G. Dhotar, Oxford University Hospitals NHS Foundation Trust, UK


A 9 year old girl attended our hospital for elective right upper lid thickness grafting surgery for ptosis. She had no previous medical history and had a previous anaesthetic in Poland for a similar surgery with no issues. She had no allergies and no family history of anaesthetic problems.

She underwent a volatile induction with sevoflurane.  She was cannulated and intubated with a non-depolarising muscle relaxant.  Anaesthesia was maintained with sevoflurane.  She had  AAGBI standard monitoring throughout this period.

Sixty minutes after the commencement of anaesthesia; a raised ETCO2 (13.0kPa), tachycardia (125 bpm) with unusual ECG morphology, and high FiO2 requirements were noted.  Later, the core temperature rose to 39.9 Celsius.  There was a high index of suspicion of Malignant Hyperthermia.

There was rapid mobilisation of the multi-disciplinary team in theatres and treatment was initiated as per the AAGBI 2011 guidance which was readily available in theatres.  Initial management took a three pronged approach, which included 1) stopping the trigger (stopping sevoflurane, switching to TIVA and use of charcoal filters); 2) the prompt administration of dantrolene; and 3) controlling temperature (with ice packs and cold bladder washouts).  PICU involvement was acquired early to aid with subsequent sequale management of acidosis and hyperkalaemia.

The patient successfully responded and stabilised within normal parameters.  They were transferred to PICU and later extubated.  The patient had no lasting adverse effects and discharged from hospital three days later. Referral to the Malignant Hyperthermia Centre in Leeds was made. Results are still pending.


Malignant Hyperthermia (MH) is a progressive, life-threatening hypothermic reaction during general anaesthesia to suxamethonium and inhalational anaesthetic gases.  Incidences are high in the paediatric populations. MH is one of the most logistically challenging anaesthetic emergencies to manage and in a paediatric patient, there is an added level of complexity.

In this case, MH was recognised quickly and management was initiated in a timely manner.  Teamwork and communication were good. Early PICU involvement was invaluable in sequalae management.

Areas which were noted to be suboptimal were: 1) MH guidelines that were readily available in theatres were outdated, new guidance in 2020 had been released; 2) Dantrolene stock was only available on one floor of our theatre complex and expired stock was provided by pharmacy.

Suggested areas of improvement include: updating existing guideline availability in theatres to include AAGBI MH 2020 guidance; discuss with pharmacy regarding in-date dantrolene supply and availability; and continuing simulation in managing MH within theatres.

This case illustrates that a history of previous uneventful GA does not rule out future MH events and how teamwork is vital in managing a complex anaesthetic emergency.


Consent provided by parents.  Oxford Anaesthetic, PICU and supporting teams involved in care of patient.


  1. Malignant Hyeprthermia 2020 Guideline for the Association of Anaesthetists. Hopkins PM, Girard T, Daley S et al. Accessed online from: https://anaesthetists.org/Home/Resources-publications/Guidelines/Malignant-hyperthermia-2020
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