Family History of Problems with Anesthesia

[Noyac]

When someone gives me this type of information I try to elicit the source of the complications but doing this is not always possible.

Todays case:
Essentially healthy 57 yo female with a retroperitoneal mass. She states that she had an aunt die at 47 you during a routine gall bladder case. She doesn't know if it was open or lap. A brother that ended up in the ICU after a routine case. And that she had some difficulty breathing after anesthesia in the past but it didn't warrant an ICU admit. All of these cases were done at a very small rural hospital and the records are unattainable.

What's your thoughts and plans.

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[Planktonmd]

The possibilities:
1- MH: one family member died during surgery and the other survived, could be!
2- Pseudo-cholinesterase Deficiency: Not very compatible with family member dying during surgery but you never know.
3- Some familial muscular or neuro muscular disease: a good history and physical can help.
4- Most likely nothing is wrong with her and the above history is just a coincidence.

Since you are not likely to get any more info, I would check CPK, myoglobin, and electrolytes then proceed to the OR and use TIVA, with O2/ N2O if you like, some non depolarizing agent if needed, no Sux or vapors.

I am sure Noyac is not going to say that she has something strange like familial Long QT syndrome, but lets make sure we look at the EKG too

 

[dhb]

Probably not MH if she's had prior anesthetics, seems like a mild pseudocholinesterase deficiency no sux or mivacurium, have dantrolene handy not much else you can do.
What's the origin of the mass though?

 

[dhb]

3- Some familial muscular or neuro muscular disease: a good history and physical can help.

Why would they died from it? freak K+ release?

 

[Planktonmd]

Why would they died from it? freak K+ release?

Yes, or from heart failure if they have cardiac involvement like in Myotonic Dystrophy, or from associated MH.

 

[rmh149]

Yes, or from heart failure if they have cardiac involvement like in Myotonic Dystrophy, or from associated MH.

I would be sure to ask the patient if she knows anything about her family members having "high fevers". Everyone I have ever talked to that had family members with hx of MH (malignant hyperthermia) said something to the effect of "their brother, sister, mother, etc. had high fevers and was in the ICU".

Also, find out how long ago her aunt and brother had surgery. They both could have had it 30+ years ago....when the risks were much higher. This information wont tell you much...but it will at least give you some peace of mind that all will be OK.

Being 57 she probably has an EKG as part of her pre-op workup...obviously if not...get one.

With all the labs mentioned by plankton and a normal EKG....(my opinion) I would proceed as I normally would. Maybe staying away from ScH (succinylcholine)...but I do that anyway to avoid post-operative myalgia.

Difficulty breathing. Could be anything from too much narcotics, larygospasm, bronchospasm, pulmonary edema, etc.....who knows. If she cant provide any other information, I proceed as planned.

I am going to be deligent anyway. I will tuck this information in the back of my head for later use.

What happened?

 

[Noyac]

What's the origin of the mass though?

Some sort of benign sarcoma or something. It isn't invading any vital structures.

The case is either going to be fairly short or real long. What technique would you use with this information? What lines would you have? Labs?

 

[rmh149]

Question: Is this an open case or laparoscopy? I am assuming that the mass is fairly large because it may be a long case. Has the surgeon communicated expectations on possible blood loss? Can you provide more information on the location of the mass....what is it connected to?

 

[cchoukal]

Probably not MH if she's had prior anesthetics, seems like a mild pseudocholinesterase deficiency no sux or mivacurium, have dantrolene handy not much else you can do.
What's the origin of the mass though?

This is a common fallacy. Half of people who develop MH have had previous uncomplicated anesthetics with triggering agents.

 

[dhb]

Thoracic epidural, ketafol, sufenta 5mcg/h for tube support, if you have access to the arm no a-line unless hemodynamic instability or anticipated blood loss, 1 perif18g if you can get a central line if you need one or else 2 peripherals, temp probe let her fly

pre-op: K+, BUN creat (kidney damage from myoglobine?) LDH, crit and cross type again if anticipated blood loss

 

[dhb]

This is a common falacy. Half of people who develop MH have had previous uncomplicated anesthetics with triggering agents.

True, i remembered that after posting

 

[Noyac]

Thoracic epidural, ketafol, sufenta 5mcg/h for tube support, if you have access to the arm no a-line unless hemodynamic instability or anticipated blood loss, 1 perif18g if you can get a central line if you need one or else 2 peripherals, temp probe let her fly

pre-op: K+, BUN creat (kidney damage from myoglobine?) LDH, crit and cross type again if anticipated blood loss

So you would do this case as is, right?

