Although malignant hyperthermia (MH) is a well-known complication of anesthesia, it presents unique considerations in the military health system. In this case report, the authors present a 26-year-old male active duty service member who experienced an MH crisis during a routine bilateral sagittal split osteotomy. The case presented here, which occurred at Brian D Allgood Army Community Hospital at Camp Humphreys, South Korea, highlights the challenges presented when caring for these patients in minimally staffed environments with frequent turnover of staff. The authors discuss the challenges to the military system such as the importance of adequate documentation of MH-susceptible service members, the benefits of rapidly dissolving dantrolene sodium nanosuspension, and the necessity for frequent training of military medical staff in the recognition and management of MH.

Heat or exercise have been implicated as potential initiators of the hypermetabolic cascade within MHS individuals. A significant amount of the MHS diagnosed population do NOT express known pathogenic mutations. Greater screening for MH susceptibility is required. Altered 3’ 5’ cyclic adenosine monophosphate (cAMP) second messenger activity and altered metabolism have correlated with the MHS genotype. It is hypothesized cAMP signaling molecules, norepinephrine (NOR) and epinephrine (EPI), may significantly alter metabolism within MHS individuals compared to MHN individuals, thereby unmasking a potential metabolic biomarker. The human Epstein‐Barr immortalized B‐lymphocyte MHN and MHS cell lines were used to compare metabolic parameters. Cell lines were cultured and treated with either NOR (1µM) or EPI (1µM). Different substrate metabolism pathways required to maintain oxidative phosphorylation were then inhibited. UK5099, bis‐2‐(5‐phenylacetamido‐1,3,4‐thiadiazol‐2‐yl) ethyl sulfide (BPTES), and etomoxir, inhibited pyruvate transport into the mitochondrial matrix, glutamine metabolism, and oxidation of fatty acids, respectively. The Seahorse Xfe96 AnalyzerTM then analyzed the oxygen consumption rate (OCR). The OCR variables such as spare respiratory capacity (SRC), maximum respiration, and basal respiration were then compared to produce a bioenergetic profile. The data revealed NOR produced different OCR changes compared to EPI treatment. NOR significantly reduced the basal (75.5 + 1.2 vs 56.2 + 2.7 pmol/min/cells) and maximal respiration (203.3 + 3.2 vs 136.9+ 9.7 pmol O2/min/cells) within the MHN group, p <.01. In contrast to the MHN group, the MHS basal and maximal respiration OCR was not diminished after NOR treatment (62.0 + 2.8 vs 56.5 + 2.3 pmol O2/min/cells) and (195.6 + 13.5 vs 187.4 pmol O2/min/cells), p >.05. EPI treatment did not significantly alter the basal, maximal, or SRC rates within the MHN or MHS groups. UK5099 unmasked the importance of glucose metabolism, significantly diminishing maximum respiration within untreated MHN groups by 136.0 and 31.4 pmol O2/min/cells and within MHS groups by 132.3 and 73.9 pmol O2/min/cells, respectively. Adding NOR or EPI did not mitigate this decrease. The MHN and MHS b‐lymphocytes rely on glucose metabolism for optimal oxidative phosphorylation capacity. NOR dependent metabolic pathways during basal and maximal respiration differ between MHN and MHS b‐lymphocytes. Disclaimers The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University (USU) or the Department of Defense. This work was prepared by a military and civilian employee of the US Government as part of the individuals’ official duties and therefore is in the public domain and does not possess copyright protection. As a courtesy it is requested USU and authors be given acknowledgement. The research protocol DBS.2019.008, was reviewed and approved by the USU Institutional Review Board, in accord...