Intraoperative hyperthermia during CS: a pertinent lesson
The present case published in the International Journal of Anesthesia serves to remind anesthesiologists who may occasionally work in malaria-endemic developing countries that the cause of intraoperative hyperthermia could be malaria.

A healthy 18-year-old nulliparous woman who underwent an emergency cesarean section under general anesthesia for fetal distress. Her preoperative examination was normal, malaria screening was negative and she was initially afebrile. She denied any previous abnormal reactions to anesthesia by herself or any family members.

A routine rapid-sequence induction with thiopental 400 mg and succinylcholine 100 mg was used. A healthy child was delivered within 3 min. Oxytocin 5 IU was injected intravenously after the placenta was removed and an infusion of 20 IU in saline 500 mL was commenced. Anesthesia was maintained with 70% nitrous oxide in oxygen and halothane 0.6 vol%; atracurium 12.5 mg and meperidine 100 mg were given. Twenty minutes later, the axillary temperature rose to 39.0°C, and subsequently as high as 40.5°C. Penicillin 1 g was given intravenously. Her blood pressure remained stable at 110/70 mmHg but she had a persistent tachycardia of 120–130 beats/min.

No muscle rigidity was noticed. A capnograph was not available. Surgery was completed in 70 min. After antagonism of residual neuromuscular block, spontaneous breathing resumed but she remained unconscious with stable vital signs except for tachycardia and pyrexia.

Differential diagnosis of malignant hyperthermia was considered but the local anesthetic technician suggested malaria despite negative preoperative screening. Since dantrolene was not readily available, quinine 600 mg in 5% glucose 500 mL was given intravenously.

Blood glucose concentration was checked hourly since it can be decreased by quinine.1 In the recovery room, cooling the patient with cold intravenous fluids and blankets soaked in cold water had little effect.

Within 3 h of starting quinine her temperature decreased to 38°C and she regained consciousness. She was extubated in the recovery room and was transferred to the intensive care unit for one night.

Subsequently, the laboratory confirmed the patient as having Plasmodium vivax malaria. She was discharged from the hospital with a healthy baby on day five.

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