Each October thousands of anesthesiologists gather together for five days under the auspices of the American Society of Anesthesiologists for an annual comprehensive meeting on issues related to anesthesiology. The meeting consists of scientific presentations, commercial exhibits, and discussions of political and organizational issues related to the specialty.
Since 1982 MHAUS has been exhibiting at the meeting, introducing new educational information and learning from those attending the meeting about their experiences with MH and how MHAUS can further assist them in managing MH patients.
For at least the past 15 years, we also have an informal reception at the meeting where we can meet our supporters and acknowledge the contributions of physicians, nurses and lay people to furthering the goals of MHAUS.
MHAUS is very fortunate to have a large cadre of anesthesiologists, nurse anesthetists and others who contribute their time and expertise to promoting preparedness and improved knowledge of MH. In addition, we are fortunate to have non physicians who also contribute their time and talent to the organization in many ways, including membership on our board, supporting us financially and promoting the goals of MHAUS in a variety of settings.
We routinely make a few awards at the reception. One or more to those who have made outstanding contributions to the organization, to a member of the hotline in recognition of his/her expertise in handling a challenging MH case, as well as to the provider at the other end of the phone actually caring for the patient. In some years we also offer a media award. Also offered is a manuscript award to a young anesthesiologist on a topic related to MH.
Dedication to MHAUS awards
This year we recognized two members of our hotline team for their outstanding dedication to MHAUS. One award went to Dr. Joseph Tobin, who in his full time job is the Chairman of Anesthesiology at Wake Forest University School of Medicine and MH biopsy center director and the other to Dr. Andy Herlich who is the Chief of Anesthesiology at Mercy Hospital in Pittsburgh. Both contribute in many ways to MHAUS on a regular basis. However, we recognized Joe because of his assistance in arranging the video production of an actual MH biopsy. This video is now posted on our web site and has narration in seven languages. This was not a trivial undertaking having to coordinate a patient, the OR, the laboratory and our MHAUS staff as well as providing the videographer and the post production editing.
Dr. Herlich helped us out in avoiding what might have been a disaster. For many years, the North American MH Registry of MHAUS was housed in the anesthesia department of the Children’s Hospital of Pittsburgh under the direction of Dr. Barbara Brandom. However, Children’s Hospital recently moved to a new building and the space for the Registry was no longer available. Andy came to our rescue. He advocated for the relocation of the Registry and provision of space, without cost, at Mercy Hospital in Pittsburgh. The Executive director of the hospital and his team were convinced after speaking with Andy that indeed the Registry did such important work that it would be important to insure the continuity of its efforts. On top of that, Andy has helped us find space to hold our next MH update meeting for the professional and scientific community at Mercy Hospital and has even come up with some partial funding for the event. That is true commitment to the cause.
Hotline Partnership Awards
The first MH hotline partnership award this year went to our long term consultant Dr. Charles Watson, Chair of Anesthesiology at Bridgeport Hospital in Connecticut, who also chairs our Quality Improvement Committee. He worked with Dr. Edward Eisler who is the Chairman of Anesthesiology at California Pacific Medical Center in handling a confusing situation involving laparoscopic surgery in a 44 year old woman who developed elevated carbon dioxide levels, a temperature increase and acidosis. Dr. Watson consulted with Dr. Eisler over the course of many hours as the patient required stabilization post episode. Eventually her surgery was completed uneventfully.
This year we awarded a second partnership award to Dr. Margaret Weglinski, a hotline consultant from Mayo Clinic, Rochester, Minnesota, who worked with Dr. Sanjeev Singwi, an anesthesiologist in Ontario Canada on the management of a 22 year old man who developed signs of MH shortly after induction of anesthesia with succinylcholine and propofol anesthesia. He developed muscle rigidity and acidosis as well as slight temperature elevation. His signs responded to dantrolene administration. Post operatively there was evidence of significant muscle destruction with the CK enzyme rising to 68,500 (normal less than 200). With Dr. Weglinski’s help the patient recovered after several days of intensive care. (Yes, our hotline also receives calls regularly from Canadian anesthesiologists).
Through the generosity of one of the founding members of MHAUS we also offer the Daniel Massik manuscript award to an anesthesia resident or someone who has recently completed training. The manuscript must relate to an MH topic.
The award was made this year to Dr. Nwamaka Pamela Nnamani, a resident in anesthesia at the John H. Stroger, Jr. Hospital of Cook County, Chicago. Her topic was “Babies in Distress: Malignant Hyperthermia in Infancy Explored”. Dr. Nnamani was moved to write the review article after having witness an MH tragedy when she was a student in England involving an infant. We hope that she will submit the article for publication in an anesthesia journal.
