This chapter will review the pharmacotherapy for management of drug-induced hyperthermia according to the expert opinion.
Malignant hyperthermia (MH) , , 5
Definition
A genetic disorder characterized by excessive release of calcium from the skeletal muscle resulting in muscle rigidity, hyperthermia, hypercarbia, and metabolic acidosis.
Triggering agents
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Halogenated inhalational anesthetic (e.g., halothane, isoflurane, enflurane, sevoflurane, desflurane)
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Depolarizing neuromuscular blocker (e.g., succinylcholine)
Pharmacologic management
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Initiate MH protocol and call MH hotline: 1-800-644-9737
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Discontinue Offending Agent(s)
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Dantrolene
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Relaxes muscles by decreasing the release of calcium from the sarcoplasmic reticulum
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2.5 mg/kg intravenous (IV) push then 1 mg/kg until symptoms abate or a cumulative dose or 10 mg/kg reached
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To prevent recurrence: 1 mg/kg q4–6h ×24 h then 4–8 mg/kg/day divided into four doses ×1–3 days
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Avoid in advanced liver disease
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Treat Acidosis
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Sodium bicarbonate 1–2 mEq/kg IV push over 5–10 min
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Treat Hyperkalemia
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Calcium chloride 0.5–1 g IV or calcium gluconate 1–2 g IV over 5–10 min
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Sodium bicarbonate 1–2 mEq IV push over 5–10 min (max 50 mEq per dose); do not give sodium bicarbonate in the same IV line as calcium
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Insulin regular 10 units IV push with dextrose 50% 50 mL
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Treat dysrhythmias according to advanced Cardiovascular Life Support protocols
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Procainamide has similar action to dantrolene and is thus drug of choice for MH-associated dysrhythmias
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See Chapter 3 .
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Calcium channel blockers in an acute MH crisis is contraindicated due to risk of worse hyperkalemia and hypotension.
Neuroleptic malignant syndrome (NMS)
Definition
An idiosyncratic drug reaction characterized by muscle rigidity, altered mental status, hyperthermia, and autonomic instability.
Triggering agents
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Antipsychotic agents: haloperidol, clozapine, olanzapine, risperidone, phenothiazines
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Antiemetic agents: metoclopramide, droperidol, prochlorperazine
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Central nervous system stimulants: amphetamines, cocaine
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Other: lithium, tricyclic antidepressants
Pharmacologic management
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Discontinue offending agent(s)
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Supportive care
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Benzodiazepines for agitation
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Lorazepam 1–2 mg intramuscular (IM)/IV q4–6h or
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Diazepam 5–10 mg IV q8h
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Dantrolene
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Drug of choice for NMS
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See MH for dosing
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Bromocriptine
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A dopamine agonist
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2.5–5 mg orally (PO)/via nasogastric tube (NG) three times daily ×10 days after NMS controlled then taper slowly
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Preferred over dantrolene in advanced liver disease
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Can worsen psychosis and hypotension
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Amantadine
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Dopaminergic and anticholinergic effects
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Alternative to bromocriptine
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100 mg PO/NG twice daily (BID) up to 200 mg BID
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Serotonin syndrome
Definition
Overstimulation of serotonin receptors in the central nervous system characterized by mental status changes, autonomic hyperactivity (hypertension or hypotension, tachycardia, hyperthermia), and neuromuscular abnormalities (hyperkinesis, hyperreflexia, and clonus).
Triggering agents
See Table 20.1 .
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