J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website https://www.journalmc.org

Case Report

Volume 11, Number 12, December 2020, pages 379-387

Malignant Hyperthermia in Bariatric Surgery: A Case Study With Clinical, Pathophysiological, Biochemical and Biophysical Correlations

**Table 1.** Anesthetics, Analgesic and Muscle Relaxant Agents Used During the Intraoperative Period
Agents	Drug class	Route of administration	Administration schedule
Propofol	Injectable general anesthetic	Intravenous	15 mL	-	-	-
Fentanyl	Opioid analgesic	Intravenous	10 mL	5.0 mL	5.0 mL	-
Alfentanil	Opioid analgesic	Intravenous	5.0 mL	5.0 mL	-	-
Atracurium	Non-depolarizing neuromuscular blocking	Intravenous	5.0 mL	2.5 mL	-	2.5 mL
Isoflurane	Volatile general anesthetic	Inhalational	80 mL

Table 1. Anesthetics, Analgesic and Muscle Relaxant Agents Used During the Intraoperative Period

Agents

Drug class

Route of administration

Administration schedule

8 am

9 am

10 am

12 am

Propofol

Injectable general anesthetic

Intravenous

15 mL

Fentanyl

Opioid analgesic

Intravenous

10 mL

5.0 mL

Alfentanil

Opioid analgesic

Intravenous

5.0 mL

Atracurium

Non-depolarizing neuromuscular blocking

Intravenous

5.0 mL

2.5 mL

Isoflurane

Volatile general anesthetic

Inhalational

80 mL

**Table 2.** Postoperative Vitals Control According to the Nursing Reports
Hour	Temperature (°C)	Heart rate (beats/min)	Blood pressure (mm Hg)	Blood O₂ saturation (%)
2 am		38.4	39.9	40.1		124	128	142		190/120	131/30	152/49		92	94	95
4 am		38.5	40.3	40.6		120	126	140		160/100	150/32	153/51		95	96	95
6 am		38.5	40.3	40.7		122	130	142		140/80	139/66	149/66		95	90	97
8 am		38.6	38.5	40.8		133	129	145		140/60	125/34	161/56		91	95	96
10 am		38.0	38.3	40.8		128	135	142		169/51	113/35	124/46		90	-	95
12 am		39.3	40.4	40.8		132	132	142		171/53	123/37	151/50		90	90	97
2 pm		39.3	40.6	41.2		126	134	143		140/60	139/40	150/50		99	95	97
4 pm		39.5	39.9	41.5		128	139	154		120/50	134/44	150/47		93	96	100
6 pm		39.7	40.3	H (42↑)		121	133	174		130/60	125/41	99/27		97	94	92
8 pm	38.0	39.4	40.3	H (42↑)		121	132	174		156/31	127/43	62/27		97	92	84
10 pm	37.8	39.8	40.4		100	126	138		180/90	136/34	133/42		97	94	96
12 pm	38.9	39.9	40.5		120	127	145		160/80	117/31	153/48		97	93	91

Table 2. Postoperative Vitals Control According to the Nursing Reports

Hour

Temperature (°C)

Heart rate (beats/min)

Blood pressure (mm Hg)

Blood O₂ saturation (%)

02/14

02/15

02/16

02/17

02/14

02/15

02/16

02/17

02/14

02/15

02/16

02/17

02/14

02/15

02/16

02/17

2 am

38.4

39.9

40.1

124

128

142

190/120

131/30

152/49

4 am

38.5

40.3

40.6

120

126

140

160/100

150/32

153/51

6 am

38.5

40.3

40.7

122

130

142

140/80

139/66

149/66

8 am

38.6

38.5

40.8

133

129

145

140/60

125/34

161/56

10 am

38.0

38.3

40.8

128

135

142

169/51

113/35

124/46

12 am

39.3

40.4

40.8

132

142

171/53

123/37

151/50

2 pm

39.3

40.6

41.2

126

134

143

140/60

139/40

150/50

4 pm

39.5

39.9

41.5

128

139

154

120/50

134/44

150/47

100

6 pm

39.7

40.3

H (42↑)