Activities at the Meeting
There were many abstracts at the meeting related to the laboratory and clinical investigations of MH. Those will be summarized in one of the next issues of the Communicator. Dr. Barbara Brandom organized and moderated an interactive panel discussion based on cases derived from the MH hotline. The audience of about 100 were actively engaged in discussing the cases. Assisting Dr. Brandom were Dr. Margaret Weglinski and Dr. Joseph Tobin.
This year we also offered something new and different. With the guidance of Dr. Meir Chernofsky, Assistant Professor of Anesthesiology at the Uniformed Services University an expert in medical simulation, we offered a workshop on “So you want to be an MH hotline consultant”. Several of the hotline consultants, Dr. Mohanad Shukry, Dr. Kumar Belani, Dr. Mary Theroux, Dr. John Capacchione and I participated in a simulation of what it is like to be at the other end of an MH hotline call. The “callers” were specially trained residents of the Anesthesia training program at Uniformed Services University and members of the audience played the role of hotline consultants with the real hotline consultants acting as their coach. It was a great deal of fun and a terrific educational experience.
Of the many abstracts presented at the meeting, there is one that bears special mention in my estimation. Dr. John Capacchione and his colleagues at the MH testing center at Uniformed Services University reported on their finding of testing 15 male patients who experienced exercise induced muscle breakdown for MH susceptibility. They tested these individuals, none of whom experienced anesthesia induced MH, for changes that are found in MH susceptibles according to the standard muscle biopsy testing protocol as well as for genetic changes associated with MH susceptibility. They also submitted specimens for genetic analysis for common metabolic muscle disorders. Six of the 15 patients, all young an otherwise healthy tested positive on the muscle biopsy test. One was found to have a mutation definitely associated with MH and three were found to have other mutations that are not found in the normal population and may be related to MH. No genetic signs of inherited metabolic muscle disorders were found. None of the patients experienced the other signs of MH, such as high temperature, acid base abnormalities or coagulation problems. There are a few other studies and case reports that have shown MH positive responses in biopsied muscle in patients who experienced either heat related problems or exercise induced muscle breakdown. These findings provide clues that at least some patients who have such problems might have the same underlying protein changes that predispose to MH, That is, a defect in the calcium channel of muscle, the ryanodine receptor that controls calcium concentration in the muscle cell which in turn influences metabolism of the cell. This study adds to accumulating evidence from human reports as well as animal studies, such as the genetically engineered mouse model for MH (reported in my blog of November 2008 and in the Communicator) that the function of this calcium channel is abnormal in other conditions than MH. One implication is that the drug dantrolene might be useful in treating patients with conditions such as exercise induced muscle breakdown and /or heat stroke. Unfortunately those studies in humans are complex because such events are not common. Therefore an expensive multicenter study would be required and most likely would therefore require a federal government or large not for profit foundation grant.
The other question raised by this study which also has no answer is which MH susceptible patient might be at risk to muscle breakdown and/or heat stroke with exercise or under conditions of high environmental heat.
The MH story continues to evolve and develop in many interesting ways.
One of the contributions that MHAUS has recently made is playing out in a different arena. As many of you know, one of the major trends in medicine has been the migration of surgery from the hospital to ambulatory centers and to office based operating rooms.
We know that several recent deaths from MH occurred in these out of the hospital settings and were concerned that perhaps the problem of stabilization of the patient and movement to the hospital during or following an MH crisis was so fraught with danger that a guideline for transportation of an MH patient from a non hospital setting to a hospital was worthy of development. Fortunately the Ambulatory Surgery Center Foundation agreed with us. Accordingly we have worked with anesthesiologists, emergency medicine physicians, emergency medical technicians who transport critically ill patients to a hospital to create such a guideline. The protocol is available on the MHAUS web site for public comment until November 15, 2009. As far as I know there is nothing comparable out there for this critical situation. It has become increasingly apparent that surgery out of the hospital is fraught with dangers different than those found in the hospital. Not the least of which is moving a critically ill patient to a hospital for treatment even if it is around the corner. In response to this danger, the state of New York now requires that any site where general anesthesia or sedation leading to loss of consciousness be accredited by one of the organizations that have such accrediting standards. We hope that our transfer of care guideline can contribute to safe care of patients in such settings. We anticipate that there will be a formal announcement of this guideline before the end of the year.
These are just a few of the many important activities of MHAUS. Your continued support is critical to meeting our goal of no further deaths and disabilities related to MH and MH like syndromes.
Thank you. I welcome your comments.