Abstract
We successfully treated two patients with severe tetanus who showed overactive hemodynamics, excessive salivation, and muscle rigidity by using prolonged isoflurane inhalation in combination with dantrolene.
The first case, a 31-year-old female with severe tetanus, required mechanical ventilation in our intensive care unit (ICU) due to dyspnea of muscle rigidity. Medications including calcium antagonists, nitroprusside, α- and β-adrenoceptor blockade, and benzodiazepam or epidural anesthesia were administered for 6 days. Mean arterial pressure (±SD) was 146±40mmHg during intravenous medication therapies, 153±29mmHg during epidural anesthesia, and 137±8mmHg during isoflurane inhalation. The hemodynamics stabilized for the first time after isoflurane inhalation from day 7. Isoflurane inhalation also markedly reduced muscle rigidity and salivation. Mechanical ventilation under isoflurane inhalation was necessary for 25 days. The muscle rigidity was alleviated after oral administration of dantrolene for 10 days. The patient was successfully discharged from the ICU on day 51.
The second 39-year-old female with severe tetanus was mechanically ventilated under isoflurane inhalation from the beginning. Mean arterial pressure before treatment, 149±44mmHg, was stabilized to 137±8mmHg with isoflurane inhalation. However, unstable hemodynamics and muscle spasms appeared as soon as we tried to wean her from isoflurane inhalation, until we tried dantrolene. Muscle rigidity was gradually reduced with oral administration of dantrolene from day 18, and the hemodynamics gradually became stable. Isoflurane was administered for 31 days. Serum free fluoride concentration was 18μmol·l-1 at an inhalation dose of 272 minimum-alveolar-concentration, which was far less than the renal toxic concentration of 50μmol·l-1.
We conclude that a combination therapy of isoflurane and dantrolene is useful for the treatment of severe tetanus.
