Mh

[DrRobert]

I often think about if I have the ability to quickly diagnose and treat MH if I'm ever taking care of a patient who develops it. I'm curious how many of you have actually had a patient develop MH. I think it would be helpful if you could share your clinical stories of firsthand encounters with this feared condition.

Some good information to include might be....

Age of patient, family history, type of surgery, location of surgery (ASC, Hospital, Office), etc.

Also, here are some questions I have...

What was the first sign or symptom you recognized?
How long before your first suspicion did you make the diagnosis?
How did you make the diagnosis?
At what point did you decide to treat? (dantrolene)
At what point did you tell the surgeon to stop surgery?
Were you alone or did you have plenty of help?
Did you call the MH hotline?
At what point did you decide to transfer the patient out of the OR and into the ICU? (assuming this occurred in the OR and not the PACU)
How long did it take before the patient started to recover? (i.e. out of the danger zone) of course this question assumes the patient survived
Did you recommend testing after the patient recovered? (testing of patient and/or family members)
What was the outcome?

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[Stank811]

Dr Robert I had a case recently.

Triggered 90min into case
Pt received glyco up front for anti-sialorrhea effects from surgical stand point so was tachy throughout case
Pt first become difficult to ventilate with concurrent temp increase both at a rate greater than would be expected from my experience
Then obtained an ABG which showed a metabolic acidosis
Treated with dantrolene and ice/iced saline, converted to TIVA, surgeon finished the lip closure while we treated, gave bicarb, placed CVL and art line, pt corrected amazingly fast and was transferred to ICU stable and was extubated the next day. Called MHAUS after the fact and refered family to local genetic testing lab and pt was confirmed to be positive.

 

[sevoflurane]

Dr Robert I had a case recently.

Triggered 90min into case
Pt received glyco up front for anti-sialorrhea effects from surgical stand point so was tachy throughout case
Pt first become difficult to ventilate with concurrent temp increase both at a rate greater than would be expected from my experience
Then obtained an ABG which showed a metabolic acidosis
Treated with dantrolene and ice/iced saline, converted to TIVA, surgeon finished the lip closure while we treated, gave bicarb, placed CVL and art line, pt corrected amazingly fast and was transferred to ICU stable and was extubated the next day. Called MHAUS after the fact and refered family to local genetic testing lab and pt was confirmed to be positive.

Wow... SDN has been clinical lately.

Thanks for sharing.

How high did your Ck levels go? Did you have to treat fro hyperK or ARF? How long after the dantrolene did it take to start to see results (minutes vs hours). Was the decrease in ventilatory complience refractory to paralytics?

You picked it up intra-op and treated accordingly. Strong work.

 

[pgg]

I had one case during residency that we thought might have been MH.

It was a CABG. ETCO2 shot up early in the case (way before CPB) to the point that i couldn't keep up with it. ETCO2 in the 50s despite more than doubling minute ventilation to 15 LPM or so. Think the ABG showed a met acidosis and hypercarbia c/w the end tidal. (It's been a while.)

His chest was already wide open and the LIMA and saphenous vein were 1/2 harvested so aborting was really undesirable. We did switch to a TIVA and gave dantrolene, and then waited about an hour to see what happened. Going on CPB if it really was MH probably would've killed him. CO2 eventually came down a bit, we blamed CO2 getting into a vein during the endoscope harvesting of the saphenous, and we finished the case.

His actual O2 consumption was way up though so I thought (and still think) there was something going on beyond CO2 absorption. No TEE bubbles either ...

Patient did fine postop.

 

[Stank811]

The interesting aspect of the case was that the CK never elevated above normal for our lab reference ranges. Because of this many people had some doubts if what happened was truly MH but fortunately this pt triggered slowly to Sevo (we didn't use Sux) so the diagnosis and treatment was made quickly before it progressed to muscle breakdown...this has been shown in the literature as well. We gave bicarb empirically to protect the kidneys but in retrospect did not need to give. There was never a decrease in ventilatory compliance just was difficult to keep up with the rate of rise on ETCO2 with increasing MV (I would double MV which would correct it for 30 sec and within 60sec the ETC02 would be creeping towards 60 again)...the rate in rise of temp and ETCO2 really took off at an abnormal rate that was difficult to control. Once dantrolene was started pt corrected in minutes...actually have some pretty cool graphs from the EMR in the OR that demonstrate the correction. This also happened at a large tertiary peds hospital so the response once MH was called honestly should have been video taped and used for training exercises...from the time the stat ABG came back (which is when MH was called) to the time of treatment could not have been more then 10-15 minutes. Extra anesthesiologist from OR and ICU, OR pharmacist with MH cart in room, extra nursing help in room within minutes. This case clearly shows how MH can present in different degrees of severity...this example would definitely be on the mild side which from what I understand is fairly common when inhalation agents trigger the event. But definitely good to experience while a resident.

