From Susceptibility to Safety: Implementing Thailand Malignant Hyperthermia Guidelines 2026
Keywords:
dantrolene, malignant hyperthermia, myopathy, susceptibility, trigger-free anesthesiaAbstract
Malignant hyperthermia (MH) is a rare but potentially fatal reaction triggered by volatile anesthetics or succinylcholine. Its rarity makes recognition and management during an acute crisis challenging for anesthesiologists. The challenge extends beyond the crisis: patients with a history of anesthetic complications or myopathy, as well as their relatives, may require evaluation for MH susceptibility and a plan for future anesthesia. The new guideline from the Royal College of Anesthesiologists of Thailand (RCAT) provides an updated, systematic approach to assessing MH susceptibility and planning perioperative care. Patients with an MH-associated genetic variant or a positive in vitro contracture test are clearly classified as MH- susceptible. However, neither a history of uneventful anesthesia nor a negative genetic test rules out susceptibility, and patients with a concerning family history should be managed accordingly. For these patients, preparation includes ensuring that the anesthesia machine is free of triggering agents and that dantrolene is immediately available. Anesthesia should be trigger-free: regional anesthesia is preferred when appropriate, while total intravenous anesthesia should be used if general anesthesia is required, with capnography and core temperature monitoring. Using a chain-of-survival framework adapted from the sepsis model, this review highlights how prevention, identification of susceptible patients, and preparation can improve care beyond the treatment of an acute MH crisis.
References
1. Hopkins PM, Girard T, Dalay S, et al. Malignant hyperthermia 2020: guideline from the Association of Anaesthetists. Anaesthesia. 2021;76:655-64.
2. Royal College of Anesthesiologists of Thailand. Clinical practice guideline for the care of patients at risk of malignant hyperthermia and patients with malignant hyperthermia crisis. Bangkok: RCAT; 2026.
3. Rosenberg H, Davis M, James D, Pollock N, Stowell K. Malignant hyperthermia. Orphanet J Rare Dis. 2007;2:21.
4. Charuluxananan S, Sriraj W, Punjasawadwong Y, et al. Perioperative and Anesthetic Adverse events in Thailand (PAAd Thai) incident reporting study: anesthetic profiles and outcomes. Asian Biomed. 2017;11:21-32.
5. Hidalgo JL, Kumar VK, Akech SO, et al. The sepsis chain of survival: a comprehensive framework for improving sepsis outcomes. Crit Care Med. 2025;53:e1886-92.
6. Del Rios M, Bartos JA, Panchal AR, et al. Part 1: Executive summary: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152:S284-312.
7. Riazi S, Larach M, Hu C, Wijeysundera D, Massey C, Kraeva N. Malignant hyperthermia in Canada: characteristics of index anesthetics in 129 malignant hyperthermia susceptible probands. Anesth Analg. 2014;118:381-7.
8. Klingler W, Rueffert H, Lehmann-Horn F, Girard T, Hopkins PM. Core myopathies and risk of malignant hyperthermia. Anesth Analg. 2009;109:1167-73.
9. Malignant Hyperthermia Association of the United States. Recommendations. Available from:https://www.mhaus.org/mhau001/assets/File/Recommendations/Recommendations%20with%20Table%20of%20Contents.pdf
10. Malignant Hyperthermia Australia and New Zealand. For anaesthetists. Available from: https://malignanthyperthermia.org.au/information-for-anaesthetists
11. Dlamini N, Voermans NC, Lillis S, et al. Mutations in RYR1 are a common cause of exertional myalgia and rhabdomyolysis. Neuromuscul Disord. 2013;23:540-8.
12. Litman RS, Joshi GP. Malignant hyperthermia in the ambulatory surgery center: how should we prepare? Anesthesiology. 2014;120:1306-8.
13. Rüffert H, Bastian B, Bendixen D, et al. Consensus guidelines on perioperative management of malignant hyperthermia suspected or susceptible patients from the European Malignant Hyperthermia Group. Br J Anaesth. 2021;126:120-30.
14. Birgenheier N, Stoker R, Westenskow D, Orr J. Activated charcoal effectively removes inhaled anesthetics from modern anesthesia machines. Anesth Analg. 2011;112:1363-70.
15. Rosenberg H, Saha A, Zingariello C, Gonzalez SN, Pinyavat T. Malignant hyperthermia moves out of the OR: the role of the anesthesia professional. APSF Newsletter. 2024;39:90-2.
Downloads
Published
How to Cite
Issue
Section
License
Copyright
Copyright of all articles published in the Thai Journal of Anesthesiology is held by the Thai Journal of Anesthesiology, the Royal College of Anesthesiologists of Thailand. Submission of a manuscript constitutes the authors' agreement that, upon acceptance for publication, copyright of the work is transferred to the Journal. The content and any opinions expressed in published articles are the sole responsibility of the authors and do not necessarily reflect the views of the editorial board or the Royal College of Anesthesiologists of Thailand.
Licensing
All articles are published open access under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND 4.0). Under this license, anyone may copy and redistribute published articles in any medium or format for non-commercial purposes, provided that appropriate credit is given to the authors and to the Thai Journal of Anesthesiology as the original source of publication, a link to the license is included, and the material is not modified in any way. Requests for commercial use or for adaptation of published material should be directed to the editorial office.
Authors' Rights
Although copyright is held by the Journal, authors retain the right to reuse their own published material in their future scholarly works, theses and dissertations, teaching, and academic presentations, and to deposit the final published version (PDF) in institutional or subject repositories or on personal and institutional websites, without embargo, provided that the Thai Journal of Anesthesiology is clearly acknowledged as the original place of publication.