 

[Planktonmd]

Some sort of benign sarcoma or something. It isn't invading any vital structures.

The case is either going to be fairly short or real long. What technique would you use with this information? What lines would you have? Labs?

There is no such thing as benign sarcoma

 

[Noyac]

I would be sure to ask the patient if she knows anything about her family members having "high fevers". Everyone I have ever talked to that had family members with hx of MH (malignant hyperthermia) said something to the effect of "their brother, sister, mother, etc. had high fevers and was in the ICU".

Also, find out how long ago her aunt and brother had surgery. They both could have had it 30+ years ago....when the risks were much higher. This information wont tell you much...but it will at least give you some peace of mind that all will be OK.

Being 57 she probably has an EKG as part of her pre-op workup...obviously if not...get one.

She does not recall anything about high fevers.

The aunt and brothers surgeries were a long time ago, maybe 20yrs.

What are you looking for in the ECG?

 

[Noyac]

There is no such thing as benign sarcoma

I saw that, but I did say or something.

 

[rmh149]

She does not recall anything about high fevers.

The aunt and brothers surgeries were a long time ago, maybe 20yrs.

What are you looking for in the ECG?

-- any obvious cardiac arhythmia
-- Any ST segment abnormalities
-- good r-wave progression in leads 1-6, which would tell me that they have decent anterior forces.

-- Any type of AV block, bundle branch blocks, axis deviations
-- Is there voltage criteria showing left ventricular hypertrophy. If so, is it concentric or eccentric hypertrophy.
-- Look at lead II to see if there is right or left atrial enlargement

Would be nice to know her EF, Did she have an echo? Does she have good exercise tolerance?
Was there anything abnormal in her EKG?

 

[Noyac]

-- any obvious cardiac arhythmia
-- Any ST segment abnormalities
-- good r-wave progression in leads 1-6, which would tell me that they have decent anterior forces.

-- Any type of AV block, bundle branch blocks, axis deviations
-- Is there voltage criteria showing left ventricular hypertrophy. If so, is it concentric or eccentric hypertrophy.
-- Look at lead II to see if there is right or left atrial enlargement

Would be nice to know her EF, Did she have an echo? Does she have good exercise tolerance?
Was there anything abnormal in her EKG?

Are you kidding? Seriously, I thought you might be looking for something that would give you some indication as to the cause of her stated problem with anesthesia. What you are describing is typically what everyone reviews when they read an ECG. If this lady was coming to you without the stated problems with her family and herself, would you want an ECG?

Echo? Why would she have had an echo? A said she was healthy.

Remember, if you order something or ask for it in your case, you need to have a reason. It is a complete waste of resources not to mention finances to just order some test b/c someone is a certain age or because its "what we do".

 

[Noyac]

Hey, I was a little harsh in my last post. What frustrated me was the knee jerk response you gave. I understand you are a nurse and that your knowledge is different here. You practice is different as well being a nurse. I think you understand what I am getting at though with ordering tests.

The answer you gave would possibly fail you in the ABA boards if you can't come up with a better reason to order the ECG. Sure your answer is right but as the examiner in the boards would say, " yea yea yea, tell me what you are looking for?"

Don't take it personal.

 

[toughlife]

When someone gives me this type of information I try to elicit the source of the complications but doing this is not always possible.

Todays case:
Essentially healthy 57 yo female with a retroperitoneal mass. She states that she had an aunt die at 47 you during a routine gall bladder case. She doesn't know if it was open or lap. A brother that ended up in the ICU after a routine case. And that she had some difficulty breathing after anesthesia in the past but it didn't warrant an ICU admit. All of these cases were done at a very small rural hospital and the records are unattainable.

What's your thoughts and plans.

Incompetency comes to mind first.

Second, that hx is shady at best and I don't see any evidence for possible MH.

 

[jetproppilot]

When someone gives me this type of information I try to elicit the source of the complications but doing this is not always possible.

Todays case:
Essentially healthy 57 yo female with a retroperitoneal mass. She states that she had an aunt die at 47 you during a routine gall bladder case. She doesn't know if it was open or lap. A brother that ended up in the ICU after a routine case. And that she had some difficulty breathing after anesthesia in the past but it didn't warrant an ICU admit. All of these cases were done at a very small rural hospital and the records are unattainable.

What's your thoughts and plans.

