Case report
Total thyroidectomy in patient with McArdle's syndrome: Anaesthetic management
Tiroidectomía total en paciente con síndrome de McArdle: manejo anestésico
A.V. Quintero Salvago
, J.D. Leal del Ojo del Ojo, L. Barrios Rodríguez, J.J. Fedriani de Matos, I. Morgado Muñoz
Corresponding author
Servicio de Anestesiología y Reanimación, Hospital de Jerez de la Frontera, Jerez de la Frontera (Cádiz), Spain
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Un caso clínico" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1160 "Ancho" => 1133 "Tamanyo" => 192454 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ultrasound imaging of the ESPB after performing the block. Note the spread of local anaesthetic beneath the erector spinae muscle. TP – transverse process, N – needle, ESM – erector spinae muscle, LA – local anaesthetic.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Brandão, R. Graça, M. Sá, J.M. Cardoso, S. Caramelo, C. 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Quintero Salvago, J.D. Leal del Ojo del Ojo, L. Barrios Rodríguez, J.J. Fedriani de Matos, I. Morgado Muñoz" "autores" => array:5 [ 0 => array:4 [ "nombre" => "A.V." "apellidos" => "Quintero Salvago" "email" => array:1 [ 0 => "anavsalvago@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.D." "apellidos" => "Leal del Ojo del Ojo" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Barrios Rodríguez" ] 3 => array:2 [ "nombre" => "J.J." "apellidos" => "Fedriani de Matos" ] 4 => array:2 [ "nombre" => "I." "apellidos" => "Morgado Muñoz" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital de Jerez de la Frontera, Jerez de la Frontera (Cádiz), Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tiroidectomía total en paciente con síndrome de McArdle: manejo anestésico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">McArdle disease, or glycogen storage disease type V, is a rare metabolic myopathy involving muscle loss and weakness that appears to be inherited in an autosomal recessive fashion. Although estimates vary, the prevalence of the disease seems to range from 1/100,000 to 1/350,000 inhabitants.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a> It is characterised by a deficiency of myophosphorylase, which prevents conversion of skeletal muscle glycogen to glucose-1-phosphate.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Clinically, it manifests as muscle weakness, myoglobinuria, and in patients over 40 years of age, weakness of the paraspinal muscles and the shoulder girdle. Intense physical exercise can lead to rhabdomyolysis, hyperkalaemia and kidney failure.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The disease is diagnosed between the ages of 10 and 30 years, but given its benign nature, which manifests with non-specific weakness, it is under-diagnosed in individuals younger than 10 years.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> The diagnosis of suspicion is based on clinical symptoms and the absence of increased lactate during the forearm ischaemia test. Definitive diagnosis can be established by measuring serum myophosphorylase or by genetic tests. At present, muscle biopsy is not needed for confirmation.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There is no specific treatment for this disease, but a number of support measures can reduce the severity and incidence of symptoms, such as low doses of oral creatine and sucrose before exercise, which have shown a statistically significant, albeit modest, benefit during anaerobic exercise by decreasing heart rate and improving effort tolerance. This treatment can also prevent exercise-induced rhabdomyolysis, but has no benefit in unscheduled exercise. Other treatment options have been described in the literature, such as sympathomimetics (clenbuterol and isoprotenerol) and oral ramipril, although none has shown a clinically significant benefit.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,6,7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients with this disease may be at risk from some anaesthetic drugs, they are prone to myoglobinuria due to muscle contractures secondary to incorrect positioning during surgery,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> and also present an increased risk of severe hypoglycaemia and complications secondary to muscle ischaemia. Anaesthesiologists must be aware of all these factors in order to correctly and safely manage these patients. The lack of muscle substrate can result in the destruction of muscle cells during exercise or when the blood supply to the tissues is compromised, a situation that potentially increases the risk of rhabdomyolysis, hyperkalaemia, myoglobinuria and, therefore, acute kidney failure.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5,9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Due to enzyme deficiency, glycogen is not released during exercise, and these patients are therefore more prone to hypoglycaemia.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This syndrome is traditionally associated with the risk of malignant hyperthermia.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,4</span></a> This association is only theoretical, and is based on the increase in the rate of positive caffeine-halothane contracture tests, although this technique has approximately 20% false positives (Malignant Hyperthermia Association of the United States; <a id="intr0010" class="elsevierStyleInterRef" href="http://www.mhaus.org/">http://www.mhaus.org</a>). There are no cases in the literature that confirm this relationship.