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World J Crit Care Med. Feb 4, 2017; 6(1): 21-27
Published online Feb 4, 2017. doi: 10.5492/wjccm.v6.i1.21
Exertional rhabdomyolysis and heat stroke: Beware of volatile anesthetic sedation
Karel Heytens, Jan De Bleecker, Walter Verbrugghe, Jonathan Baets, Luc Heytens
Karel Heytens, Department of Anesthesiology, University Hospital Antwerp, 2650 Edegem, Belgium
Jan De Bleecker, Department of Neurology, AZ Sint-Lucas, 9000 Ghent, Belgium
Jan De Bleecker, Department of Neurology, University Hospital Ghent, 9000 Ghent, Belgium
Walter Verbrugghe, Department of Intensive Care, University Hospital Antwerp, 2650 Edegem, Belgium
Jonathan Baets, Department of Neurology, University Hospital Antwerp, 2650 Edegem, Belgium
Jonathan Baets, Laboratory of Neurogenetics and Biobank, Institute Born-Bunge, University of Antwerp, 2610 Wilrijk, Belgium
Luc Heytens, MH Research Unit, University of Antwerp, 2610 Wilrijk, Belgium
Luc Heytens, Departments of Anesthesiology and Neurology, University Hospital Antwerp, 2650 Edegem, Belgium
Author contributions: Heytens K is the main author of the manuscript; De Bleecker J and Baets J provided information about the different cases and reviewed the manuscript; Verbrugghe W helped with his experience on volatile anesthetic sedation; Heytens L designed the aim of the manuscript and acted as co-writer.
Conflict-of-interest statement: The authors have no interests with the manufacturers of the AnaConDaR or MirusTM devices. Heytens L is a medical expert with Norgine NV, manufacturer of DantriumR.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Luc Heytens, MD, PhD, MH Research Unit, University of Antwerp, Campus Drie Eiken, 2610 Wilrijk, Belgium. luc.heytens@uantwerpen.be
Telephone: +32-34-433926
Received: June 28, 2016
Peer-review started: July 1, 2016
First decision: September 5, 2016
Revised: October 21, 2016
Accepted: November 16, 2016
Article in press: November 17, 2016
Published online: February 4, 2017
Processing time: 207 Days and 20.4 Hours
Abstract

In view of the enormous popularity of mass sporting events such as half-marathons, the number of patients with exertional rhabdomyolysis or exercise-induced heat stroke admitted to intensive care units (ICUs) has increased over the last decade. Because these patients have been reported to be at risk for malignant hyperthermia during general anesthesia, the intensive care community should bear in mind that the same risk of life-threatening rhabdomyolysis is present when these patients are admitted to an ICU, and volatile anesthetic sedation is chosen as the sedative technique. As illustrated by the three case studies we elaborate upon, a thorough diagnostic work-up is needed to clarify the subsequent risk of strenuous exercise, and the anesthetic exposure to volatile agents in these patients and their families. Other contraindications for the use of volatile intensive care sedation consist of known malignant hyperthermia susceptibility, congenital myopathies, Duchenne muscular dystrophy, and intracranial hypertension.

Keywords: Exertional rhabdomyolysis; Heat stroke; Intensive care sedation; Inhalational anesthetics; Malignant hyperthermia; Congenital myopathies

Core tip: Recent research has shown that a substantial proportion of patients with exercise-induced heatstroke harbor mutations in the ryanodine-receptor one gene on Chromosome 19 (RYR1), encoding for the principal calcium-release channel in striated muscle. These same mutations are known to result in a massively increased calcium-conductivity and life-threatening rhabdomyolysis when malignant hyperthermia (MH) susceptible patients are exposed to volatile anesthetics during general anesthesia. In view of this, exposure to volatile anesthetic sedation - an emerging trend in intensive care units - is contraindicated, not only in patients with known MH susceptibility and other congenital myopathies, but also in patients admitted because of exertional rhabdomyolysis and heatstroke.