I'd take the information in with a grain of salt, albeit with a higher index of suspicion if anything looks weird during the case....unexplained tachycardia, increasing CO2, temp 38.0 with no Bare Hugger, etc.

Probably means diddly squat. But enter the case with Eyes Wide Open.

If there is pseudocholinesterase deficiency, doesnt really matter in the grand scheme of things. Chances are she's gotta good chance of going to the ICU intubated anyway. Remember, pseudocholinesterase deficiency is highlighted as a major deal in our residency training....but it isnt, really......nobody dies from it in the hands of anesthesiologists....its more of an inconvenience....academic thing to put major stress into residents minds?.....yes....ever really a groundbreaking scenerio?.....no.....patients just need a vent post-op when it's discovered.....then it doesnt happen again. So keep this genetic aberration in perspective.....its just an inconvenience. No more, no less.

Not enough real info to warrant radically changing your anesthetic (to TIVA, for example) in my humble opinion. If you think so, I respect that. I wouldnt.

I'd do the case normally.

Type & match 4 units prbcs.

Midazolam 2mg, fentanyl 100 ug on the way to the back.

Into the OR. Pre O2, monitors on.

Propofol 100-150 mg.

Lid reflex gone, rocuronium 50 mg.

Tape her eyes.

Think about how great your GRMN investment is doing (300% beaaatch...geez....thats about sixty large-profit for yours truly!!!!) while you bag for a minute or so.

Tube in. Tape it.

Connect da circuit.

Sevo at 3%, fresh gas flow at 6 liters for the first fifteen minutes. I usta use N20 but now its all oxygen.

Wanna place an A line? Youre justified.

I'd definitely place a subclavian/IJ. You can do it without as long as you have a cuppla big peripherals but with this big surgery, what with the ICU stay etc, the patient will benefit from it.

Position the patient where da surgeon needs her.

If you've placed an A line, draw an H&H to see where you stand.

You can reduce your sevoflurane by now.

Fresh gas flow (all O2....hey its my case) down to 2L/min.

Update da chart.

Think about ordering fried oysters and crawfish, with a potato salad side, from The Galley on Metairie Road for dinner.

 

[rmh149]

No worries...being harsh isnt necessarily a bad thing.

Knowing the EF is always nice. She might have an echo result in her chart already. If she didn't, I wouldn't order one...If she stated she had good exercise tolerance, thats good enough for me. But with this patient, no way would I cancel if there wasnt one available.

Her cause of her stated problem: Doesn't sound like she is a great historian. Could she tell you anything else about her "problems breathing". Does she smoke? I assume there is no hx of asthma. Any drug allg? I would ask if she has obstructive sleep apnea or snores really bad. What does her airway look like? Does she look like she would obstruct her airway with just a little narcotic? If I couldn't get any other information other than her stating "problems breathing", then I wouldn't do anything extra....go as planned. Throughout the anesthetic though I would be more conservative with the neuromuscular blockers (zemuron). I would avoid ScH due to possible pseudocholinesterace dificiency. I have no concerns of malignant hyperthermia due to the limited history. Besides, ScH is not being used. From what I understand, the combination of ScH and Agents combined are triggers for MH, not the use of agents alone.

Now, with an EKG, yes, I would order one being that she is 57. It is cheap and quick. I imagine that she probably had one in her chart already ordered by the surgeon.

You asked what I would be looking for in an EKG. I told you what I always look for....sorry.

If she doesn't smoke - I would just listen to her lungs, I am assuming they are clear. Otherwise, chest x-ray being a smoker and had a history of breathing problems with previous surgery.

Labs.... Only a basic metabolic panel and HGB. If she prefers regional technique, then a CBC to ensure her platelet count is above 100. A type and cross match....in case she bleeds.

How much does she weigh? Is she on any other medications?

If the EKG and chest films are normal, and she appears to be a healthy 57 y/o woman with no known co-existing diseases, normal assessment, I would either proceed with a general anesthetic with ETT or lumbar epidural with a propofol gtt. I would explain both and let her choose.

General: Versed 2mg in pre-op, 50-100mcg fentanyl when in the OR. Induction with propofol, intubation with zemuron 30mg (keep it low in case it is a short case). Maintain with desflurane 6%, flows .5L O2 and .5L air. No N20. Fentanyl as needed. Load with 10mg MS04 slowly at the end of the case. Reversal (if needed) with neostigmine and glycopyrrolate. Extubate when TOF 4/4, sustained tetany, SV, following commands. Pain control after with morphine PCA. IV access with 18g is good with me....unless a blood bath is expected. Then I would put in a RIJ and an A-line.

