恶性高热的早期诊断及丹曲洛林缺乏条件下的治疗方案

Early diagnosis of malignant hyperthermia and its treatment regimen without dantrolene

目的:探讨恶性高热(malignant hyperthermia,MH)的早期诊断思路及丹曲洛林缺乏条件下的治疗方案。方法:1例ASAⅠ级拟行特发性脊柱侧弯矫正术患者麻醉诱导过程中突发肌肉抽搐及咬肌痉挛等症状,确诊为MH,在无丹曲洛林的条件下及时采取去除诱因、控制体温、充分给氧、维持酸碱和水电解质平衡以及保护肾功能等措施进行救治,观察诊治过程中患者血和尿中肌红蛋白、血中肌酸激酶、血气指标以及呼气末二氧化碳(EtCO2)等指标的动态变化及股四头肌的病理学改变,总结诊治经验。结果:患者经过积极抢救后完全康复出院,无任何并发症。MH发生后血和尿中肌红蛋白、血中肌酸激酶及其同工酶迅速升高,于1 h左右达到峰值,维持10 h余开始逐渐下降,5 d后基本恢复正常。EtCO2于恶性高热发生后立即升高,动脉血气迅速呈高碳酸血症性酸中毒,但因治疗过程中输注大量碳酸氢钠使pH保持正常或偏碱,碱剩余明显升高。股四头肌部分肌细胞发生空泡样变性和溶解现象。结论:非通气因素所致的EtCO2异常升高是早期诊断MH的较可靠指标,对于MH易感人群应避免使用琥珀胆碱等麻醉药,常规监测EtCO2;一旦确诊,首选丹曲洛林,丹曲洛林缺乏条件下,早期诊断并及时采取去除诱因、控制体温、充分给氧、维持内环境稳定、控制心律失常和保护肾功能等措施,也可取得良好效果。

Objective：To discuss the early diagnosis of malignant hyperthermia （MH） and its treatment regimen without dantrolene. Methods： A patient of American Society of Anesthesiologist class Ⅰ had sudden muscle spasms and masseter muscle spasm during induction of anesthesia for idiopathic scoliosis surgery, and was diagnosed as having MH. Without using dantrolene, the patient was treated promptly with removal of inducement, control of temperature, adequate oxygen supply, maintaining of pH, water and electrolyte balance, and protection of renal function. The dynamic changes of the myoglobin in the blood and urine, serum creatine kinase, the blood gas indicators, and EtCO2, together with the pathological changes of the quadriceps were observed. Our experience on diagnosis and treatment was summarized. Results： The patient fully recovered and was discharged without any complications. The myoglobin in the blood and urine, serum creatine kinase and its isoenzyme increased rapidly and reached the peak one hour after MH, and maintained for about ten hours, then returned gradually to normal level about five days later. The temperature and EtCO2 increased immediately after development of MH, arterial blood gas quickly showed hypercapnic acidosis, but pH maintained normal or partial alkali during the treatment due to sodium bicarbonate administration; the alkali maintained obviously higher. Some quadriceps muscle cell had vacuolar degeneration and lysis. Conclusion： Non ventilation induced increase of EtCO2 is a reliable indicator for early diagnosis of MH. Anesthetics, such as succinylcholine, should be avoided in patients at high risk of MH, and EtCO2 should be monitored. Once MH is diagnosed, dantrolene is the first choice. When without dantrolene, satisfactory outcome can be achieved through early diagnosis, timely removal of incentives, control of temperature, adequate oxygen supply, maintaining of stable internal environment, control of arrhythmia and protection of renal function.