Download Deaths Associated With MH in North America 1987

Transfer Guidelines for
Malignant Hyperthermia
Marilyn Green Larach M.D.
Senior Research Associate
The North American
Malignant Hyperthermia Registry of MHAUS
Disclosure Statement

Dr. Larach received an MHAUS
honorarium
–

To support guideline development
Both MHAUS and the ASF sell transfer
of care posters
–
No financial benefit to Dr. Larach
Goals of Talk
Introduce Transfer of Care Guidelines
 Discuss Need for Guidelines
 Provide Overview of Content
 Review MH Presentation & Treatment

Assumes an ASC using MH
Triggers has Available:

Anesthesia Care
Provider

36 Vials of Dantrolene

MHAUS Emergency
Therapy Poster

MH Crisis Drills
Development of Guidelines for
Emergent MH Transfers

Joint Consensus Document
–
–

ASF
MHAUS
13 Panel Members
–
–
–
–
–
–
Anesthesiologists
CRNA
Emergency Medicine Physician
Emergency Medical Technician
ASC nurse/administrator
ASF nurse/administrator
Guideline Goals

Assist ASC to prepare own individual
emergent MH transfer plan predicated
on the facilities and capabilities of the:
–
ASC
– Emergency transport services
– Receiving hospital
Guidelines and Not Protocol

ASC Locations Vary
–
–
–
Staff Resources
Lab Resources
Distance to
Receiving Hospital
Guidelines and Not Protocol

Emergency
Transport Services
Vary
–
Availability
– Weather
– Distance to
Receiving Hospital
– Severity of Patient
Condition
Guidelines and Not Protocol

Receiving Hospitals
Vary
–
Facilities
–
Personnel
Recognition of Suspected MH

First signs
–
–
–
Hypercarbia
Sinus tachycardia
Masseter spasm
Temperature abnormalities may be
early MH sign
 Most common pattern

–
Respiratory acidosis and muscular
abnormalities
Begin Treatment




Declare MH Emergency
Discontinue Triggering Agents
100% Oxygen at High Flow
Give Dantrolene
–
–

2.5 mg/kg IV push
Titrate to effect
Initiate Transfer Plan
–
Whenever possible, don’t move unless
clinician judges patient to be stable
Key Patient Stability Indicators
ETCO2 is declining or normal
 HR is stable or decreasing
 No ominous dysrhythmias
 Temperature is declining
 Generalized muscular rigidity is
resolving (if present)
 IV dantrolene administration has begun

MH Morbidity and Mortality









Consciousness Level Change/Coma
Cardiac Dysfunction
Pulmonary Edema
Renal Dysfunction
Disseminated Intravascular Coagulation
Hepatic Dysfunction
Other
Relapse
Death
Factors Increasing MH
Complication Likelihood

Increased time 1st sign to 1st dantrolene
–

For every 30 minute increase in the interval between 1st
MH sign and 1st dantrolene dose, the complication
likelihood increased 1.6 times.
Increased maximal temperature
–
For every 2C increase in maximal temperature, the
complication likelihood increased 2.9 times.
Transport Team

Type varies with scenario & transport time
 Capabilities
–
–
–
–
–
–

Ventilatory support
Cardiopulmonary & temperature monitoring
Fluid resuscitation
Medication administration
Life support
Phone communication
May require ASC anesthesia staff
Receiving Health Care Facility

Existing transfer agreement
 Inpatient capabilities
–
–
–
–
–
–
–
Adult/Pediatric Critical Care
Continuous temperature and cardiopulmonary
monitoring
Non-invasive/invasive cooling
Continuous sedation
Dantrolene
Dysrhythmia treatment
Hemodialysis
Receiving Health Care Facility
Consultant Availabilities
Anesthesiology
 Critical Care
 Hematology
 Surgery
 Nephrology
 Medical Toxicology

Report Data from ASC
Cardiovascular signs
 Temperature and site
 Minute ventilation with ETCO2
 Dantrolene amount given & response
 Muscular rigidity status
 Electrolytes
 I.V. site
 Urinary catheter & urine color

Communication Coordination

Direct communication concerning
patient status & admission location
between
–
Anesthesia care provider at ASC
AND
– Physicians accepting care at Receiving
Hospital
Transfer Decisions by On-Site
ASC Health Care Professional

Timing of Transfer
 Factor In:
– Transport time
 Choice of Transfer
– Bed availability
Team
– Clinical stability
 Choice of Receiving
Hospital
Implementation of Transfer
Decision

Don’t delay transfer pending specific
personnel or equipment availability if
emergent transfer is mandatory

**Accompany patient with appropriate
medications and equipment if needed to
serve the best interests of the patient
**Personal Recommendation
Create Your Own ASC
MH Transfer Plan

Start with Guidelines
 Research available transport teams
 Consult with physicians at referral hospitals
Clinical Characteristics

24.1% Emergency
–

Orthopedic, ENT, General Surgery
–

Sux 3.8 times more often
Sux 1.9 times more often
Temperature Monitoring (n=259)
–
14% skin liquid crystal sole probe
– In 10 patients, skin liquid crystal didn’t
trend with core temp probe
Anesthetic Triggers (n=284)
Anesthetic Agent
Percent
+ succinylcholine – volatile
0.7
+ succinylcholine + volatile
53.9
– succinylcholine + volatile
45.1
– succinylcholine – volatile
0.4
Presentation

99% Respiratory Acidosis

26% Metabolic Acidosis

80% Muscular Abnormalities
Clinical Presentation Pattern (n=196)
Presentation Pattern
%
+Respiratory +Metabolic +Muscular 20.4
+Respiratory +Metabolic –Muscular 5.1
+Respiratory –Metabolic +Muscular 58.2
–Respiratory +Metabolic +Muscular 0.5
+Respiratory –Metabolic –Muscular 15.3
–Respiratory –Metabolic +Muscular 0.5
Dantrolene Dosage (n=229)
Dose
Median 1st Q 3rd Q Range
Initial
2.4
1.9
2.8
.01-15.0
8
3
11
1 - 58
5.9
3.0
10.0
.02-100.0
17
7
36
1 - 343
(mg/kg)
Initial
(vials)
Total
(mg/kg)
Total
(vials)
Adjunctive Treatment (n=284)
Treatment
%
Hyperventilation with FiO2=1
IV fluid loading
Active cooling
Bicarbonate
Anesthesia circuit change
Mannitol
Furosemide
Glucose and insulin
87
77
70
54
48
34
32
14