20) Complications of General Anaesthesia – Thermal Pertubations,

Hypothermia and Shivering

MALIGNANT HYPERTHERMIA:

Malignant hyperthermia (MH) is a rare, life-threatening condition due to an autosomal dominant

disorder of muscle metabolism. Exposure to certain drugs, such as volatile anaesthetic agents or
suxamethonium, leads to a hypermetabolic state associated with increased oxygen consumption,
carbon dioxide production and acidosis. Clinically this presents as:

 Hyperthermia – rapidly increasing temperature, usually >38.8°C

 Hypercapnoea – ETCO2 > 55 mmHg
 Tachycardia – sinus, VT or VF
 Generalised muscle rigidity, often with severe masseter muscle rigidity

Untreated MH has a mortality of 80%. Definitive treatment is with the weak muscle relaxant
dantrolene (3 mg/kg IV every 5 min, to maximum of 10 mg/kg) and supportive care (100% O2;
remove trigger agent; treat acidosis and hyperkalaemia with bicarbonate; increase ventilation to
reduce paCO2; active cooling; intensive care admission). Treatment with dantrolene reduces MH
mortality to 10%.

HYPOTHERMIA:

During anaesthesia, hypothermia may be defined as a core body temperature less than 36°C. This
can cause physiological derangement in the operating theatre and in recovery, and may increase
perioperative morbidity.

The effects of hypothermia are proportional to the change in temperature. Metabolic rate is reduced
by up to 10% for every 1°C fall in body temperature. There is a reduction in cardiac output and an
increase in haemoglobin oxygen affinity. This leads to a decrease in tissue oxygen delivery.
Significant hypothermia is associated with metabolic acidosis, oliguria, altered platelet and clotting
function and reduced hepatic blood flow with slower drug metabolism. The MAC of inhalational
agents is reduced and muscle relaxants have a prolonged effect. Postoperative shivering increases
oxygen consumption and myocardial work. There may also be an increased incidence of wound
breakdown and infection.

Aetiology

1. Abolished behavioural responses

2. Increased heat loss through:
a. Radiation (accounts for over 50% of heat loss). This is exacerbated when the
ambient temperature falls below 24°C
b. Evaporation from body surfaces (cleaning fluids)
c. Evaporation from open body cavities
3. Cooling effect of cold anaesthetic gases and intravenous fluids
 4. Widened interthreshold range. Heat production falls as anaesthetic agents alter
hypothalamic function. The lowering of the hypothermic threshold is related to MAC. The
interthreshold range widens so that thermoregulatory responses are not triggered until core
temperature has deviated much further than normal from 37°C.
5. Reduced metabolic heat production (15-40%), particularly by:
a. Reduced muscle activity
b. Decreased brain metabolism

Induction of general anaesthesia typically results in a 1°C fall in core temperature within the first 30
minutes. Changes in core temperature are due to redistribution at this early stage. As a result, the
core compartment cools and expands, while the peripheral compartment warms and contracts.

 SHIVERING:

Postanesthetic shivering is one of the leading causes of discomfort in patients recovering from
general anesthesia. It usually results due to the anesthetic inhibiting the
body's thermoregulatory capability, although cutaneous vasodilation (triggered by post-operative
pain) may also be a causative factor. First-line treatment consists of warming the patient; more
persistent/severe cases may be treated with medications such
as tramadol, pethidine, clonidine and nefopam, which work by reducing the shivering threshold
temperature and reducing the patient's level of discomfort. As these medications may react and/or
synergize with the anesthetic agents employed during the surgery, their use is generally avoided
when possible.