Regional: lumbar epidural at L3-4, 17gT epidural needle, dosed with .5% bupivicain 20 - 25cc dosed in 5cc increments to reach a t-6 level. Maintain with epidural pump about 12-14cc/hr, depending on her height. Push propofol 100mg slowly, maintain SV....then Propofol gtt infusing at 100 to 120mcg/kg/min. Put an airway in, O2 mask. EtCO2 monitor, Let her sleep.
Maintain epidural over night at 12cc/hr, ropivicaine .1% with 5mcg fentanyl/cc. In the morning, DC epidural after injecting 4mg duramorph. Supplement pain with lortab PRN and toradol 30mg q6h prn (as long as bleeding doesnt seem to be an issue).

Alternatively, Spinal only and general with ETT to benefit from the duromorph .25mg spinal injection for post-operative pain control. Her choice.

 

[toughlife]

-- any obvious cardiac arhythmia
-- Any ST segment abnormalities
-- good r-wave progression in leads 1-6, which would tell me that they have decent anterior forces.

-- Any type of AV block, bundle branch blocks, axis deviations
-- Is there voltage criteria showing left ventricular hypertrophy. If so, is it concentric or eccentric hypertrophy.
-- Look at lead II to see if there is right or left atrial enlargement

Would be nice to know her EF, Did she have an echo? Does she have good exercise tolerance?
Was there anything abnormal in her EKG?

Yeah, what are you looking for in an EKG that would indicate whether this person has a risk of developing MH?

 

[rmh149]

Yeah, what are you looking for in an EKG that would indicate whether this person has a risk of developing MH?

Im not worried about MH at all with this patient. There isnt anything in the patients history that shows any possibility of MH other than her aunt that died and brother had problems in surgery they received more than 20 years ago. Nothing about that spells MH.

I would look at the EKG because she is a 57 year old woman. Now...granted...if she was an avid runner or cyclist, 110lbs wet and a HR of 60....I probably would blow it off. However, just about everyone in their 50's, in my experience, that is about to undergo a long surgical case will have an EKG as part of their pre-op workup.

 

[Noyac]

rmh149 may I ask you what level you are? Student, practicing new grad, seasoned veteran? No ill indent just curious.

 

[rmh149]

rmh149 may I ask you what level you are? Student, practicing new grad, seasoned veteran? No ill indent just curious.

Practicing 4 years out of school.

 

[jetproppilot]

Practicing 4 years out of school.

Nice, ambiguous answer.

Now, for real, ANSWER THE WARDEN.

 

[rmh149]

Nice, ambiguous answer.

Now, for real, ANSWER THE WARDEN.

LOL, what exactly do you want to know? I have been practicing as a CRNA for 4 years.

 

[Noyac]

Knowing the EF is always nice. She might have an echo result in her chart already. If she didn’t, I wouldn’t order one...If she stated she had good exercise tolerance, thats good enough for me. But with this patient, no way would I cancel if there wasnt one available.

From what I understand, the combination of ScH and Agents combined are triggers for MH, not the use of agents alone.

Now, with an EKG, yes, I would order one being that she is 57. It is cheap and quick. I imagine that she probably had one in her chart already ordered by the surgeon.

Labs.... Only a basic metabolic panel and HGB. If she prefers regional technique, then a CBC to ensure her platelet count is above 100. A type and cross match....in case she bleeds.

How much does she weigh? Is she on any other medications?

If the EKG and chest films are normal, and she appears to be a healthy 57 y/o woman with no known co-existing diseases, normal assessment, I would either proceed with a general anesthetic with ETT or lumbar epidural with a propofol gtt. I would explain both and let her choose.

Regional: lumbar epidural at L3-4, 17gT epidural needle, dosed with .5% bupivicain 20 - 25cc dosed in 5cc increments to reach a t-6 level. Maintain with epidural pump about 12-14cc/hr, depending on her height. Push propofol 100mg slowly, maintain SV....then Propofol gtt infusing at 100 to 120mcg/kg/min. Put an airway in, O2 mask. EtCO2 monitor, Let her sleep.
Maintain epidural over night at 12cc/hr, ropivicaine .1% with 5mcg fentanyl/cc. In the morning, DC epidural after injecting 4mg duramorph. Supplement pain with lortab PRN and toradol 30mg q6h prn (as long as bleeding doesnt seem to be an issue).