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0040" class="elsevierStylePara elsevierViewall">We report the case of a 47-year-old patient with McArdle's disease diagnosed 17 years prior and confirmed by genetic testing. Since then, she had been monitored by the neurology service. The only disease-related symptom she reported was fatigue on moderate exercise, and neurological examination showed tetraparesis 4/5. The patient was also allergic to metamizole, declared intolerance to clarithromycin, was a smoker of 10 cigarettes a day, with bronchial hyperreactivity (normal spirometry) currently controlled, without treatment. She had had pneumonia at 39 years of age, which required hospital admission, and discaethrosis at the level of C5–C6. She received home treatment with betahistine, naproxen, pyridoxine and paracetamol. She had no history of surgery. The patient had been diagnosed with euthyroid multinodular goitre 7 years previously, and total thyroidectomy had been scheduled due to the progressive increase in size. Before surgery she was seen for a pre-anaesthesia evaluation. No alterations were detected in the physical examination, the lab workup was normal (creatinine kinase [CK], creatinine [Cr], ions, lactate dehydrogenase [LDH] and transaminases were all normal). Early morning surgery was programmed. The patient was premedicated with oral bromazepam (3<span class="elsevierStyleHsp" style=""></span>mg). Upon arrival in the operating room, an 18-gauge intravenous line was inserted and infusion of lactate-type ringer solution warmed to body temperature was started. Standard monitoring was performed (SatO<span class="elsevierStyleInf">2</span>, ECG [5 leads], non-invasive blood pressure, ETCO<span class="elsevierStyleInf">2</span>, and body temperature). Depth of anaesthesia was monitored using qCON/qNOX and depth of neuromuscular block using train of four (TOF). Normothermia maintained through surgery with infusion of warmed fluid and a thermal blanket at 38<span class="elsevierStyleHsp" style=""></span>°C. Anaesthesia was induced with fentanyl 2<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span> and propofol (2.5<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span>). Rocuronium (0.6<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span>) was administered for muscle relaxation, and the patient was ventilated for 2<span class="elsevierStyleHsp" style=""></span>min without difficulty. Following this, intubation was performed using a 7.5<span class="elsevierStyleHsp" style=""></span>mm diameter reinforced tube. Laryngeal view was Cormack I, and intubation was uneventful. After induction, a urinary catheter was placed. Anaesthesia was maintained with remifentanil 0.05–0.2<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">−1</span> and propofol 6–8<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleSup">−1</span> to maintain qCON values between 40 and 60. Thirty minutes after the induction dose, a further dose of 10<span class="elsevierStyleHsp" style=""></span>mg rocuronium was administered. No additional muscle relaxants were administered intraoperatively. The intervention lasted 90<span class="elsevierStyleHsp" style=""></span>min.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Once surgery had been completed, maintenance drugs were withdrawn, analgesia and antiemetics were administered (1<span class="elsevierStyleHsp" style=""></span>g paracetamol, dexketoprofen 50<span class="elsevierStyleHsp" style=""></span>mg, ranitidine 50<span class="elsevierStyleHsp" style=""></span>mg, and ondansetron 4<span class="elsevierStyleHsp" style=""></span>mg) and residual NMB (TOF 0.8) was reversed with sugammadex 2<span class="elsevierStyleHsp" style=""></span>mg/kg, achieving a TOF ratio of over 90%. Extubation was uneventful, and the patient was transferred to the post anaesthesia care unit (PACU) with good mechanical ventilation and adequate blood oxygen levels. A total of 800<span class="elsevierStyleHsp" style=""></span>ml of saline were administered between the start of anaesthesia and transfer to the PACU, where fluid replacement continued, alternating glucosaline with lactated ringers solution at a rate of 100<span class="elsevierStyleHsp" style=""></span>ml/h.</p><p id="par0050" class="elsevierStylePara elsevierViewall">No complications were observed in either the immediate postoperative period in PACU or later on the ward, nor were there any signs of respiratory muscle weakness that would require ventilatory or other support. Blood glucose was measured every 2<span class="elsevierStyleHsp" style=""></span>h. It remained within normal ranges, and the follow-up testing at 24<span class="elsevierStyleHsp" style=""></span>h after surgery was also normal. The patient was discharged home the next day.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">McArdle's disease is a rare condition, and there is scant information in the literature on perioperative management in these patients. Anaesthesia management can be complex, and complications must be avoided.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The recommendations for perioperative management in patients with McArdle's disease are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The association between McArdle syndrome and malignant hyperthermia is only hypothetical, since no cases have been reported in the literature. Gurrieri et al. identified 4 patients with McArdle's disease who underwent general anaesthesia using drugs that could potentially trigger malignant hyperthermia (halogenated anaesthetics and succinylcholine), without complications.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> Despite this, we chose to avoid drugs that could possibly trigger malignant hyperthermia. Although the prophylactic use of dantrolene is not recommended, we believe that rapid access to this medication is necessary in the operating room. In our patient, we performed total intravenous anaesthesia with propofol. The muscle relaxant administered was rocuronium, since it is not contraindicated, and can now be rapidly reversed with sugammadex.</p><p id="par0065" class="elsevierStylePara elsevierViewall">CK, Cr, LDH, transaminases and ions should be measured both pre- and postoperatively.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Muscle contractions caused by shivering or surgical stimulus should be avoided, given the risk of cell lysis that can potentially lead to rhabdomyolysis, increased serum potassium, myoglobinuria and acute kidney failure. Therefore, normothermia should be maintained, and for the same reason, pressure cuffs and intermittent compression measures should not be used in order to avoid ischaemia that can trigger muscle damage and, consequently, myoglobinuria. In our case, we used a conventional pressure cuff, given the short duration of the surgery, even though other authors recommend invasive blood pressure measurement via an arterial line in some patients.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4,6</span></a> We maintained our patient's temperature at a steady 36–38<span class="elsevierStyleHsp" style=""></span>°C using a thermal blanket and warmed fluids.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Correct positioning is essential in patients with McArdle disease. Any position that may trigger muscle contractures, which can lead to myoglobinuria as described above, should be avoided.