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Action Points
Approximately 50 cases are thought to occur each year in U.S. ambulatory surgical centers, Larach and c0-authors reported in the January issue of Anesthesia and Analgesia.
These facilities are unlikely to have the resources to manage the sequelae of malignant hyperthermia, which can include coma, disseminated intravascular coagulation, and heart, kidney, and liver dysfunction.
Symptoms and signs include an elevated end-tidal carbon dioxide concentration, high temperature, muscle rigidity, acidosis, and myoglobinuria.
The American Academy of Pediatrics and the American College of Critical Care Medicine have published guidelines on the transfer of critically ill patients that emphasize careful planning and preparation for monitoring and preservation of vital functions, but these guidelines have not specifically addressed the transfer of patients who develop malignant hyperthermia in ambulatory facilities.
The Malignant Hyperthermia Association of the United States and the Ambulatory Surgery Foundation convened an expert panel to develop a guideline addressing the entire transfer process, from the ambulatory center to the transport vehicle and the receiving center.
The intent of the guideline is to aid each individual ambulatory surgical center in establishing its own procedures, tailored to available resources.
Central to the management of the patient is the prompt withdrawal of the triggering agent and administration of intravenous dantrolene sodium (2.5 mg/kg) dissolved in sterile water.
At least 36 vials of dantrolene must be on hand whenever agents that can trigger malignant hyperthermia are used, the guideline states.
Monitoring of the patient should include assessment of cardiovascular signs, temperature, ventilatory status, muscle rigidity, and color of urine.
Moving the patient can begin when the patient appears stable, with declining end-tidal carbon dioxide concentration, stable heart rate, falling temperature, and easing of muscle rigidity.
The decision to do so should be made by a healthcare professional at the ambulatory center, with direct physician-to-physician coordination between the initiating and receiving centers to handle any emerging crises.
The transport vehicle, whether ground or air, should be able to provide ventilatory support, vital function monitoring, and medications including muscle relaxants, sedatives, and analgesics.
The receiving facility should be prepared to continue monitoring and administering medications for possible complications such as dysrhythmias and renal failure, and to provide any consultations needed such as with anesthesia, hematology, and neurology departments.
'Prior planning regarding who will make decisions during a [malignant hyperthermia] emergency, and staff awareness of their respective roles, will go a long way in assuring preparedness and providing the patient with the best chance for prompt diagnosis, appropriate treatment, and appropriate monitoring during the transfer,' Larach and colleagues stated.
The guideline authors also suggested that individual ambulatory surgical centers review their transfer plans by means of a quality outcomes program.
A survey of 29 ambulatory surgical centers that have already implemented the guideline recommendations showed that many have revised their plans, checked on the availability of dantrolene, and verified procedures in the transport vehicle and receiving center.
A more formal survey has been proposed that will address the impact of this guideline once larger numbers of ambulatory centers have the opportunity to review their transport procedures and incorporate any needed changes, the guideline authors noted.
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