Alternatively, Spinal y and general with ETT to benefit from the duromorph .25mg spinal injection for post-operative pain control. Her choice.

First, I said she was healthy. I don't know any 57 yo healthy people walking around with echo results. Do you? There's no echo.

Second, suxx and volatile agents are triggers of MH. They don't need to be given together and you CAN get MH with just volatile agents. If you thought otherwise, you are seriously jeopardizing your pts. You need to review:
http://www.mhaus.org/index.cfm/fuse...urePK/8AABF3FB-13B0-430F-BE20FB32516B02D6.cfm

Third, Just cause ECG's are cheap and easy doesn't mean we need them. Like I said earlier, you NEED to have a reason to get it. And so far I haven't heard a good reason.

Fourth, we are all experienced in anesthesia enough to not need someone to explain TOF, sustained tetany, SV, following commands, reversal of relaxants, etc. Please spare us the details.

Fifth, your epidural management is horendous. You need to review this as well.

Now I am being harsh again but you are on a doctors forum and you are not a doctor. While you are welcome hear, you still need to understand the basics. If you can take the criticism then keep posting. If not then stop posting. I just hope your supervising physicians are aware of your knowledge base.

And do you really place epidurals and central lines? Really?

 

[bubalus]

I'd probably lean toward a TIVA for this. For us, a remi/propofol TIVA is roughly 2-2.5x the cost of a sevo-fentanyl anesthetic, but when you look at the total cost of an operation, it's not that much. The PMH is kind of ambiguous, but concerning enough that I think you could really have a hard time justifying your actions if you used gas and she went into an MH crisis and died. You can be sure that somewhere there's an expert prostitute ready to say that TIVA was clearly called for. That said, I think the odds of having MH susceptibility are pretty slim, but it's relatively easily to do a nontriggering anesthetic.

A friend told me that after an operation when she was 10, the anesthesiologist told her parents they "almost lost her" and that they should "never allow anyone to give her Quelicin." I'm not sure what happened in that case, and neither does she, but I'd give her a TIVA too.

 

[rmh149]

Second, suxx and volatile agents are triggers of MH. They don't need to be given together and you CAN get MH with just volatile agents. If you thought otherwise, you are seriously jeopardizing your pts. You need to review:
http://www.mhaus.org/index.cfm/fuse...urePK/8AABF3FB-13B0-430F-BE20FB32516B02D6.cfm

Third, Just cause ECG's are cheap and easy doesn't mean we need them. Like I said earlier, you NEED to have a reason to get it. And so far I haven't heard a good reason.

Fourth, we are all experienced in anesthesia enough to not need someone to explain TOF, sustained tetany, SV, following commands, reversal of relaxants, etc. Please spare us the details.

Fifth, your epidural management is horendous. You need to review this as well.

And do you really place epidurals and central lines? Really?

I stand corrected. I cant remember where I read it....it doesnt matter. The MHAUS says they are all triggering agents...alone or together. Thats what I will go with. Honestly, if I were truly concerned about MH as a possibility in a patient, then I would use the TIVA technique...remove the vaporizers...etc.

Also, everyone on this forum is NOT experienced in anesthesia....I give the details not for you....but for those that have not even started their residency. As I remember it....there are students on this forum, right?

My epidural management is fine...because it works. There are many ways to do aneshtesia....not just your way. If you think it is horendous....explain or provide an example of what you would do. Otherwise your opinion means nothing.

Why an EKG: Because age is an independent risk factor for heart disease. Wanting an EKG on a 57 y/o is NOT unreasonable. read my post....if she was an avid runner I would probably blow it off. Otherwise...get the EKG.

About the echo....FINE, she doesnt have one...I dont need one. I said it would be nice....not required. If someone tells me they had breathing problems.....I look at potential cardiac and pulmonary problems. Why? Because many times patients dont know what they are talking about when it comes to their hospitalizations.

 

[Noyac]

My epidural management is fine...because it works. There are many ways to do aneshtesia....not just your way. If you think it is horendous....explain or provide an example of what you would do. Otherwise your opinion means nothing.

Sure, you can do your epidurals your way and I agree that there are many ways to practice.

So in order to accomadate your wishes I will explain my epidural technique for this case.

THORACIC.

There's more but we are off topic now.

 

[BlackSails]

Premed student here:

If you suspect that a patient would be susceptible to MH, do you simply avoid succinylcholine and halogenated agents, order a caffeine biopsy test, or just have dantrolene nearby when you do a case?

