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

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Thank you for your comments Meera - all great points!

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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?

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Thanks for the questions Anthony....propofol is a good start to treat partial laryngospasm that isn't yet causing hypoxemia. If the child is on the larger side, you may have some time to try propofol prior to O2 desaturation. But, sux (or high-dose non-depolarizer) is the treatment of choice when hypoxia has already occurred or if the child is small, say under 15 kg as a rough guess, because they will desaturate so fast and propofol isn't totally reliable. Maybe it's my aging nerves, but I tend to use sux more as I get older. I'm not sure I understand the local anesthetic question. I know that many years ago some folks thought that local anesthetics could be a trigger for MH, but that was disproved convincingly. The only triggers are the inhalational anesthetics and sux. All local anesthetics are perfectly safe for MH susceptible patients.

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Thanks Ron! Sorry for not being clear about LAs, but your response is what I was looking for. I appreciate it! Like you, I'm much more thoughtful as I have gotten older though I have found propofol to be very successful instead of sux. In fact, I have not administered sux in several years as I go right to propofol if I'm not able to quickly terminate the spasm physically (Larsen Maneuver). This was an excellent discussion!!

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