National insights on Malignant Hyperthermia: a SIAARTI Survey on clinical practices, preparedness, and future directions

National insights on Malignant Hyperthermia: a SIAARTI Survey on clinical practices, preparedness, and future directions | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article National insights on Malignant Hyperthermia: a SIAARTI Survey on clinical practices, preparedness, and future directions Roberta Monzani, Daniela Alampi, Elena Bignami, Andrea Cortegiani, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6881142/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Malignant Hyperthermia Syndrome is a rare pharmacogenetic disorder, highly life-threatening if diagnosis and treatment is delayed. The purpose of this study is to assess the knowledge and current practices of Italian anesthesiogists in managing Malignant Hypertermia episodes. Methods We conducted a national survey. Data were collected via an online questionnaire distributed by the Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Responses were collected over 15 weeks between July 15 and October 15, 2024, using an online GDPR-compliant platform Results A total of 395 anesthetists completed the survey. The majority are employed in public (35%) and university hospitals (26%), with an average of 20 years of professional experience. MH had been managed at least once by 31% of respondents, and 70% of them declared they always report adverse reactions In over 90% of cases, preventive measures (removal of trigger drugs, ventilator wash-out, perioperative care) are indentified, although only 49% reported having an internal protocol in place at their institution. In most centers (89%) non anesthesiologists are responsible for the storgae and supply of dantrolene and only 66% of respondents correctly identifying sterile water as its appropriate solvent. Discussion Our results highlight the need for broader standardization of MH management. Despite limitation in sample size and difference in geographical and hospital setting, the survey reveales a discrepancy between clinical practice and recommended strategies. While preventive measures are widely recognized, they are often not strandardized, and a correct treatment remains an area for significant improvement. Malignant Hyperthermia Anesthesia Dantrolene Adverse Events Figures Figure 1 Background Malignant hyperthermia (MH) is a rare but life-threatening pharmacogenetic disorder affecting skeletal muscle metabolism, primarily triggered by exposure to volatile anesthetics and depolarizing muscle relaxants [ 1 ]. If not promptly diagnosed and treated, MH can rapidly lead to multi-organ failure and death [ 2 ]. Given its critical clinical significance, SIAARTI conducted a nationwide survey among Italian anesthesiologists and critical care specialists to assess their experience, knowledge, and preparedness in managing MH cases. The findings of the survey were integrated with expert opinions to provide an in-depth analysis of current clinical practices, challenges, and recommended strategies. Methods Setting, partecipant and recruitment This study is based on a nationwide online survey developed by experts belonging to SIAARTI (the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care) and approved by its research committee approval in 2024. IRB approval was not required for this study. The survey aimed to assess the knowledge of healthcare professionals regarding MH, with a particular focus on clinical management strategies and the use of dantrolene. Data collection was conducted between July 15 and October 15, 2024, through an online GDPR-compliant platform (SurveyMonkey 2024, Survey tool, Momentive Inc.), ensuring anonymity while allowing robust data aggregation and analysis. The survey was delivered by mail to among 11.000 anesthesiologists and intensivists across Italy via SIAARTI’s network, targeting professionals with direct involvement in perioperative care and intensive care management. An explicit consent to partecipation is included, before starting the compilation of survey form, Questionnaire design The survey was structured into three main sections designed to gather a comprehensive understanding of how MH is managed in clinical settings : 1. Demographic and professional data Age distribution and professional background. Geographic location (region and city of practice) to evaluate potential regional disparities. Year of specialization to define levels of seniority and professional expertise. Type of healthcare facility (public, private, university hospital or other institutions) to determine differences in resource availability and adherence to standardized protocols. 2. Experience with malignant hyperthermia: Number of MH cases managed during professional careers or training programs. Identification of patient groups perceived as at risk for MH, including those with neuromuscular disorders or a history of adverse anesthetic reactions. Differential diagnosis awareness, including conditions that can mimic MH, such as neuroleptic malignant syndrome, sepsis, or thyroid storm. 3. Management strategies: Existence of formalized hospital protocols for MH crisis management. Preventive measures taken to mitigate the risk of MH, including preoperative screening and selection of non-trigger anesthetics. Use of dantrolene in preoperative prophylaxis and the extent to which institutions maintain an adequate stock. Post-crisis patient management, including referral to specialized centers and pharmacovigilance reporting practices. Free comment fields were available to elicit further information where appropriate. The estimated time to complete the survey was 20 min. Each survey was reviewed for readability and non-ambiguity by experts in MH. Statistical Analysis The collected data were analyzed using descriptive statistical methods, including frequency distributions, medians, means, standard deviations, and other summary statistics to characterize the key variables. Qualitative variables were examined using contingency tables and graphical representations to provide a clear visualization of response distributions. For ordinal scale variables, such as the frequency of drug use or the application of dantrolene prophylaxis, an agreement indicator was employed. This indicator synthesizes response convergence : values close to 1 reflect consensus regarding the adoption of specific practices; values closer to 0 reflect divergence in clinical decision-making. This approach was used to provide a structured measurement of consensus levels on complex clinical decisions. Results Characteristics of the sample The total number of professionals who responded to the survey was 395. The majority of them are empolyed in public hospitals (35%) and university hospitals (26%), with an average professional experience of 20 years. The average age of the sample was 46 years (26yrs ÷ 76yrs) and the age group 31 ÷ 50 gave the 61% of the answers. Geographically, the sample was mainly composed of professionals from Northern Italy (55%), followed by Central (24%) and Southern Italy (21%). The regional distribution suggests potential disparities in MH preparedness, with a higher concentration of responses from Lombardia (22%), Lazio (11%), and Emilia-Romagna (8%), whereas Basilicata, is not represented in the responses. (Fig. 1 ) The average length of work experience is 20 years with a standard deviation of 12 years, which ensures a good balance in the sample detected by the survey Management of malignant hyperthermia The survey provided valuable insights into how MH is managed in Italian healthcare facilities, from prevention strategies to crisis response and post-crisis care. Institutional preparedness for MH varies significantly across healthcare settings (Table 1 ). Table 1 Case distribution for institutional setting. MH patients treated Nr (%) Major Public Hospital 41 (35%) University Hospital 30 (26%) Minor Public Hospital 15 (13%) Private IRCCS 5 (4%) Public IRCCS 7 (6%) Private Hospital with public role 11 (9%) Private Hospital 5 (4%) Altro 2 (2%) Totale 116 (100%) One hundred sixteen (31%) of professionals declare having treat almost a case of MH, but only 7% more than 5 cases. There is a geographical trend with higher incidence in Central Italy (50%) and in public (35%) and university (26%) hospitals, suggesting that larger institutions may be better equipped to diagnose and manage MH. The recurrence of MH in patients previously exposed to trigger agents showed a reported prevalence of 1–15%, lower figure than that found in scientific literature [ 3 ], where approximately 50% of MH cases occur in patients with previous uneventful exposures. But this discrepancy may be attributed to the survey’s limited sample size. A consistent trend emerged in the adoption of preventive measures (Table 2 ), with 91% of respondents confirming that they actively avoid the use of volatile anesthetics and succinylcholine in patients identified as being at risk. This finding demonstrates strong adherence to internationally recognized best practices in minimizing MH triggers [ 4 ]. Table 2 Preventive strategies – Age Group Age group I avoid exposure in subjects susceptible to trigger drugs I identify susceptible subjects I identify susceptible subjects and avoid exposure to trigger drugs I do not implement strategies Othe 61 6 (10%) 0 (0%) 53 (87%) 0 (0%) 2 (3%) Totale 26 (6%) 3 (1%) 400 (91%) 4 (1%) 4 (1%) The use of trigger agents was found to be uniformly low, with a Likert-scale indicator of 0.07 confirming that these drugs are almost never administered to susceptible patients. Their use, although rare, is the prerogative of the youngest professionals and of some regions, Calabria, Umbria and Veneto suggesting potential gaps in standardized protocols or educational initiatives. The same gap is about creatine phosphokinase (CK) requirement: 51% of professionals require the exam only in high risk patients while 38% always require CK in preoperative setting. The results of the survey confirm the presence of an internal protocol for the management of MH (49%) or its absence (21%). 16% of professionals are not aware of specific documentation on MH. Intraoperative management The preparation of the anesthesia ventilator is widely standardized (92%) through the removal of the vaporizer, the change of soda lime and the replacement of the circuits as well as anesthesia techniques with a bias towards regional anesthesia in patients at risk for MH, rather than general anesthesia demonstrating strong adherence to national best practices [ 5 ]. However, in the case of pregnant patients requiring non-obstetric surgery, 71% of respondents favores Total Intravenous Anesthesia (TIVA) over neuraxial anesthesia (25%). This deviates from MH and obstetric guidelines, which recommend neuraxial anesthesia [ 6 ]. Factors influencing this preference may include limited access to specialized obstetric anesthesia teams or regional differences in epidural anesthesia utilization. Dantrolene dilution practices also vary among respondents, with 66% correctly identifying sterile water as the appropriate solvent and 20% erroneously indicate normal saline (NaCl 0.9%) [ 7 ]. (Table 3 ) Table 3 Diluent indicated for dantrolene reconstitution Diluent Nr (%) NaCl 0,9% 86 (20%) Glucose 5% 46 (11%) Water for injectable preparation 276 (66%) Bicarbonate 2 (1%) Other 10 (2%) Regarding dantrolene stock management [ 8 ], 64% of respondents indicate that the operating room nurse coordinator was responsible for verifying and maintaining dantrolene supply, followed by intensive care nurse coordinators (16%) and hospital pharmacists (9%). Postoperative management and discharge The referral of post-MH patients to specialized centers is reported in 60% of cases; 22% turn to geneticists, 7% to neurologists. However, uncertainty remains regarding how many patients ultimately undergo confirmatory diagnostic testing. The 59% of respondents report providing both verbal and written discharge instructions about follow up; 13% give only verbal instructions and 22% inform family members of the risk. About pharmacovigilance, while 70% of respondents say they always report adverse reactions, 16% do not consider MH an adverse drug reaction, and 23% report accidents only to department heads. The survey also identified an underreporting trend, with only six MH-related reports filed in Italy up to 2018, compared to the 116 cases identified in the survey. The European pharmacovigilance database Eudravigilance is managed by the European Medicine Agency (EMA) and is publicly available online on the EMA website ( www.adrreports.eu ). Discussion Our results highlight the need for broader standardization and dissemination of MH management guidelines across different hospital settings, ensuring that all surgical centers operate under a unified crisis response framework. The data suggest that professional experience correlates with confidence in managing MH emergencies, although it may also influence resistance to adopting newer techniques. Most respondents were affiliated with public (35%) and university hospitals (26%), institutions where structured protocols and institutional directives are more common. The majority of respondents are aged between 31 and 50 years (61%), with a balanced distribution across Northern (55%), Central (24%), and Southern (21%) Italy. The highest number of responses came from Lombardia (22%), followed by Lazio (11%) and Emilia-Romagna (8%). The absence of responses from Basilicata suggests a potential need for further engagement in MH training and protocol implementation in specific regions. Regional differences also emerged in MH case distribution. This geographical variation could be attributed to response rate differences rather than an actual discrepancy in case prevalence. Furthermore, the number of MH cases reported by respondents seems influenced by chance, as MH is not an endemic condition and should theoretically be uniformly distributed across the country. Regarding at risk patients, 72% of respondents correctly identified individuals carrying mutations associated with MH and congenital myopathies [ 9 ]. Additionally, 91% reported avoiding exposure to trigger agents as a preventive strategy. International guidelines recommend the absolute avoidance of these drugs in myopathy patients due to the risk of rhabdomyolysis, reinforcing the need for continued training on this issue [ 10 , 11 ]. However, age-based differences in trigger agent use were noted, with senior professionals demonstrating a lower likelihood of administering these drugs (index of 0.02 vs the overall average of 0.07). This finding suggests that experience may promote a more tailored and cautious approach to anesthesia management. Geographically, agreement on the use of trigger agents was highest in Calabria (0.29), Umbria (0.14), and Veneto (0.14), which could indicate regional gaps in protocol standardization or disparities in MH training. Addressing these inconsistencies through targeted educational initiatives and internal clinical protocols standardization could help ensure consistent best practices nationwide. The survey also explored the role of preoperative CK testing [ 12 ]. Most respondents agreed with a selective approach (“depends”), aligning with current guidelines recommending CK testing only in cases with a suggestive medical history. However, systematic CK testing was notably more prevalent in public IRCCS facilities (52%), highlighting the need for harmonized preoperative screening protocols. The