Also, if MH develops, but is quickly caught and treated, do you proceed with the case? What if the case is an emergency?

Thanks!

 

[Noyac]

Alright,enough speculation. Here's what we did.

Thoracic epidural in pre-op. Dosed with to surgical block with 0.5% Bupiv 10cc. Propofol zemuron induction followed by ETT. TIVA with propofol. A-line and central line for management. These lines were not necessary in the end. End of case and she woke up perfectly comfortable.

The idea of the thread was to see what everyone thinks about a pt that gives you a story like this but you have no real information. Do you test and workup the pt to the hilt or do you use your judgement and proceed as you see fit.

I still don't know what her history really involves but she did fine.

 

[Noyac]

Premed student here:

If you suspect that a patient would be susceptible to MH, do you simply avoid succinylcholine and halogenated agents, order a caffeine biopsy test, or just have dantrolene nearby when you do a case?

Also, if MH develops, but is quickly caught and treated, do you proceed with the case? What if the case is an emergency?

Thanks!

If you suspect that they may be susceptible to MH you do TIVA (total intravenous anesthetic) and avoid triggers like succinycholine and volatile agents.

If MH is caugh and treated you do not proceed with the case unless it is an emergency, life or death, or can be wrapped up very quickly. MH is not esily treated and requires much effort to resolve.

 

[jetproppilot]

Premed student here:

If you suspect that a patient would be susceptible to MH, do you simply avoid succinylcholine and halogenated agents, order a caffeine biopsy test, or just have dantrolene nearby when you do a case?

Also, if MH develops, but is quickly caught and treated, do you proceed with the case? What if the case is an emergency?

Thanks!

Depends on your index of suspicion, Rogue.

If the dude has a close family relative (brother, sister) who has had MH, you take all the precautions. No sux. No halogenated agents. Propofol infusion instead of gas for anesthesia maintenance, with a non-depolarizing muscle relaxant. In addition to all the prepatory steps....change soda lime on the machine, high O2 gas flow for 30 minutes before case, etc

The caffeine test is almost never ordered in private practice.

If your index of suspicion is that high, you proceed with an anesthetic that would fit the patient if they had a positive caffeine test (which you never ordered).

If MH EVER develops, it is treated.

Case cancelled.

Period.

Even if its an emergency....like an appendicitis.

The MH will kill you CDAZY FAST.

More important to get that under control.....100% oxygen, no gas, change the soda lime, dantrolene in volumes, cooling procedures, etc etc.

The risk-benefit ratio has now changed.

Its now riskier to proceed with the surgery, even in an emergency, than to stop and fully treat MH.

MH is like the IRS.

Won't go away until you address it.

We'll come back in 24 hours with a different, MH friendly anesthetic to treat the emergency.

If youre still alive and kikkin'.

 

[BlackSails]

If you suspect that they may be susceptible to MH you do TIVA (total intravenous anesthetic) and avoid triggers like succinycholine and volatile agents.

So you would do the anaesthesia with something like vecuronium and propofol?

If MH is caugh and treated you do not proceed with the case unless it is an emergency, life or death, or can be wrapped up very quickly. MH is not esily treated and requires much effort to resolve.

In a writing class, I did a paper on Richard Selzer. He was a general surgeon who did some writing. During a mission to some South American country, the patient developed MH. They had nothing available to treat it, and they could do nothing for her.

 

[jetproppilot]

So you would do the anaesthesia with something like vecuronium and propofol?

Yep. That would work.



In a writing class, I did a paper on Richard Selzer. He was a general surgeon who did some writing. During a mission to some South American country, the patient developed MH. They had nothing available to treat it, and they could do nothing for her.

Without dantrolene and clinicians experienced in treating MH, the likelihood is that she'll die. But........she may live....like those cases of patients with pancreatic cancer that live, against all odds. God is the dude calling the shots in a case like this. Not us meager earthlings.

 

[rmh149]

Ordering a caffiene muscle biopsy test takes a while to do. There are only eight centers in the US that can perform that test. It is difficult and costs about $5000.
(hell, all I wanted was an EKG )

In other words...you have to cancel the case and reschedule after the results are back.

I have had a case where the patient stated they had an episode of MH as a child. He was scheduled for a hernia repair. We quickly canceled the case pending the muscle biopsy.


Noyak, I still dont get why you were worried about MH with this patient?