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">A urinary catheter should also be placed in order to visualise urine colour and detect myoglobinuria, and to treat acute kidney failure, if this should occur during the perioperative period. If myoglobinuria is detected, furosemide or even mannitol should be administered to force diuresis and prevent acute kidney failure secondary to massive rhabdomyolysis.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Finally, because of their glucose deficiency, patients with McArdle present anaerobic glycolysis, so serial blood glucose testing is needed to maintain levels above 100<span class="elsevierStyleHsp" style=""></span>mg/dl. Hypoglycaemia can be treated with 5% glucose solutions. Blood sugar should be measured hourly in the PACU.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In the event of postoperative respiratory failure due to muscle fatigue secondary to hypoglycaemia, pressure controlled NIMV may be necessary until recovery.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to report.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1160514" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1086809" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1160515" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1086810" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-05-19" "fechaAceptado" => "2018-10-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1086809" "palabras" => array:7 [ 0 => "McArdle's syndrome" 1 => "Glycogenosis" 2 => "General anaesthesia" 3 => "Myopathy" 4 => "Myoglobinuria" 5 => "Hypoglycaemia" 6 => "Malignant hyperthermia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1086810" "palabras" => array:7 [ 0 => "Síndrome de McArdle" 1 => "Glucogenosis" 2 => "Anestesia general" 3 => "Miopatía" 4 => "Mioglobinuria" 5 => "Hipoglucemia" 6 => "Hipertermia maligna" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">McArdle disease or type V glycogenosis is a rare metabolic myopathy consisting of muscle loss and weakness. These patients have risks associated with anaesthesia. They can present with hypoglycaemia, rhabdomyolysis, acute renal failure, and electrolyte changes. It has also been associated with a higher incidence of malignant hyperthermia during the anaesthetic procedure. Intermittent compression due to the measurement of non-invasive pressure, postures on the operating table that may cause muscle contractures, or tremor caused by hypothermia or anaesthesia itself, may trigger rhabdomyolysis in these patients.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this article we present our experience in submitting a patient with McArdle's syndrome to general anaesthesia for total thyroidectomy due to multinodular euthyroid goitre.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La enfermedad de McArdle o glucogenosis de tipo V es una miopatía metabólica rara que consiste en pérdida muscular y debilidad. Los pacientes con esta enfermedad presentan riesgos asociados a la anestesia. Pueden presentar hipoglucemia, rabdomiólisis, fallo renal agudo, alteraciones iónicas y también se ha relacionado con una mayor incidencia de hipertermia maligna durante el procedimiento anestésico. La compresión intermitente debido a la medición de la presión no invasiva, las posturas en la mesa de quirófano que puedan provocar contracturas musculares o el temblor ocasionado por la hipotermia o por la misma anestesia pueden desencadenar rabdomiólisis en estos pacientes. En este artículo exponemos nuestra experiencia con una paciente con síndrome de McArdle bajo anestesia general para tiroidectomía total por bocio multinodular eutiroideo.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Quintero Salvago AV, Leal del Ojo del Ojo JD, Barrios Rodríguez L, Fedriani de Matos JJ, Morgado Muñoz I. Tiroidectomía total en paciente con síndrome de McArdle: manejo anestésico. Rev Esp Anestesiol Reanim. 2019;66:163–166.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Rhabdomyolysis prevention measures</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Monitor body temperature to avoid shivering (warmed fluids, thermal blanket). Meperidine can be used to control shivering \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Urinary catheter for hourly diuresis and urine colour monitoring (reddish-brown urine if myoglobinuria) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Avoid tourniquets and other forms of compression \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>If myoglobinuria is detected, force diuresis to avoid acute kidney failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Monitor the position of the patient on the operating table at all times, avoiding extreme and anti-physiological positions that may cause muscle contraction.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Strict glycaemic control</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Measure blood sugar hourly throughout the perioperative period \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>If blood sugar falls below 100<span class="elsevierStyleHsp" style=""></span>mg/dl, administer 5% glucose solution until the start of oral intake \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">In the event of postoperative respiratory muscle weakness, consider the use of NIMV</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Perform CK, Cr, LDH, ions and transaminases tests</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Due to the theoretical risk of triggering malignant hyperthermia</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Drugs that can potentially trigger malignant hyperthermia should be avoided (halogenated agents and depolarizing relaxants) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rapid access to dantrolene in the operating room \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Surveillance in the first 24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h after surgery (continuous monitoring, hourly urine output, strict control of blood sugar until start of oral intake)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1981144.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Recommended anaesthetic management in patients with McArdle's scheduled for surgery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Skeletal muscle disorders of glycogenolysis and glycolysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. 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