In today’s TGI MH Friday, we’ll try to unpack a thorny issue that lies at the intersection between politics, economics, and patient safety: Should a free-standing surgicenter that ONLY uses IV anesthesia be required to stock dantrolene? And if so, how much is enough? The logical extension of that question is: What is the risk of a patient developing acute MH from a dose of succinylcholine? And finally, what is the likelihood that a patient will be administered succinylcholine during an IV anesthetic? Before we try to answer these questions, some background…and a disclaimer:
Dr. Litman -Thank you for your unwavering committment to education and patient safety. A whole bunch of us are sending you strength and positive vibes for a complete and rapid recovery.
I agree that sugammadex may be a game changer in this. I am not sure how the cost of sugammadex compares to the cost of dantrolene.
Will it help if ambulatory facilities and free standing surgical centers have to put up signs in their facilities to indicate whether they stock dantrolene and succinycholine or not. They also need to make sure the proceduralists are aware of this information. Then the recommendation can be modified as follows: "Succinylcholine can trigger malignant hyperthermia (MH) in susceptible patients. Treatment for MH includes the immediate admnistration of dantrolene. Succinylcholine is also used to reverse life-threatening laryngospasm. Facilities must weigh the risks and benefits of stocking these medications and also make the providers and patients using their facilities aware of the availability of these medications for the treatment of rare but life-threatening emergencies during their procedures."
This issue reminds me of NPO status and sedation for laceration repairs, fracture reductions etc. Anesthesiologists will insist on rapid sequence induction with an endotracheal tube and emergency medicine providers sedate children for these procedures without a protected airway all the time. Do we make children undergo these procedures without sedation because of the tiny miniscule risk of aspiration ? The multidisciplinary consensus statement for unscheduled procedural sedation, organized by the american college of emergency physicians states:
"Providers of unscheduled procedural sedation should assess the timing and nature of recent oral intake. The urgency of the procedure will dictate the necessity of providing sedation without delay, regardless of fasting status. For patients with established risk factors for
aspiration (eg, serious underlying illness,obstructive sleep apnea, obesity, age less than 12 months, upper endoscopy as the procedure, or bowel obstruction), consider the risks versus benefits of delaying procedural sedation after recent ingestion of a substantial meal. "
Green SM, et al Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline. Ann Emerg Med. 2019 May;73(5):e51-e65. doi: 10.1016/j.annemergmed.2019.02.022. PMID: 31029297.
1. What about propofol as a substitute for succinylcholine when treating a laryngospasm?
2. Isn't this the same argument that was presented regarding local anesthetics indicating the risk was so low that it was necessary to have an MH cart prepared and ready?
Dr. Litman -Thank you for your unwavering committment to education and patient safety. A whole bunch of us are sending you strength and positive vibes for a complete and rapid recovery.
I agree that sugammadex may be a game changer in this. I am not sure how the cost of sugammadex compares to the cost of dantrolene.
Will it help if ambulatory facilities and free standing surgical centers have to put up signs in their facilities to indicate whether they stock dantrolene and succinycholine or not. They also need to make sure the proceduralists are aware of this information. Then the recommendation can be modified as follows: "Succinylcholine can trigger malignant hyperthermia (MH) in susceptible patients. Treatment for MH includes the immediate admnistration of dantrolene. Succinylcholine is also used to reverse life-threatening laryngospasm. Facilities must weigh the risks and benefits of stocking these medications and also make the providers and patients using their facilities aware of the availability of these medications for the treatment of rare but life-threatening emergencies during their procedures."
This issue reminds me of NPO status and sedation for laceration repairs, fracture reductions etc. Anesthesiologists will insist on rapid sequence induction with an endotracheal tube and emergency medicine providers sedate children for these procedures without a protected airway all the time. Do we make children undergo these procedures without sedation because of the tiny miniscule risk of aspiration ? The multidisciplinary consensus statement for unscheduled procedural sedation, organized by the american college of emergency physicians states:
"Providers of unscheduled procedural sedation should assess the timing and nature of recent oral intake. The urgency of the procedure will dictate the necessity of providing sedation without delay, regardless of fasting status. For patients with established risk factors for
aspiration (eg, serious underlying illness,obstructive sleep apnea, obesity, age less than 12 months, upper endoscopy as the procedure, or bowel obstruction), consider the risks versus benefits of delaying procedural sedation after recent ingestion of a substantial meal. "
Green SM, et al Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline. Ann Emerg Med. 2019 May;73(5):e51-e65. doi: 10.1016/j.annemergmed.2019.02.022. PMID: 31029297.
Thank you,
Meera Gangadharan
2 questions,
1. What about propofol as a substitute for succinylcholine when treating a laryngospasm?
2. Isn't this the same argument that was presented regarding local anesthetics indicating the risk was so low that it was necessary to have an MH cart prepared and ready?