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Can Patients with a Suspected Personal or Family History of MH be Safely Anesthetized Prior to Diagnostic Testing for MH Susceptibility?

Can Patients with a Suspected Personal or Family History of MH be Safely Anesthetized Prior to Diagnostic Testing for MH Susceptibility

Topic

Can Patients with a Suspected Personal or Family History of MH be Safely Anesthetized Prior to Diagnostic Testing for MH Susceptibility?

Developed by Dr. Lena Mayes                                             

Supporting Evidence

Background: 

Patients with a known or suspected personal or family history of MH are often denied access to general anesthesia prior to diagnostic testing for MH susceptibility, resulting in cancellation and postponement of necessary surgical procedures. Also, MH susceptible patients may be told they cannot have surgery in ambulatory surgery centers but must have surgery at inpatient hospitals.

Discussion: 

A suspected personal or family history of possible MH is not uncommon in patients requiring general anesthesia for medical or surgical procedures.1 The details of the presumed episode may be unclear, and in many instances, it is impossible to determine these details because medical records cannot be accessed in a timely manner. However, some patients suspected of being MH susceptible may require surgical management before formal MH susceptibility testing has been performed. Additionally, for many patients, diagnostic testing for MH susceptibility is not feasible because of the geographical distance to an MH biopsy-testing center, or their lack of insurance coverage for muscle contracture or genetic testing.

Conclusions

Care of MH susceptible patients need not be restricted by the lack of formal MH susceptibility testing, nor should care be limited to inpatient hospitals facilities.4 MH susceptible patients can be safely cared for in most anesthetizing locations, including appropriately staffed and resourced ambulatory surgery centers, provided non-MH triggering agents are used.4 However, the chosen anesthetizing location should meet the following criteria: 1. The facilities should be prepared to recognize and treat an MH crisis 2,3,6,8,9 according to the established guidelines by MHAUS and accrediting organizations .4,5  2. Dantrolene should be accessible within ten minutes of the first signs of MH, and the facility should have the capacity to administer at least 10mg/kg of dantrolene in the event of an acute MH episode requiring multiple dantrolene doses to abort the crisis.3,4 3. The anesthesia machine should be flushed according to its specific manufacture’s recommendations and/or charcoal filters placed on both inspiratory and expiratory limbs to minimize residual volatile agent in the circuit (http://www.mhaus.org/healthcare-professionals/be-prepared/preparing-the-anesthesia-machine/).4,5 4. There should be a formal agreement in place between ambulatory surgery centers and hospitals for transfer of patients to higher care after a suspected MH episode.4,5

References

  1. Lu Z1, Rosenberg H, Brady JE, Li G. Prevalence of Malignant Hyperthermia Diagnosis in New York State Ambulatory Surgery Center Discharge Records 2002 to 2011. Anesth Analg. 2016 Feb;122(2):449-53.
  1. Larach MG, Gronert GA, Allen GC, Brandom BW, Lehman EB: Clinical presentation, treatment, and complications of malignant hyperthermia in North America from 1987 to 2006. Anesth. Analg 2010; 110: 498-507
  1. Larach MG, Brandom BW, Allen GC, Gronert GA, Lehman EB: Malignant hyperthermia deaths related to inadequate temperature monitoring, 2007-2012: a report from the North American malignant hyperthermia registry of the malignant hyperthermia association of the United States. Anesth Analg 2014; 119: 1359-66
  1. Litman, R.S., Joshi, G.P. Malignant Hyperthermia in the Ambulatory Surgery Center: How Should We Prepare? Anesthesiology, June 2014, Vol.120(6), pp.1306-8
  1. Larach MG, Dirksen SJ, Belani KG, Brandom BW, Metz KM, Policastro MA, Rosenberg H, Valedon A, Watson CB. Special article: Creation of guide for the transfer of care of the malignant hyperthermia patient from ambulatory surgery centers to receiving hospital facilities.  Society for Ambulatory Anesthesiology; Malignant Hyperthermia Association of the United States; Ambulatory Surgery Foundation; Society for Academic Emergency Medicine; National Association of Emergency Medical Technicians.  Anesth Analg. 2012 Jan;114(1):94-100.
  1. Birgenheier, N., Stroker, R., Westenskow, D., Orr, J.: Activated Charcoal Effectively Removes Inhaled Anesthetics from Modern Anesthesia Machines. Anesth Analg. 2011, 112(6):1363-1370.
  1. Riazi S, Larach MG, Hu C, Wijeysundera D, Massey C, Kraeva N: Malignant hyperthermia in Canada: characteristics of index anesthetics in 129 malignant hyperthermia susceptible probands. Anesth. Analg 2014; 118: 381-387
  1. Nelson, P.; Litman, R.S. Malignant Hyperthermia in Children: An Analysis of the North American Malignant Hyperthermia Registry. Anesth Analg., Feb 2014, Vol.118(2), pp.369-74
  1. Litman RS, Griggs, S.M., Dowling, J..J., Riazi, S.: Malignant Hyperthermia Susceptibility and Related Diseases. Anesthesiology, 1 2018, Vol.128, 159-167

 

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