 

[jetproppilot]

I have had a case where the patient stated they had an episode of MH as a child. He was scheduled for a hernia repair. We quickly canceled the case pending the muscle biopsy.

Doesnt happen that way out here in the real world.

Spinal-plus sedation or GA-TIVA for the hernia. Assume the worst. F uk the academic outcome of the muscle biopsy. We'll assume its positive and take care of you so you don't have to miss another day at work.

Cancelling the case and ordering a biopsy is for triumphant-seeking academecians.

We can do the case.

And do it safely.

Today.

And save you a buncha money for some stupid muscle biopsy.

Come on, Slim.

Get outta your high and mighty academic mode.

Most of the people you put to sleep earn five hundred bucks a week.

What good are you doing cancelling their case, making them miss more days of work cuz they have to reschedule, in addition to paying for this esoteric muscle biopsy you ordered, when you can assume the test is positive and take care of their problem, TODAY???

 

[rmh149]

Doesnt happen that way out here in the real world.

Spinal-plus sedation or GA-TIVA for the hernia. Assume the worst. F uk the academic outcome of the muscle biopsy. We'll assume its positive and take care of you so you don't have to miss another day at work.

Cancelling the case and ordering a biopsy is for triumphant-seeking academecians.

We can do the case.

And do it safely.

Today.

And save you a buncha money for some stupid muscle biopsy.

Come on, Slim.

Get outta your high and mighty academic mode.

Most of the people you put to sleep earn five hundred bucks a week.

What good are you doing cancelling their case, making them miss more days of work cuz they have to reschedule, in addition to paying for this esoteric muscle biopsy you ordered, when you can assume the test is positive and take care of their problem, TODAY???

Hey, dont worry. It was my attending that cancelled the case...I was a student...NO SAY SO what so ever.

I'm with you totally....just providing an experience. I remember...that guy was pissed. He even said "cant we just try and see what happens". The attending wanted no part in it.

 

[jetproppilot]

I'm with you totally....just providing an experience. I remember...that guy was pissed. He even said "cant we just try and see what happens". The attending wanted no part in it.

Know what?

I aint no Stephen Hawking.

But I'm smart enough to recognize the paucity of common sense practiced in most academic centers.

And its sad to say that many clinicians practicing medicine in our United States academic "clinical powerhouses" are there for a reason.....they are inept in some area of their personal growth....be it emotional, common sensual ((i just made that up), lack of hand skills, lack of interpersonal skills, or whatever....

And this case proves that.

And I can give a hundred more to corroborate my theory that academic medicine, overall, is weak, uninspired, and stuck in academic thinking.

 

[Planktonmd]

Im not worried about MH at all with this patient. There isnt anything in the patients history that shows any possibility of MH other than her aunt that died and brother had problems in surgery they received more than 20 years ago. Nothing about that spells MH.

I would look at the EKG because she is a 57 year old woman. Now...granted...if she was an avid runner or cyclist, 110lbs wet and a HR of 60....I probably would blow it off. However, just about everyone in their 50's, in my experience, that is about to undergo a long surgical case will have an EKG as part of their pre-op workup.

How can you say you are not worried at all about MH??
I can never say that about any patient. I always worry about MH.
If a patient had a family history of unknown anesthetic complications you absolutely have to worry about MH, and a bunch of other things.

 

[rmh149]

How can you say you are not worried at all about MH??
I can never say that about any patient. I always worry about MH.
If a patient had a family history of unknown anesthetic complications you absolutely have to worry about MH, and a bunch of other things.

Poor choice of wording on my part. Let me rephrase.

For this particular patient I am no more worried about MH than any other patient.

Yes this patient had a family history of an unknown complication during surgery.....not necessarily anesthetic complication. The information she provided was very vague. I would accept it, but I don't think I would change my anesthetic plan according to her vague statements about procedures on family members more than 20 years ago.

Of course you worry about a bunch of other things...but again, I do that for every patient. Nothing she said would make me change my plan.

Like Noyak said, I would try to gain more information from the patient. Ask specific questions. Unfortunately, as in this case, this is not always possible.

 

[Planktonmd]

Poor choice of wording on my part. Let me rephrase.

For this particular patient I am no more worried about MH than any other patient.

Yes this patient had a family history of an unknown complication during surgery.....not necessarily anesthetic complication. The information she provided was very vague. I would accept it, but I don’t think I would change my anesthetic plan according to her vague statements about procedures on family members more than 20 years ago.