necessity of preoperative dantrolene prophylaxis was generally dismissed, aligning with international best practices. However, standardizing dantrolene administration, particularly with the introduction of new formulation [ 13 ], remains a key recommendation to ensure optimal preparedness. Given recent European guideline updates recommending at least 600 mg of dantrolene in each operating theater and at least 1200 mg available hospital-wide, facilities must reassess their storage and inventory strategies [ 10 ]. The coexistence of new and old formulation for the next years further necessitates clarity in dosing recommendations, shifting from a vial-based count to precise milligram-based storage guidelines. Training remains a crucial component of MH preparedness [ 14 ]. Simulation-based emergency training should be routinely implemented across all surgical centers, ensuring that operating room personnel are proficient in MH recognition and rapid dantrolene administration. Additionally, updating treatment guidelines to incorporate newer formulations, is necessary to optimize response times in crisis scenarios. A significant concern is pharmacovigilance compliance. Given that European regulations mandate the reporting of all suspected adverse reactions through the EudraVigilance network, increasing compliance with these regulations is critical. The fear of professional or legal repercussions may contribute to underreporting, underscoring the need for greater awareness and simplification of reporting procedures. Furthermore, improving patient education and discharge protocols is essential [ 15 ]. Standardized discharge instructions should provide clear recommendations for future anesthesia procedures, referral pathways, and genetic screening options. Finally, improving patient education post-MH episode is pivotal [ 16 , 17 ]. The survey highlighted a lack of standardized discharge criteria, raising concerns about inconsistent patient follow-up. Strengthening the referral process through a standardized national pathway would ensure that at-risk individuals receive appropriate follow-up care. Limited collaboration between anesthesiologists, myologists, and neurologists, as well as the lack of well-publicized specialized centers, contributes to post-discharge challenges. The development of a nationally recognized patient information protocol, including a formal discharge format and structured follow-up recommendations, is strongly recommended. The findings of this study emphasize the importance of a structured and interdisciplinary approach to malignant hyperthermia (MH) management. Collaboration among anesthesiologists, pharmacists, myologists, and neurologists is essential to refining diagnostic criteria, improving adherence to standardized protocols, and ensuring effective patient follow-up [ 18 ]. Establishing a national communication network among these specialists would facilitate the exchange of knowledge and streamline referral pathways, ultimately enhancing patient care[ 19 ]. Ensuring that all operating room personnel are trained to rapidly recognize and manage an MH episode is critical. The survey highlights the necessity of routine simulation-based training and emergency preparedness drills, which should be reinforced across all surgical centers. Additionally, maintaining an adequate and readily accessible stock of dantrolene remains a priority to ensure timely intervention in an MH crisis. The introduction of new formulation for an update of treatment guidelines regarding dantrolene administration. Clear, standardized recommendations on dosing, preparation, and the specific characteristics of each formulation should be developed to optimize clinical decision-making and reduce delays in treatment. This revision will help ensure that anesthesiologists and emergency teams are equipped with the necessary knowledge to administer the most appropriate formulation in a timely manner. Pharmacovigilance also remains an area for improvement [ 20 ]. Despite European regulations mandating the reporting of adverse drug reactions, MH-related cases appear to be significantly underreported. Encouraging compliance with reporting requirements and simplifying the process would improve epidemiological data, enhance clinical decision-making, and contribute to better public health outcomes. Addressing these challenges requires a coordinated effort between healthcare professionals, scientific societies, and policymakers. By refining MH management protocols, improving training and preparedness, updating pharmacological guidelines, and enhancing patient referral and pharmacovigilance practices, it is possible to create a more standardized, evidence-based approach to MH care in Italy. Ensuring that at-risk patients receive optimal medical support and structured follow-up care will ultimately lead to improved patient safety and better long-term outcomes in the management of this rare but critical condition. Overall, the survey results indicate that while strong preventive measures are widely implemented, gaps persist in institutional preparedness, postoperative management, and referral pathways. Addressing these discrepancies through standardization, education, and improved interdisciplinary collaboration will be essential to optimizing MH care in Italy. Conclusion This survey underscores the importance of standardizing malignant hyperthermia (MH) management protocols and strengthening interdisciplinary collaboration. Despite widespread adherence to preventive strategies, gaps persist in intraoperative practices, postoperative follow-up, and pharmacovigilance. A unified national approach is essential to ensure timely treatment and long-term care for MH-susceptible patients. Limitations This survey has several limitations. First, when compared to the whole population of anesthesiologists in Italy, the sample size was relatively low to achieve a clear data generalization. In addition we considered only SIAARTI members, and it could hide a further bias in the sample. Nevertheless, geographical distribution, age categories and hospital type is respondent with previous national surveys [ 21 ]. The last limitation is due to the nature of the survey. Respondents declared their point of view, but, as suggested by pharmacovigilance data, a mismatch with real data could be considered. Abbreviations CK Creatine phosphokinase EMA European Medicine Agency SIAARTI Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care MH Malignant hyperthermia TIVA Total Intravenous Anesthesia Declarations Human Ethics and Consent to Participate declarations: not applicable Data availability : Data is available from the corresponding author upon request Funding: This project was supported by an unrestricted grant from Norgine Italia, exclusively aimed at enabling the dissemination of the survey. The company did not take part in the scientific design, data collection, analysis, or writing of this manuscript. Authors’ contributions: FR RM and FS had the idea. EB FR RM FS and AG prepared the study questionnaire. RM and EB were responsible for data analysis. DA and RM wrote the initial draft of the manuscript. FR and FS reviewed the manuscript for the final version. All authors revised the paper for important intellectual content Acknowledgements: we acknowledge the invaluable support of the SIAARTI secretarial office for their administrative assistance and coordination during the development of this work References Rosenberg H, Pollock N, Schiemann AH, Bulger T, Stowell KM. Malignant hyperthermia: A review. Orphanet J. Rare Dis. 2015, 10, 93 Toyota Y, Kondo T, Shorin D, Sumii A, Kido K, Watanabe T, et al. Rapid Dantrolene Administration with Body Temperature Monitoring Is Associated with Decreased Mortality in Japanese Malignant Hyperthermia Events. BioMed Res. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6881142","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":473105390,"identity":"3a6488d3-44a7-434a-9011-52e6bcb97543","order_by":0,"name":"Roberta Monzani","email":"","orcid":"","institution":"Humanitas Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Roberta","middleName":"","lastName":"Monzani","suffix":""},{"id":473105391,"identity":"bff065e3-014c-4959-9bc0-be91df66b021","order_by":1,"name":"Daniela Alampi","email":"","orcid":"","institution":"Sapienza University of Rome, A.O.U. Sant'Andrea","correspondingAuthor":false,"prefix":"","firstName":"Daniela","middleName":"","lastName":"Alampi","suffix":""},{"id":473105392,"identity":"e4444ba5-917d-4dcb-9d38-1fa192b6d3a2","order_by":2,"name":"Elena Bignami","email":"","orcid":"","institution":"University of Parma","correspondingAuthor":false,"prefix":"","firstName":"Elena","middleName":"","lastName":"Bignami","suffix":""},{"id":473105393,"identity":"efc337e7-6cf0-4bc5-9378-4f2fa2509c34","order_by":3,"name":"Andrea Cortegiani","email":"","orcid":"","institution":"University of Palermo","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Cortegiani","suffix":""},{"id":473105394,"identity":"2cdf3467-6c13-485e-add3-1f08fb35414d","order_by":4,"name":"Antonino Giarratano","email":"","orcid":"","institution":"University of Palermo","correspondingAuthor":false,"prefix":"","firstName":"Antonino","middleName":"","lastName":"Giarratano","suffix":""},{"id":473105395,"identity":"a5c9040e-5f86-417d-b5ef-a95553b5824b","order_by":5,"name":"Fabrizio Racca","email":"","orcid":"","institution":"AO Ordine Mauriziano","correspondingAuthor":false,"prefix":"","firstName":"Fabrizio","middleName":"","lastName":"Racca","suffix":""},{"id":473105396,"identity":"2bb0b51f-f2ad-4987-874d-b1bb921fec3f","order_by":6,"name":"Fabio Sbaraglia","email":"data:image/png;base64,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","orcid":"","institution":"Fondazione Policlinico Universitario A. Gemelli IRCCS","correspondingAuthor":true,"prefix":"","firstName":"Fabio","middleName":"","lastName":"Sbaraglia","suffix":""}],"badges":[],"createdAt":"2025-06-12 14:08:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6881142/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6881142/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85388753,"identity":"1de9742e-74db-4e0e-a3e4-df1e8fe4a19b","added_by":"auto","created_at":"2025-06-25 10:11:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48158,"visible":true,"origin":"","legend":"\u003cp\u003eSample Geographical distribution rate. 0.1 is 10% of respondents.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6881142/v1/a63e23b6b12fced75b3ce85d.png"},{"id":85388769,"identity":"b93853cc-0cf9-4be1-bc14-d7f64d22a075","added_by":"auto","created_at":"2025-06-25 10:11:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":791277,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6881142/v1/c892d1aa-3f9b-4f13-97db-e1309fad1cb6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"National insights on Malignant Hyperthermia: a SIAARTI Survey on clinical practices, preparedness, and future directions","fulltext":[{"header":"Background","content":"\u003cp\u003eMalignant hyperthermia (MH) is a rare but life-threatening pharmacogenetic disorder affecting skeletal muscle metabolism, primarily triggered by exposure to volatile anesthetics and depolarizing muscle relaxants [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. If not promptly diagnosed and treated, MH can rapidly lead to multi-organ failure and death [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Given its critical clinical significance, SIAARTI conducted a nationwide survey among Italian anesthesiologists and critical care specialists to assess their experience, knowledge, and preparedness in managing MH cases. The findings of the survey were integrated with expert opinions to provide an in-depth analysis of current clinical practices, challenges, and recommended strategies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting, partecipant and recruitment\u003c/h2\u003e \u003cp\u003e This study is based on a nationwide online survey developed by experts belonging to SIAARTI (the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care) and approved by its research committee approval in 2024. IRB approval was not required for this study. The survey aimed to assess the knowledge of healthcare professionals regarding MH, with a particular focus on clinical management strategies and the use of dantrolene. Data collection was conducted between July 15 and October 15, 2024, through an online GDPR-compliant platform (SurveyMonkey 2024, Survey tool, Momentive Inc.), ensuring anonymity while allowing robust data aggregation and analysis.\u003c/p\u003e \u003cp\u003e The survey was delivered by mail to among 11.000 anesthesiologists and intensivists across Italy via SIAARTI\u0026rsquo;s network, targeting professionals with direct involvement in perioperative care and intensive care management. An explicit consent to partecipation is included, before starting the compilation of survey form,\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQuestionnaire design\u003c/h3\u003e\n\u003cp\u003eThe survey was structured into three main sections designed to gather a comprehensive understanding of how MH is managed in clinical settings :\u003c/p\u003e\n\u003ch3\u003e1. Demographic and professional data\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAge distribution and professional background.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGeographic location (region and city of practice) to evaluate potential regional disparities.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eYear of specialization to define levels of seniority and professional expertise.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eType of healthcare facility (public, private, university hospital or other institutions) to determine differences in resource availability and adherence to standardized protocols.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003e2. Experience with malignant hyperthermia:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eNumber of MH cases managed during professional careers or training programs.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIdentification of patient groups perceived as at risk for MH, including those with neuromuscular disorders or a history of adverse anesthetic reactions.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDifferential diagnosis awareness, including conditions that can mimic MH, such as neuroleptic malignant syndrome, sepsis, or thyroid storm.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003e3. Management strategies:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eExistence of formalized hospital protocols for MH crisis management.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePreventive measures taken to mitigate the risk of MH, including preoperative screening and selection of non-trigger anesthetics.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUse of dantrolene in preoperative prophylaxis and the extent to which institutions maintain an adequate stock.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePost-crisis patient management, including referral to specialized centers and pharmacovigilance reporting practices.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFree comment fields were available to elicit further information where appropriate. The estimated time to complete the survey was 20 min. Each survey was reviewed for readability and non-ambiguity by experts in MH.