Aim A case report to highlight an unusual cause of submalignant hyperthermia and rhabdomyolysis. To also reiterate the importance of the WHO checklist prior to routine operations.
Methods A 10 year old male underwent routine ear surgery.He went to surgery wearing multiple layers of clothing. Post operatively he suffered with severe pain in his buttocks, and an MRI showed extensive subcutaneous oedema and in the area signal change within both gluteus maximus muscles consistent with diffuse oedema. Bloods showed a raised creatine kinase but normal renal function. He was managed on the paediatric ward with input from anaesthetic and surgical teams, as well as verbal input from the tertiary nephrology and metabolic centre. Main medical management included hyperhydration at two millilitres per kilogram per hour of 0.9% saline and 5% dextrose, with six hourly urea and electrolytes and urine output maintained at greater than two millilitres per kilogram per hour. His renal function remained stable at the time and three months later his renal function remains normal and creatine kinase measurements are normal. The metabolic team recommended urinary organic acids and free and total acyl carnitine as this can be a rare presentation of fatty oxidative defects and usually associated with hyperpyrexia. These investigations were normal.
Results A root cause analysis decided the cause of the unpredicted post-operative complication to be submalignant hyperthermia secondary to the patient’s own clothes.
Conclusion All cases of rhabdomyolysis should be discussed with a tertiary renal team: if there is any evidence of kidney dysfunction the patient should have escalation of care and be managed on a high dependency unit. This case demonstrates the anaesthetic clerking and WHO checklist as vital pieces of evidence when reviewing unusual cases for a RCA. There is only one similar documented case in the Journal of Clinical Anaesthesia in 2007.
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