Transfer Guidelines for Malignant Hyperthermia Marilyn Green Larach

Transfer Guidelines for Malignant Hyperthermia Marilyn Green Larach M. D. Senior Research Associate The North American Malignant Hyperthermia Registry of MHAUS

Disclosure Statement l Dr. Larach received an MHAUS honorarium – To support guideline development l Both MHAUS and the ASF sell transfer of care posters – No financial benefit to Dr. Larach

Goals of Talk l Introduce Transfer of Care Guidelines l Discuss Need for Guidelines l Provide Overview of Content l Review MH Presentation & Treatment

Assumes an ASC using MH Triggers has Available: l Anesthesia Care Provider l 36 Vials of Dantrolene l MHAUS Emergency Therapy Poster l MH Crisis Drills

Development of Guidelines for Emergent MH Transfers l Joint Consensus Document – – l ASF MHAUS 13 Panel Members – – – Anesthesiologists CRNA Emergency Medicine Physician Emergency Medical Technician ASC nurse/administrator ASF nurse/administrator

Guideline Goals l 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 l ASC Locations Vary Staff Resources – Lab Resources – Distance to Receiving Hospital –

Guidelines and Not Protocol l Emergency Transport Services Vary Availability – Weather – Distance to Receiving Hospital – Severity of Patient Condition –

Guidelines and Not Protocol l Receiving Hospitals Vary – Facilities – Personnel

Recognition of Suspected MH l First – – – signs Hypercarbia Sinus tachycardia Masseter spasm l Temperature abnormalities may be early MH sign l Most common pattern – Respiratory acidosis and muscular abnormalities

Begin Treatment l l Declare MH Emergency Discontinue Triggering Agents 100% Oxygen at High Flow Give Dantrolene – – l 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 l ETCO 2 is declining or normal l HR is stable or decreasing l No ominous dysrhythmias l Temperature is declining l Generalized muscular rigidity is resolving (if present) l IV dantrolene administration has begun

MH Morbidity and Mortality l l l l l Consciousness Level Change/Coma Cardiac Dysfunction Pulmonary Edema Renal Dysfunction Disseminated Intravascular Coagulation Hepatic Dysfunction Other Relapse Death

Factors Increasing MH Complication Likelihood l Increased time 1 st sign to 1 st dantrolene – l For every 30 minute increase in the interval between 1 st MH sign and 1 st 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 l Capabilities l – – – l 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 l Inpatient capabilities l – – – – 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 l Anesthesiology l Critical Care l Hematology l Surgery l Nephrology l Medical Toxicology

Report Data from ASC l Cardiovascular signs l Temperature and site l Minute ventilation with ETCO 2 l Dantrolene amount given & response l Muscular rigidity status l Electrolytes l I. V. site l Urinary catheter & urine color

Communication Coordination l 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 l Factor In: – Transport time l Choice of Transfer – Bed availability Team – Clinical stability l Choice of Receiving Hospital l

Implementation of Transfer Decision l Don’t delay transfer pending specific personnel or equipment availability if emergent transfer is mandatory l **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 l Research available transport teams l Consult with physicians at referral hospitals l

Clinical Characteristics l 24. 1% – Emergency Sux 3. 8 times more often l Orthopedic, – ENT, General Surgery Sux 1. 9 times more often l 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)

Presentation l 99% Respiratory Acidosis l 26% Metabolic Acidosis l 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 1 st Q 3 rd Q Range Initial 2. 4 1. 9 2. 8 . 01 -15. 0 Initial 8 3 11 1 - 58 Total 5. 9 3. 0 10. 0 . 02 -100. 0 Total 17 7 36 1 - 343 (mg/kg) (vials)

Adjunctive Treatment (n=284) Treatment % Hyperventilation with Fi. O 2=1 IV fluid loading Active cooling Bicarbonate Anesthesia circuit change Mannitol Furosemide Glucose and insulin 87 77 70 54 48 34 32 14