Malignant Hyperthermia

[surgblumm]

Malignant Hyperthermia- A Daily Life Threatening Problem for Surgical Patients

Bob Blumm, MA, PA-C, DFAAPA

Past President , AASPA, Past Chairman, Surgical Congress AAPA, Past AAPA Liaison to ACS, President, APSPA, Past President, American College of Clinicians, Faculty, President, Senior Clinicians Society.

Malignant Hyperthermia is a life threatening, acute pharmocogenic myopathic disorder developing during or after general anesthesia. The crisis is triggered in susceptible individuals by potent inhalation anesthetics and depolarizing muscle relaxants. This in turn results in hypermetabolism, skeletal muscle damage and hyperthermia. If the symptoms of MH are not recognized immediately and treated accordingly with the proper protocols, the crisis will result in the death of a patient in more than 80% of the patients. National attention was brought to this crisis with the death of an 18 year old female in Florida on March 22, 2008. Stephanie Jude Kuleba died while undergoing a minor surgical procedure in a Surgicenter. The joint commission is now requiring MH protocols to be posted in all OR facilities and to perform a mock MH drill yearly.

Although the exact incidence is unknown, MH is most common in children, adolescents and young adults. All races and ethnic backgrounds `are affected. The occurrence rate is 1:5,000-1:65,000 in administrations of general anesthesia with triggering agents. Incidence varies depending upon the number of susceptible families in a given geographical area. High incidence areas in the U.S. are Nebraska, Wisconsin, West Virginia and Michigan. This is a genetically influenced disease that requires a certain pre-operative check list to prevent or be prepared for a MH crisis.

Who should be familiar with this life threatening problem. Everyone in an OR or PACU. All clinicians, particularly Nurses in a Surgicenter or emergency Room. All dental surgical personnel, all EMS providers who will be transferring these patients from an outside facility to an ER. This is always an important issue for pre-operative exam performed in both the office and facility. The author gives these courses to all above groups and can be contacted at surgblumm@gmail.com. All personnel should join or go to the MHAUS website and drills need to be performed every six months. The AORN thought enough of this to place MH in their Practice and Protocols starting 2010. If you are unaware as to how to treat this surgical emergency you place the life of your trusting patient in jeopardy.

Although a small percentage of PAs and NPs are aware of this modality, it is incumbent upon the PA/NP professions to know the disease, the risk factors, the protocols available, the medication that is life saving and the source of all information that has a hotline in the United States. This is applicable to the PA who assists in surgery in a hospital, a Surgicenter or an office situation. This is also an area of applicable learning for all Family Practice PAs who interview patients and perform an H&P prior to surgery. Discovering a potential MH patient can be life saving. The Malignant Hyperthermia Association of the United States is the international source of a database, protocols and education concerning this condition.

I ill be giving this lecture at the AASPA meeting in Chicago, ILL in September and at the NPA annual meeting this Fall in Saratoga, NY. If your group wishes to attend or wants to have this lecture at their next CME meeting, contact the organizations or myself at the e-mail address supplied.

General Bibliography- Malignant Hyperthermia Association of the United States. MHAUS- P.O. Box 1069, 11 East State Street, Sherburne, NY 13460-1069 www.mhaus.org:

Preventing MH- An Anesthesia Protocol, Managing MH- drugs, Equipment and Dantrolene, Clinical Update

:=D:

[bgdog]

I've seen it once in 20 yrs in the OR, most frightening, we were closing an ORIF ankle, next thing the temp was a hundred and something and climbing fast, there was panic in the anesthesiologist eyes, the nursing staff had the cart and was all over it, iced him down lickity split, he was rushed to ICU and the surgeon and I thought that was it for said pt. Did rounds a few days later and he was sitting up eating a cheeseburger, I stopped in my tracks, "boy it sure is nice seeing you" "I been hearing that a lot" he says.

 

freaky stuff

[EMEDPA]

never seen it. all I remember from my training regarding it is that dantrolene is the life saving tx.

similar to this syndrome:

http://en.wikipedia.org/wiki/Neuroleptic_malignant_syndrome

[LT_Oneal_PAC]

Similar, except for the hyperthermia.

 

First you'll likely see trismus, then elevated co2 and temp. Stop trigger (likely sux or anesthetic gas) Ice fluids and dantrolene 2.5mg/kg and repeat up to 10mg/kg. also make sure you have plenty of CO2 absorbent as its almost impossible to prevent acidosis without it in the initial attack.

 

Never seen it in my short anesthesia career, but the best thing is avoidance. Anyone related to someone with it (or died during surgery and it sounds similar) gets propofol/narcotic only anesthetic. No sux, no gas.

[LT_Oneal_PAC]

Anyone want to guess the test for it?

[EMEDPA]

Similar, except for the hyperthermia.

 

.

my understanding is that nms often presents with hyperthermia as well. a few yrs ago a bunch of prisoners on haldol at some jail died of it with temps> 104 on a nl temp day.

Symptoms overview NMS

 

 

• Increased body temperature >38°C (>100.4°F), or
  
• Confused or altered consciousness
  
• Diaphoresis "sweat shock"
  
• Rigid muscles
  
• Autonomic imbalance
  

[LT_Oneal_PAC]

I apologize, I meant the hypercarbia. While I'm sure that NMS also has elevated CO2 from fever, it's nothing compared to what happens in MH. I've seen video of co2 absorbent being almost immediately exhausted.

 

I will admit they are very similar and if not witnessed DURING anesthesia when co2 and temp is constantly monitored (and where trismus can be immediately recognized by lack of ventilation through ET), it would be VERY difficult to diagnose. Gotta know the triggers for both

[surgblumm]

Caffiene-Halothane Contracture Test. Only three sites in USA and one in Ottawa. I have seen an MH crisis only once and in the same year that Dantrolene was discovered and made available. It had not yet at that time become a mandatory drug in the OR and our anesthesiologist remembered the name and sent for it from the pharmacy at the hospital. MH Crisis is sheer terror for the unprepared team and organized terror for us so called experts. I have been teaching this and keep updated for the past ten years. Every surgical and Emergency medicine PA should be knowledgeable as well as primary care who does the pre-op exam and can ask the six magic questions. As I have seen before, this forum is quick to respond to questions and generates good solid information. Revonto is the quick mixing variation of the same drug and came out last year.

bob blumm

[jsfelder0417]

Never seen it, thankfully.

[jsfelder0417]

Mind if I ask what the six magic questions are for the pre-op interview?

[surgblumm]

The Six Questions for pre-operative exam

1. Is there a family or personal history of MH and or/ any atypical response to anesthesia?

2. Is there a family or personal history of a muscle or neuromuscular disorder (e.g.muscle weakness or severe cramps?)

3.Is there a family history or blood rekatives of any complications or death arising from any anesthesia in any setting including a dentist's office?

4. Is there a personal history of unexplained or unanticipated fever post anesthesia or during anesthesia?

6. Is there a personal or family history of high temperature or death during exercise?

See, You're getting close to not being obliged to hear this lecture at one of my future meetings. Contact MHAUS for further information.

Bob

[jsfelder0417]

Most informative. Thank you, Bob.