121

133

174

130/60

125/41

99/27

8 pm

38.0

39.4

40.3

H (42↑)

121

132

174

156/31

127/43

62/27

10 pm

37.8

39.8

40.4

100

126

138

180/90

136/34

133/42

12 pm

38.9

39.9

40.5

120

127

145

160/80

117/31

153/48

**Table 3.** Follow-Up Labs and Arterial-Blood Gas Results
Parameters (levels range^a)	Preoperative	Postoperative
^aLevels range for adult men. CPK: creatine phosphokinase; AST: aspartate aminotransferase; ALT: alanine aminotransferase; pH: potential of hydrogen; PaO₂: partial pressure of oxygen; PaCO₂: partial pressure of carbon dioxide; HCO₃^-: bicarbonate ion; BE: base excess; ab-SatO₂: arterial blood oxygen saturation level.
Glucose (mg/dL) (75 - 99)	91	98	141	128
CPK (U/L) (< 190)		2,384	6,280	6,890	7,200
Calcium (mg/dL) (8.5 - 10.3)	10.2	6.8	9.5	8.4
Sodium (mEq/L) (138 - 146)		141	143	155	147
Potassium (mEq/L) (3.8 - 5.5)		5.0	5.9	4.8	4.0
Urea (mg/dL) (18 - 40)	28	50		140	207
Creatinine (mg/dL) (0.6 - 1.2)	0.6	2.0	2.8	6.9	13.0
AST (U/L) (10 - 34)	26	579	1,088		649
ALT (U/L) (9 - 43)	42	667	1,160		554
pH (7.38 - 7.44)		7.41	7.17
PaO₂ (mm Hg) (80 - 90)		127.6	105.5
PaCO₂ (mm Hg) (31 - 41)		35.5	68.4
HCO₃^- (mEq/L) (21 - 27)		22.0	24.3
BE (mEq/L) (-2.4 - +2.4)		-1.9	-5.8
ab-SatO₂ (%) (95 - 97)		98.0	95.7

Table 3. Follow-Up Labs and Arterial-Blood Gas Results

Parameters (levels range^a)

Preoperative

Postoperative

12/27/2010

02/15 morning

02/15 afternoon

02/16 afternoon

02/17 afternoon

^aLevels range for adult men. CPK: creatine phosphokinase; AST: aspartate aminotransferase; ALT: alanine aminotransferase; pH: potential of hydrogen; PaO₂: partial pressure of oxygen; PaCO₂: partial pressure of carbon dioxide; HCO₃^-: bicarbonate ion; BE: base excess; ab-SatO₂: arterial blood oxygen saturation level.

Glucose (mg/dL) (75 - 99)

141

128

CPK (U/L) (< 190)

2,384

6,280

6,890

7,200

Calcium (mg/dL) (8.5 - 10.3)

10.2

6.8

9.5

8.4

Sodium (mEq/L) (138 - 146)

141

143

155

147

Potassium (mEq/L) (3.8 - 5.5)

5.0

5.9

4.8

4.0

Urea (mg/dL) (18 - 40)

140

207

Creatinine (mg/dL) (0.6 - 1.2)

0.6

2.0

2.8

6.9

13.0

AST (U/L) (10 - 34)

579

1,088

649

ALT (U/L) (9 - 43)

667

1,160

554

pH (7.38 - 7.44)

7.41

7.17

PaO₂ (mm Hg) (80 - 90)

127.6

105.5

PaCO₂ (mm Hg) (31 - 41)

35.5

68.4

HCO₃^- (mEq/L) (21 - 27)

22.0

24.3

BE (mEq/L) (-2.4 - +2.4)

-1.9

-5.8

ab-SatO₂ (%) (95 - 97)

98.0

95.7