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe collected data were analyzed using descriptive statistical methods, including frequency distributions, medians, means, standard deviations, and other summary statistics to characterize the key variables. Qualitative variables were examined using contingency tables and graphical representations to provide a clear visualization of response distributions.\u003c/p\u003e \u003cp\u003eFor ordinal scale variables, such as the frequency of drug use or the application of dantrolene prophylaxis, an agreement indicator was employed. This indicator synthesizes response convergence : values close to 1 reflect consensus regarding the adoption of specific practices; values closer to 0 reflect divergence in clinical decision-making. This approach was used to provide a structured measurement of consensus levels on complex clinical decisions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the sample\u003c/h2\u003e \u003cp\u003eThe total number of professionals who responded to the survey was 395.\u003c/p\u003e \u003cp\u003eThe majority of them are empolyed in public hospitals (35%) and university hospitals (26%), with an average professional experience of 20 years. The average age of the sample was 46 years (26yrs\u0026thinsp;\u0026divide;\u0026thinsp;76yrs) and the age group 31\u0026thinsp;\u0026divide;\u0026thinsp;50 gave the 61% of the answers.\u003c/p\u003e \u003cp\u003eGeographically, the sample was mainly composed of professionals from Northern Italy (55%), followed by Central (24%) and Southern Italy (21%). The regional distribution suggests potential disparities in MH preparedness, with a higher concentration of responses from Lombardia (22%), Lazio (11%), and Emilia-Romagna (8%), whereas Basilicata, is not represented in the responses. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe average length of work experience is 20 years with a standard deviation of 12 years, which ensures a good balance in the sample detected by the survey\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eManagement of malignant hyperthermia\u003c/h2\u003e \u003cp\u003eThe survey provided valuable insights into how MH is managed in Italian healthcare facilities, from prevention strategies to crisis response and post-crisis care. Institutional preparedness for MH varies significantly across healthcare settings (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCase distribution for institutional setting.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMH patients treated\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNr (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor Public Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinor Public Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate IRCCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic IRCCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate Hospital with public role\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAltro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e116 (100%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOne hundred sixteen (31%) of professionals declare having treat almost a case of MH, but only 7% more than 5 cases. There is a geographical trend with higher incidence in Central Italy (50%) and in public (35%) and university (26%) hospitals, suggesting that larger institutions may be better equipped to diagnose and manage MH. The recurrence of MH in patients previously exposed to trigger agents showed a reported prevalence of 1\u0026ndash;15%, lower figure than that found in scientific literature [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], where approximately 50% of MH cases occur in patients with previous uneventful exposures. But this discrepancy may be attributed to the survey\u0026rsquo;s limited sample size.\u003c/p\u003e \u003cp\u003eA consistent trend emerged in the adoption of preventive measures (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), with 91% of respondents confirming that they actively avoid the use of volatile anesthetics and succinylcholine in patients identified as being at risk. This finding demonstrates strong adherence to internationally recognized best practices in minimizing MH triggers [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreventive strategies \u0026ndash; Age Group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI avoid exposure in subjects susceptible to trigger drugs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI identify susceptible subjects\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI identify susceptible subjects and avoid exposure to trigger drugs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI do not implement strategies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOthe\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e119 (92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130 (92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80 (92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e26 (6%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3 (1%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e400 (91%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e4 (1%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e4 (1%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe use of trigger agents was found to be uniformly low, with a Likert-scale indicator of 0.07 confirming that these drugs are almost never administered to susceptible patients. Their use, although rare, is the prerogative of the youngest professionals and of some regions, Calabria, Umbria and Veneto suggesting potential gaps in standardized protocols or educational initiatives.\u003c/p\u003e \u003cp\u003eThe same gap is about creatine phosphokinase (CK) requirement: 51% of professionals require the exam only in high risk patients while 38% always require CK in preoperative setting.\u003c/p\u003e \u003cp\u003eThe results of the survey confirm the presence of an internal protocol for the management of MH (49%) or its absence (21%). 16% of professionals are not aware of specific documentation on MH.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIntraoperative management\u003c/h2\u003e \u003cp\u003eThe preparation of the anesthesia ventilator is widely standardized (92%) through the removal of the vaporizer, the change of soda lime and the replacement of the circuits as well as anesthesia techniques with a bias towards regional anesthesia in patients at risk for MH, rather than general anesthesia demonstrating strong adherence to national best practices [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, in the case of pregnant patients requiring non-obstetric surgery, 71% of respondents favores Total Intravenous Anesthesia (TIVA) over neuraxial anesthesia (25%). This deviates from MH and obstetric guidelines, which recommend neuraxial anesthesia [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Factors influencing this preference may include limited access to specialized obstetric anesthesia teams or regional differences in epidural anesthesia utilization.\u003c/p\u003e \u003cp\u003eDantrolene dilution practices also vary among respondents, with 66% correctly identifying sterile water as the appropriate solvent and 20% erroneously indicate normal saline (NaCl 0.9%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiluent indicated for dantrolene reconstitution\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiluent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNr (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNaCl 0,9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (20%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucose 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWater for injectable preparation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e276 (66%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBicarbonate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding dantrolene stock management [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], 64% of respondents indicate that the operating room nurse coordinator was responsible for verifying and maintaining dantrolene supply, followed by intensive care nurse coordinators (16%) and hospital pharmacists (9%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative management and discharge\u003c/h2\u003e \u003cp\u003eThe referral of post-MH patients to specialized centers is reported in 60% of cases; 22% turn to geneticists, 7% to neurologists. However, uncertainty remains regarding how many patients ultimately undergo confirmatory diagnostic testing.