Of course you worry about a bunch of other things...but again, I do that for every patient. Nothing she said would make me change my plan.

Like Noyak said, I would try to gain more information from the patient. Ask specific questions. Unfortunately, as in this case, this is not always possible.

So, If a patient can not give you a history this gives you the right to risk their lives?

If you have any doubt at all you just use non triggering agents and a clean machine, how difficult is that?

 

[Planktonmd]

.
not necessarily anesthetic complication.

How do you know they are not anesthetic complications?

 

[The_Sensei]

Know what?

I aint no Stephen Hawking.

But I'm smart enough to recognize the paucity of common sense practiced in most academic centers.

And its sad to say that many clinicians practicing medicine in our United States academic "clinical powerhouses" are there for a reason.....they are inept in some area of their personal growth....be it emotional, common sensual ((i just made that up), lack of hand skills, lack of interpersonal skills, or whatever....

And this case proves that.

And I can give a hundred more to corroborate my theory that academic medicine, overall, is weak, uninspired, and stuck in academic thinking.

ABSOLUTELY CORRECT, SIR!

 

[Noyac]

rmh149, the more post of yours that I read, the more doubt I have that you are a practicing crna. Your knowledge has to be somewhere in the srna range. And your mentors are not teaching you crap. Sure you can push some drugs and put a tube in someone but as we have said here b/4, a monkey can do that.

So I recommend you stick with this site and learn as much as you can here. We are your new attendings. As long as you are not afraid to ask questions and be ridiculed from time to time.

 

[Noyac]

Know what?

I aint no Stephen Hawking.

But I'm smart enough to recognize the paucity of common sense practiced in most academic centers.

And its sad to say that many clinicians practicing medicine in our United States academic "clinical powerhouses" are there for a reason.....they are inept in some area of their personal growth....be it emotional, common sensual ((i just made that up), lack of hand skills, lack of interpersonal skills, or whatever....

And this case proves that.

And I can give a hundred more to corroborate my theory that academic medicine, overall, is weak, uninspired, and stuck in academic thinking.

I have one example of academic folks are stuck in an academic thinking mode. We hired a faculty member from a very prestigious academic program 2 1/2 years ago. This person did everything at their program, hearts, peds, neuro, regional, etc. This person was highly regarded at their program and had excellent LOC's. Once this person arrived, we noticed that the practice style was different, lazy, slow, looking for ways to cancel cases, uncomfortable with some types of cases. The list goes on. We dealt with it as much as we could but it was starting to put a burden on the rest of us. The bottomline is that we sent this person packing. This is a very hard thing to do b/c I personally like the person but I just don't like practicing with them.

 

[rmh149]

So, If a patient can not give you a history this gives you the right to risk their lives?

If you have any doubt at all you just use non triggering agents and a clean machine, how difficult is that?

I agree with you Plankton, if had any doubt in my mind I would use non triggering agents and a clean machine. Its not difficult....However, with this patient I wasnt worried. I proceed as normal. Of course I would be deligent....I always am.

My approach to this case is very similar to Jetprops:

I'd take the information in with a grain of salt, albeit with a higher index of suspicion if anything looks weird during the case....unexplained tachycardia, increasing CO2, temp 38.0 with no Bare Hugger, etc.

Probably means diddly squat. But enter the case with Eyes Wide Open.

If there is pseudocholinesterase deficiency, doesnt really matter in the grand scheme of things. Chances are she's gotta good chance of going to the ICU intubated anyway. Remember, pseudocholinesterase deficiency is highlighted as a major deal in our residency training....but it isnt, really......nobody dies from it in the hands of anesthesiologists....its more of an inconvenience....academic thing to put major stress into residents minds?.....yes....ever really a groundbreaking scenerio?.....no.....patients just need a vent post-op when it's discovered.....then it doesnt happen again. So keep this genetic aberration in perspective.....its just an inconvenience. No more, no less.

Not enough real info to warrant radically changing your anesthetic (to TIVA, for example) in my humble opinion. If you think so, I respect that. I wouldnt.

I'd do the case normally.

Sevo at 3%, fresh gas flow at 6 liters for the first fifteen minutes. I usta use N20 but now its all oxygen.

Would you say that he is putting their lives at risk? I wouldnt.

So my question to you: What would you have done differently?

 

[rmh149]

How do you know they are not anesthetic complications?

I dont. Keep in mind the information from the patient was vague. I would take it into consideration throughtout her anesthesia....but there wasnt enough information for me to change my anesthetic plan.