It had been stated by Flewellen & A ; Nelson 1980 that, 95 % of the skeletal musculus of swine was depressed with the disposal of 3.5mg/kg dantrolene intravenously. In add-on, clinical survey showed that disposal of 2.4mg/kg of dantrole intravenously was able to deject 75 % of the skeletal musculus in human. [ Flewellen et al. , 1983 ] . The dosage was proved to be effectual in the intervention of malignant hyperthermy. [ Hall et Al, 1980 ; Kolb et Al, 1982 ] . Therefore, for acute malignant hyperthermy crisis, 2.4mg/kg of endovenous dantrolene is effectual in life-saving of handling malignant hyperthermy. [ Harrison 1988 ; Allen et Al. 1988 ; Flewellen et al. , 1983 ] . The individual dosage of unwritten dantrolene that is presently given to patient is 1-2mg/kg four times a twenty-four hours. [ Pandit et Al, 1979 ; Fitzgibbons, 1981 ] . However, it was found that this recommended dosage of unwritten dantrolene was non effectual in forestalling malignant hyperthermy in human. [ Fitzgibbons, 1981 ; Flewellen et Al, 1983 ] . Administration of unwritten dantrolene has been recommended before the operation and after the malignant hyperthermy crisis to forestall the recrudescence. Besides disposal unwritten dantrolene, dantrolene can besides be given intravenously as a prophylaxis therapy after the crisis. [ Flewellen et Al, 1983 ] . The contraceptive uninterrupted endovenous dosage of dantrolene is about 2.4mg/kg. [ Flewellen et Al, 1983 ] .
Dantrolene is a musculus relaxant, which, acts on skeletal musculus cell to suppress the release of Ca from sarcoplasmic Reticulum. This will cut down the contractility of the skeletal musculus cell. Harmonizing to Ellis,1973, the relaxant action of dantrolene acted straight and specifically on skeletal musculus but did non move on cardiac and smooth musculus. Besides that, dantrolene did non hold any action on cardinal nervous system. [ Harrison,1988 & A ; Ellis, 1972 ] . Harrison and Chapman 1982, stated that the decrease in the sum and rate of Ca release by dantrolene is effectual in forestalling and change by reversaling the pathophysiology of malignant hyperthermy in patient. In the experiment carried out by Harrison, 1975 has demonstrated that disposal of dantrolene will do a relaxation of the musculus asperity, surcease of the production of heat and acid.
Based on the survey carried out by Nelson, 1996 dantrolene is clinically effectual in the intervention of malignant hyperthermy and showed a singular decrease in decease and syndrome associated with malignant hyperthermy. When the syndrome of malignant hyperthermy was foremost noticed by the universe during 60s, the rate of mortality was approximately 80 % . The increasing consciousness of syndrome with end point in earlier diagnosing and intervention markedly reduced the mortality to 28 % during 70s. With the debut of the dantrolene, the rate of mortality reduced to 7 % . [ Harrison, 1988 ] . In add-on, the experiment done by Harrison, 1988 showed that 100 % survival rate was achieved with the disposal of dantrolene.
Long term disposal of dantrolene orally is associated with some side effects such as hepatotoxicity and emesis, which sometimes may be accompanied by diarrhoea. [ Faling et Al, 1980 ; Wilkinson et Al, 1979 ] . However, the happening of hepatotoxicity is rare and several surveies have been failed to turn out whether hepatotoxicity is due to consumption of dantrolene orally entirely. [ Flewellen et Al, 1983 ; Dykes 1975 ; Durham et Al, 1984 ] . As the reconstitution solution that is formulated for endovenous injection is extremely alkalic, if extravasation occur it may annoy the vena which will take to phlebitis and weave mortification. Therefore, dantrolene is recommended that to be injected into the big vena via a cardinal venous catherter. [ Ward et Al, 1986 ; Muehlschlegel & A ; Sims, 2009 ] . Besides that, the Osmitrol that added to the dantrolene pulverization will do osmotic diuresis with the loss of fluids and electrolytes. This will increase the hazard of the patient who has hapless nephritic map. [ Bastron,1983 ] . In add-on, in the experiment that carried out by Flewellen and Nelson, chronic administered of dantrolene intravenously will ensue in trouble in walking particularly down step. Muscle failing enduring up to 48hours in 12 malignant hyperthermy topics and associated with trouble in walking, particularly down stepss. [ Flewellen & A ; Nelson,1983 ] . In the clinical surveies that performed by Flewellen and Nelson and Oikkonen and his co-workers, patients were experienced weariness and trouble in get downing accompanied to the long term disposal of uninterrupted endovenous dantrolene. [ Flewellen & A ; Nelson, 1983 ; Oikkonen et Al, 1987 ] . The other common side effects of administered of dantrolene are dizziness, light-headedness, sleepiness, failing, unease and sickness. [ Ward et Al, 1986 ; Dkyes, 1975 ] .
There is an inauspicious interaction of dantrolene when co-administration with Calan. Co-administration of dantrolene and Calan will do hyperkalaemia and depression of the cardiac contractility. [ Rubin & A ; Zablocki,1987 ; Saltzman et al, 1984 ] . The surveies carried out by Lynch and co-workers and Saltzman and co-workers stated that administered dantrolene and Calan concomitantly will do singular hyperkaelemia and cardiac depression in Canis familiariss and swine. [ Saltzman et Al, 1984 ; Lynch et Al, 1986 ] . However, non all the Ca channel blockers will do hyperkaleamia and the depression of cardiac contractility. Neither nifedipine nor amlodipine has important of hyperkalaemia and depression of cardiac contractility when given together with dantrolene. [ Freysz, 1996 ; Saltzman et al, 1984 ] .
Besides holding inauspicious effects and inauspicious interaction, another disadvantage of dantrolene is its cost. Dantrolene is an expensive drug, for endovenous dantrolene, it costs A?15.08 per 20mg phial. As it is a immense sum of dantrolene are needed for immediate usage, this has became an issue for some infirmaries when purchase the dantrolene as dantrolene is really expensive particularly endovenous dantrolene and dantrolene has a limited shelf life of 18 months to 2 old ages. [ Allen et Al, 1988 ; Hall, 1980 ] .
In decision, malignant hyperthermy is uncommon dangerous familial upset of the musculus cells. A sudden hypermetabolic reaction of the skeletal musculus when exposed to potent volatile anesthetics and depolarising musculus relaxants such as succinylcholine will jeopardize the patient by doing hyperthermy and monolithic rhabdomyolysis. Surveies showed that appropriate dose endovenous dosage of dantrolene is effectual in handling patient during acute malignant hyperthermy crisis. Thus, 2.4mg/kg of dantrolene should be given intravenously during acute malignant hyperthermy crisis and go on giving 2.4mg/kg dantrolene after the crisis for 48 hours to avoid recrudescence of malignant hyperthermy. Besides, hypermetabolic reaction and the mortality rate of malignant hyperthermy can be reduced by taking safeguards and increasing the consciousness of patient who is malignant hyperthermy susceptible. With appropriate guidance, pre-operative showing and intraoperative monitoring the critical marks and symptoms of malignant hyperthermy can forestall the possible deadly complications arise.