Epidural Anesthesia for Caesarean Section in a Patient with Risk of Malignant Hyperthermia

Malignant hyperthermia is a hypermetabolic disorder of skeletal muscle that occurs in genetically susceptible individuals after exposure to anesthetic. Basic disorder is an increase of calcium ions inside the skeletal muscle, increasing metabolism and reducing cell energy supplies leading to development of acidosis, cell membrane destruction and cell death. Due to the increased metabolism occurs hypercarbia and strong stimulation of the sympathetic nervous system (tachycardia, hypertension, ventricular arrhythmia, tachypnea dropped for the neuromuscular blockade). Sweating, cyanosis, muscle rigidity and hyperthermia are also present.

This work presents the case of a female patient aged 32 who was heterozygous for the mutation RYR1 gene and therefore has an increased risk of malignant hyperthermia. Per anamnesis we got data that patient’s brother suffers from central core disease (myopathy). Patient has no muscle disease, 41^st week of pregnancy and was admitted to the hospital for childbirth. Vaginal delivery in epidural analgesia was planned. Epidural catheter is placed in the space L3 - L4, through which she received 0.25% levobupivacaine 10 ml. Due to adverse obstetric findings cesarean section underwent after two hours. Given the increased risk of malignant hyperthermia, the safest type of anesthesia for cesarean is epidural anesthesia. Over the epidural catheter has received 0.5% levobupivacaine 18 ml. Anesthesia machine was verified, hoses were replaced with new ones, CO2 absorber system was replaced, and whole system is flushed with pure oxygen, before surgery started. During the operation the patient had stable vital parameters that are monitored. She got a male child Apgar score of 9/10 and saw her child at birth. After the operation was transferred to the intensive care unit where we monitored the vital parameters, laboratory analysis, the amount and color of urine. Since all parameters were satisfactory, following day she was transferred to the ward, and she was discharged with a child on the fourth day after the surgery.