Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment

Author:

Larach Marilyn Green1,Klumpner Thomas T.2,Brandom Barbara W.3,Vaughn Michelle T.2,Belani Kumar G.4,Herlich Andrew5,Kim Tae W.6,Limoncelli Janine7,Riazi Sheila8,Sivak Erica L.9,Capacchione John6,Mashman Darlene10,Kheterpal Sachin2,Kooij Fabian11,Wilczak Janet12,Soto Roy13,Berris Joshua14,Price Zachary15,Lins Steven16,Coles Peter17,Harris John M.18,Cummings Kenneth C.19,Berman Mitchell F.20,Nanamori Masakatsu21,Adelman Bruce T.22,Wedeven Christopher23,LaGorio John24,McCormick Patrick J.25,Tom Simon26,Aziz Michael F.27,Coffman Traci28,Ellis Terri A.29,Molina Susan30,Peterson William31,Mackey Sean C.32,van Klei Wilton A.33,Ginde Adit A.34,Biggs Daniel A.35,Neuman Mark D.36,Craft Robert M.37,Pace Nathan L.38,Paganelli William C.39,Durieux Marcel E.40,Nair Bala J.41,Wanderer Jonathan P.42,Miller Scott A.43,Helsten Daniel L.44,Turnbull Zachary A.45,Schonberger Robert B.46,

Affiliation:

1. From The North American Malignant Hyperthermia Registry of the Malignant Hyperthermia Association of the United States, University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, Pennsylvania; Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida

2. Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan

3. From The North American Malignant Hyperthermia Registry of the Malignant Hyperthermia Association of the United States, University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, Pennsylvania; Department of Nurse Anesthesia, University of Pittsburgh, Pittsburgh, Pennsylvania

4. Department of Anesthesiology, School of Medicine, University of Minnesota, Minneapolis, Minnesota; School of Public Health, University of Minnesota, Minneapolis, Minnesota

5. Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

6. Department of Anesthesiology, School of Medicine, University of Minnesota, Minneapolis, Minnesota

7. Department of Anesthesiology, Weill Cornell Medical College and New York−Presbyterian Hospital, New York, New York

8. Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Canada

9. Department of Anesthesiology, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

10. Department of Anesthesiology and Pediatrics, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Egleston Hospital, Atlanta, Georgia

11. Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands

12. Beaumont Health, Dearborn, Michigan

13. Beaumont Health, Royal Oak, Michigan

14. Beaumont Health, Farmington Hills, Michigan

15. Beaumont Health, Grosse Pointe, Michigan

16. Bronson Healthcare, Battle Creek, Michigan

17. Bronson Healthcare, Kalamazoo, Michigan

18. CHOC Children’s Hospital, Orange, California

19. Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio

20. Department of Anesthesiology, Columbia University Medical Center, New York, New York

21. Henry Ford Health System, Detroit, Michigan

22. Henry Ford Health System, West Bloomfield, Michigan

23. Holland Hospital, Holland, Michigan

24. Mercy Health, Muskegon, Michigan

25. Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York

26. Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Medical Center, New York, New York

27. Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon

28. St. Joseph Mercy, Ann Arbor, Michigan

29. St. Joseph Mercy Oakland, Pontiac, Michigan

30. St. Mary Mercy Hospital, Livonia, Michigan

31. Sparrow Health System, Lansing, Michigan

32. Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California

33. Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands

34. Department of Anesthesiology, University of Colorado, Aurora, Colorado

35. Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma

36. Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania

37. Department of Anesthesiology, University of Tennessee Medical Center, Knoxville, Tennessee

38. Department of Anesthesiology, University of Utah, Salt Lake City, Utah

39. Department of Anesthesiology, University of Vermont, Larner College of Medicine, Burlington, Vermont

40. Department of Anesthesiology, University of Virginia, Charlottesville, Virginia

41. Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington

42. Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee

43. Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina

44. Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri

45. Department of Anesthesiology, Weill Cornell Medical College, New York, New York

46. Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut

Abstract

Abstract EDITOR’S PERSPECTIVE What We Already Know about This Topic Dantrolene effectively treats malignant hyperthermia, but there are discrepant recommendations for dantrolene availability in facilities that stock succinylcholine for airway rescue but do not use volatile anesthetics. What This Article Tells Us That Is New The authors performed an analysis of data from three databases and a systematic literature review. Providers frequently use succinylcholine, including during difficult mask ventilation. Succinylcholine given without volatile anesthetics triggered 24 malignant hyperthermia events, 13 of which were treated with dantrolene. Fourteen patients experienced substantial complications, and one died. Delayed dantrolene treatment worsened patient outcomes. Background Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. Methods The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. Results Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. Conclusions Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

Publisher

Ovid Technologies (Wolters Kluwer Health)

Subject

Anesthesiology and Pain Medicine

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