\u003c/p\u003e \u003cp\u003eThe 59% of respondents report providing both verbal and written discharge instructions about follow up; 13% give only verbal instructions and 22% inform family members of the risk.\u003c/p\u003e \u003cp\u003eAbout pharmacovigilance, while 70% of respondents say they always report adverse reactions, 16% do not consider MH an adverse drug reaction, and 23% report accidents only to department heads.\u003c/p\u003e \u003cp\u003eThe survey also identified an underreporting trend, with only six MH-related reports filed in Italy up to 2018, compared to the 116 cases identified in the survey. The European pharmacovigilance database Eudravigilance is managed by the European Medicine Agency (EMA) and is publicly available online on the EMA website (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.adrreports.eu\u003c/span\u003e\u003cspan address=\"http://www.adrreports.eu\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e Our results highlight the need for broader standardization and dissemination of MH management guidelines across different hospital settings, ensuring that all surgical centers operate under a unified crisis response framework.\u003c/p\u003e \u003cp\u003eThe data suggest that professional experience correlates with confidence in managing MH emergencies, although it may also influence resistance to adopting newer techniques. Most respondents were affiliated with public (35%) and university hospitals (26%), institutions where structured protocols and institutional directives are more common.\u003c/p\u003e \u003cp\u003eThe majority of respondents are aged between 31 and 50 years (61%), with a balanced distribution across Northern (55%), Central (24%), and Southern (21%) Italy. The highest number of responses came from Lombardia (22%), followed by Lazio (11%) and Emilia-Romagna (8%). The absence of responses from Basilicata suggests a potential need for further engagement in MH training and protocol implementation in specific regions.\u003c/p\u003e \u003cp\u003eRegional differences also emerged in MH case distribution. This geographical variation could be attributed to response rate differences rather than an actual discrepancy in case prevalence. Furthermore, the number of MH cases reported by respondents seems influenced by chance, as MH is not an endemic condition and should theoretically be uniformly distributed across the country.\u003c/p\u003e \u003cp\u003eRegarding at risk patients, 72% of respondents correctly identified individuals carrying mutations associated with MH and congenital myopathies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Additionally, 91% reported avoiding exposure to trigger agents as a preventive strategy.\u003c/p\u003e \u003cp\u003eInternational guidelines recommend the absolute avoidance of these drugs in myopathy patients due to the risk of rhabdomyolysis, reinforcing the need for continued training on this issue [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, age-based differences in trigger agent use were noted, with senior professionals demonstrating a lower likelihood of administering these drugs (index of 0.02 vs the overall average of 0.07). This finding suggests that experience may promote a more tailored and cautious approach to anesthesia management.\u003c/p\u003e \u003cp\u003eGeographically, agreement on the use of trigger agents was highest in Calabria (0.29), Umbria (0.14), and Veneto (0.14), which could indicate regional gaps in protocol standardization or disparities in MH training. Addressing these inconsistencies through targeted educational initiatives and internal clinical protocols standardization could help ensure consistent best practices nationwide.\u003c/p\u003e \u003cp\u003eThe survey also explored the role of preoperative CK testing [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Most respondents agreed with a selective approach (\u0026ldquo;depends\u0026rdquo;), aligning with current guidelines recommending CK testing only in cases with a suggestive medical history. However, systematic CK testing was notably more prevalent in public IRCCS facilities (52%), highlighting the need for harmonized preoperative screening protocols.\u003c/p\u003e \u003cp\u003eThe necessity of preoperative dantrolene prophylaxis was generally dismissed, aligning with international best practices. However, standardizing dantrolene administration, particularly with the introduction of new formulation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], remains a key recommendation to ensure optimal preparedness.\u003c/p\u003e \u003cp\u003eGiven recent European guideline updates recommending at least 600 mg of dantrolene in each operating theater and at least 1200 mg available hospital-wide, facilities must reassess their storage and inventory strategies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The coexistence of new and old formulation for the next years further necessitates clarity in dosing recommendations, shifting from a vial-based count to precise milligram-based storage guidelines.\u003c/p\u003e \u003cp\u003eTraining remains a crucial component of MH preparedness [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Simulation-based emergency training should be routinely implemented across all surgical centers, ensuring that operating room personnel are proficient in MH recognition and rapid dantrolene administration. Additionally, updating treatment guidelines to incorporate newer formulations, is necessary to optimize response times in crisis scenarios.\u003c/p\u003e \u003cp\u003eA significant concern is pharmacovigilance compliance. Given that European regulations mandate the reporting of all suspected adverse reactions through the EudraVigilance network, increasing compliance with these regulations is critical. The fear of professional or legal repercussions may contribute to underreporting, underscoring the need for greater awareness and simplification of reporting procedures.\u003c/p\u003e \u003cp\u003eFurthermore, improving patient education and discharge protocols is essential [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Standardized discharge instructions should provide clear recommendations for future anesthesia procedures, referral pathways, and genetic screening options.\u003c/p\u003e \u003cp\u003eFinally, improving patient education post-MH episode is pivotal [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The survey highlighted a lack of standardized discharge criteria, raising concerns about inconsistent patient follow-up. Strengthening the referral process through a standardized national pathway would ensure that at-risk individuals receive appropriate follow-up care. Limited collaboration between anesthesiologists, myologists, and neurologists, as well as the lack of well-publicized specialized centers, contributes to post-discharge challenges.\u003c/p\u003e \u003cp\u003eThe development of a nationally recognized patient information protocol, including a formal discharge format and structured follow-up recommendations, is strongly recommended.\u003c/p\u003e \u003cp\u003eThe findings of this study emphasize the importance of a structured and interdisciplinary approach to malignant hyperthermia (MH) management. Collaboration among anesthesiologists, pharmacists, myologists, and neurologists is essential to refining diagnostic criteria, improving adherence to standardized protocols, and ensuring effective patient follow-up [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Establishing a national communication network among these specialists would facilitate the exchange of knowledge and streamline referral pathways, ultimately enhancing patient care[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEnsuring that all operating room personnel are trained to rapidly recognize and manage an MH episode is critical. The survey highlights the necessity of routine simulation-based training and emergency preparedness drills, which should be reinforced across all surgical centers. Additionally, maintaining an adequate and readily accessible stock of dantrolene remains a priority to ensure timely intervention in an MH crisis.\u003c/p\u003e \u003cp\u003e The introduction of new formulation for an update of treatment guidelines regarding dantrolene administration. Clear, standardized recommendations on dosing, preparation, and the specific characteristics of each formulation should be developed to optimize clinical decision-making and reduce delays in treatment. This revision will help ensure that anesthesiologists and emergency teams are equipped with the necessary knowledge to administer the most appropriate formulation in a timely manner.\u003c/p\u003e \u003cp\u003ePharmacovigilance also remains an area for improvement [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Despite European regulations mandating the reporting of adverse drug reactions, MH-related cases appear to be significantly underreported. Encouraging compliance with reporting requirements and simplifying the process would improve epidemiological data, enhance clinical decision-making, and contribute to better public health outcomes.\u003c/p\u003e \u003cp\u003eAddressing these challenges requires a coordinated effort between healthcare professionals, scientific societies, and policymakers. By refining MH management protocols, improving training and preparedness, updating pharmacological guidelines, and enhancing patient referral and pharmacovigilance practices, it is possible to create a more standardized, evidence-based approach to MH care in Italy. Ensuring that at-risk patients receive optimal medical support and structured follow-up care will ultimately lead to improved patient safety and better long-term outcomes in the management of this rare but critical condition.\u003c/p\u003e \u003cp\u003eOverall, the survey results indicate that while strong preventive measures are widely implemented, gaps persist in institutional preparedness, postoperative management, and referral pathways. Addressing these discrepancies through standardization, education, and improved interdisciplinary collaboration will be essential to optimizing MH care in Italy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis survey underscores the importance of standardizing malignant hyperthermia (MH) management protocols and strengthening interdisciplinary collaboration. Despite widespread adherence to preventive strategies, gaps persist in intraoperative practices, postoperative follow-up, and pharmacovigilance. A unified national approach is essential to ensure timely treatment and long-term care for MH-susceptible patients.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e This survey has several limitations. First, when compared to the whole population of anesthesiologists in Italy, the sample size was relatively low to achieve a clear data generalization. In addition we considered only SIAARTI members, and it could hide a further bias in the sample. Nevertheless, geographical distribution, age categories and hospital type is respondent with previous national surveys [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The last limitation is due to the nature of the survey. Respondents declared their point of view, but, as suggested by pharmacovigilance data, a mismatch with real data could be considered.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCK Creatine phosphokinase\u003c/p\u003e\n\u003cp\u003eEMA European Medicine Agency\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSIAARTI Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care\u003c/p\u003e\n\u003cp\u003eMH Malignant hyperthermia\u003c/p\u003e\n\u003cp\u003eTIVA Total Intravenous Anesthesia\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e: Data is available from the corresponding author upon request\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This project was supported by an unrestricted grant from Norgine Italia, exclusively aimed at enabling the dissemination of the survey. The company did not take part in the scientific design, data collection, analysis, or writing of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e FR RM and FS had the idea. EB FR RM FS and AG prepared the study questionnaire. RM and EB were responsible for data analysis. DA and RM wrote the initial draft of the manuscript. FR and FS reviewed the manuscript for the final version. All authors revised the paper for important intellectual content\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e we acknowledge the invaluable support of the SIAARTI secretarial office for their administrative assistance and coordination during the development of this work\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRosenberg H, Pollock N, Schiemann AH, Bulger T, Stowell KM. Malignant hyperthermia: A review. Orphanet J. Rare Dis. 2015, 10, 93\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToyota Y, Kondo T, Shorin D, Sumii A, Kido K, Watanabe T, et al. Rapid Dantrolene Administration with Body Temperature Monitoring Is Associated with Decreased Mortality in Japanese Malignant Hyperthermia Events. BioMed Res. Int. 2023, 2023, 8340209.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrady JE, Sun LS, Rosenberg H, Li G. Prevalence of Malignant Hyperthermia Due to Anesthesia in New York State, 2001\u0026ndash;2005. Obstet. Anesth. Dig. 2009, 109, 1162\u0026ndash;1166\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchieren M, Defosse J, B\u0026ouml;hmer A, Wappler F, Gerbershagen MU. Anaesthetic management of patients with myopathies. Eur. J. Anaesthesiol. 2017, 34, 641\u0026ndash;649.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSbaraglia F, Racca F, Maiellare F, Longhitano Y, Zanza C, Caputo CT. Prevenzione, Gestione e Trattamento Dell\u0026rsquo;ipertermia Maligna. 2020. Available online: www.siaarti.it (accessed on 10 April 2023). Italian\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchuster F, Johannsen S. [Malignant Hyperthermia and Pregnancy - Guidelines of the European Malignant Hyperthermia Group]. Anasthesiol Intensivmed Notfallmed Schmerzther. 2021;56(5):367\u0026ndash;372. German.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg Kwet Shing RH, Clayton LB, Smith SL, Watson MJ, McKenzie LM, Chalmers DP, et al. The novel rapid formulation of intravenous dantrolene (NPJ5008) versus standard dantrolene (Dantrium): A clinical part-randomised phase 1 study in healthy volunteers..Eur J Anaesthesiol. 2024;41(5):381\u0026ndash;390.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarach MG, Riazi S, Rosenberg H. Dantrolene Should Be Readily Available Wherever Malignant Hyperthermia Triggering Drugs Are Stocked. Anesth Analg. 2019;129(5):e175-e176.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRadkowski P, Suren L, Podhorodecka K, Harikumar S, Jamrozik N. A Review on the Anesthetic Management of Patients with Neuromuscular Diseases. Anesthesiol. Pain Med. 2023;13:e132088.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlahn KPE, Girard T, Hellblom A, Hopkins PM, Johannsen S, R\u0026uuml;ffert H, et al. Recognition and management of a malignant hyperthermia crisis: updated 2024 guideline from the European Malignant Hyperthermia Group. Br J Anaesth. 2025;134(1):221\u0026ndash;223.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHopkins PM, Girard T, Dalay S, Jenkins B, Thacker A, Patteril M, et al. Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists. Anaesthesia. 2021;76(5):655\u0026ndash;664.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR\u0026uuml;ffert H, Bastian B, Bendixen D, Girard T, Heiderich S, Hellblom A, 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\u0026ndash;130\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg Kwet Shing RH, Wright DJ, Pal S, Smith SL, Clayton LB, Bilmen JG. 2-Hydroxypropyl-β-cyclodextrin, solubiliser in a novel dantrolene formulation: Its binding affinities to clinical compounds that may be used during anaesthesia or management of malignant hyperthermia. Eur J Pharm Biopharm. 2025 Jun 5:114765\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCain CL, Riess ML, Gettrust L, Novalija J. Malignant hyperthermia crisis: optimizing patient outcomes through simulation and interdisciplinary collaboration. AORN J. 2014;99(2):300\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodrigues G, de Andrade PV, Dos Santos JM, do Amaral JLG, da Silva HCA. Impact of a digital manual for guidance on malignant hyperthermia: patient education. Orphanet J Rare Dis. 2022;17(1):265.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHughes AM, Gregory ME, Joseph DL, Sonesh SC, Marlow SL, Lacerenza CN, et al. Saving lives: a meta-analysis of team training in healthcare. J Appl Psychol. 2016;101(9):1266\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopov V, Rochlen LR From communication to action: using ordered network analysis to model team performance in clinical simulation. BMC Med Educ. 2025;25(1):479.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUrman RD, Rajan N, Belani K, Gayer S, Joshi GP. Malignant Hyperthermia-Susceptible Adult Patient and Ambulatory Surgery Center: Society for Ambulatory Anesthesia and Ambulatory Surgical Care Committee of the American Society of Anesthesiologists Position Statement. Anesth Analg. 2019;129(2):347\u0026ndash;349.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarfaoui W, Alilou M, El Adib AR, Zidouh S, Zentar A, Lekehal B, et al. Patient Safety in Anesthesiology: Progress, Challenges, and Prospects. Cureus. 2024;16(9):e69540.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan MAA, Sara T, Babar ZU. Pharmacovigilance: the evolution of drug safety monitoring. J Pharm Policy Pract. 2024;17(1):2417399.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreco M, Luca E, Chiumiento F, Behr AU, Bettelli G, Bignami E, et al. Perioperative assessment and management of frailty in elderly patients: a national survey of Italian anesthesiologists. J Anesth Analg Crit Care. 2025;5(1):11.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-anesthesia-analgesia-and-critical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Journal of Anesthesia, Analgesia and Critical Care](https://janesthanalgcritcare.biomedcentral.com/)","snPcode":"44158","submissionUrl":"https://submission.nature.com/new-submission/44158/3","title":"Journal of Anesthesia, Analgesia and Critical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Malignant Hyperthermia, Anesthesia, Dantrolene, Adverse Events","lastPublishedDoi":"10.21203/rs.3.rs-6881142/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6881142/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e Malignant Hyperthermia Syndrome is a rare pharmacogenetic disorder, highly life-threatening if diagnosis and treatment is delayed. The purpose of this study is to assess the knowledge and current practices of Italian anesthesiogists in managing Malignant Hypertermia episodes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e We conducted a national survey. Data were collected via an online questionnaire distributed by the Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Responses were collected over 15 weeks between July 15 and October 15, 2024, using an online GDPR-compliant platform\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e A total of 395 anesthetists completed the survey. The majority are employed in public (35%) and university hospitals (26%), with an average of 20 years of professional experience. MH had been managed at least once by 31% of respondents, and 70% of them declared they always report adverse reactions\u003c/p\u003e\n\u003cp\u003eIn over 90% of cases, preventive measures (removal of trigger drugs, ventilator wash-out, perioperative care) are indentified, although only 49% reported having an internal protocol in place at their institution.\u003c/p\u003e\n\u003cp\u003eIn most centers (89%) non anesthesiologists are responsible for the storgae and supply of dantrolene and only 66% of respondents correctly identifying sterile water as its appropriate solvent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion \u003c/strong\u003eOur results highlight the need for broader standardization of MH management. Despite limitation in sample size and difference in geographical and hospital setting, the survey reveales a discrepancy between clinical practice and recommended strategies. While preventive measures are widely recognized, they are often not strandardized, and a correct treatment remains an area for significant improvement.\u003c/p\u003e","manuscriptTitle":"National insights on Malignant Hyperthermia: a SIAARTI Survey on clinical practices, preparedness, and future directions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-25 09:55:31","doi":"10.21203/rs.3.rs-6881142/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-03T08:13:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-03T08:11:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30968300580088260882659228074506423009","date":"2025-07-03T08:08:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-29T09:58:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36298267665054531386300502554889855211","date":"2025-06-25T16:50:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136465618826866932682887574249697218312","date":"2025-06-23T16:57:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173833358231238260967242919547586919872","date":"2025-06-21T11:02:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-18T12:43:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T13:56:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-16T13:54:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Anesthesia, Analgesia and Critical Care","date":"2025-06-12T14:05:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-anesthesia-analgesia-and-critical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Journal of Anesthesia, Analgesia and Critical Care](https://janesthanalgcritcare.biomedcentral.com/)","snPcode":"44158","submissionUrl":"https://submission.nature.com/new-submission/44158/3","title":"Journal of Anesthesia, Analgesia and Critical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"69bad42f-3f21-41ee-be0b-166aff71387f","owner":[],"postedDate":"June 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-02T08:38:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-25 09:55:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6881142","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6881142","identity":"rs-6881142","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}