 

[sevoflurane]

Yep. It is my understanding that MH can present from mild to horrific. I've personally never experienced it, but have had several colleagues who have. Biopsy positive results gives you some closure.

 

[BLADEMDA]

MY case had elevated CPKs for days and the gurus recommended Dantrolene for several days. Patient survived to leave the hospital.

First sign was tachycardia then increase in CO2. A few minutes later temperature increased. Switched to Tiva and started protocol. I recommend you rip the MH chart off a nearby wall if this ever happens to you.

Stay calm and get extra help. Call for at least 2 RNs and a tech to assist you if are alone

 

[soonerfrog]

Great Thread!!! Ahhh, MH. The terror we all think about but fortunately, rarely see.
Here's my coworker's event just recently.
Healthy 8 y/o ASA 1E male s/p dog bite with full stomach. RSI...masseter spasm/trismus to the point of unable to insert any sort of airway. Easy mask...no improvement with non-depol. agent. Pt appears obviously hyperdynamic, hypermetabolic. Attending thought pt just needed to be deepened. 8% Sevo later, no improvement. CO2 now over 100. Dantrolene shortly thereafter. Relaxation ensues. Easy intubation. Vitals normalize. CPK's very high, myoglobinuria, but no major sequala. I loathe this disorder. But fortunately, we all know what to do...it just stinks when it happens. A little refresher is always nice though.

 

[Dirtball]

Anyone had to treat MH afterhours (3pm) in a surgi-ctr with one room running and only a Pacu RN in the building besides your surgeon, scrub tech and circ RN ? No access to labs, A-line. I am knockin on wood now, as I have worked with the possiblilty of this scene for over a decade. I avoid Succ like the plague, but use GA all day long. I conduct a drill annually using outdated Dantrolene. It goes nice with the entire 3 room OR crew joining in but I think it would be a challenge to stay ahead with just a couple skilled hands in the afterhours scenario.

 

[BLADEMDA]

Anyone had to treat MH afterhours (3pm) in a surgi-ctr with one room running and only a Pacu RN in the building besides your surgeon, scrub tech and circ RN ? No access to labs, A-line. I am knockin on wood now, as I have worked with the possiblilty of this scene for over a decade. I avoid Succ like the plague, but use GA all day long. I conduct a drill annually using outdated Dantrolene. It goes nice with the entire 3 room OR crew joining in but I think it would be a challenge to stay ahead with just a couple skilled hands in the afterhours scenario.

IMHO, the incidence of "severe" MH is significantly reduced with the avoidance of Sux.
One should strongly consider avoiding Sux at a surgicenter late in the day. I routinely avoided using it at outpatient centers. I'd rather pretreat for GERD, aspiration risk, etc and give low dose Rocuronium combined with higher doses of Propofol for intubation. There are more than one way to skin a cat so using Sux was low on my list. Still, there were ENT cases I had to use Sux from time to time. Fortunately, they were always morning cases.

 

[Ashers]

I haven't seen it yet (fortunately), but I have done a bunch of TIVA this year for MH precautions, one could have potentially led to an MH case. I went to talk to this guy before the case, and his sister was there. The guy said his family had no problems with anesthesia, and his sister corrected him, about a sister who coded with most surgeries "high blood pressure and heart rate, possibly fever." The sister didn't quite remember since it had been 7 or so years. It actually happened a couple of times, and wasn't worked up, and she died after a surgery. I decided to just go ahead with a TIVA, and my attending told me it didn't sound suspicious enough for MH, so I didn't need to do TIVA, but I told him I already had it all set up.

When we got into the OR and after the case had started (hardware removal or something), another sister came to the hospital, and called in from day surgery and said she actually had MH. I was so relieved that I just gone ahead with the TIVA.

The weird thing was, the guy having the surgery had no idea of any of these problems. He didn't know why his sister died, apparently, he kept questioning his one sister in day surgery.

 

[BLADEMDA]

I haven't seen it yet (fortunately), but I have done a bunch of TIVA this year for MH precautions, one could have potentially led to an MH case. I went to talk to this guy before the case, and his sister was there. The guy said his family had no problems with anesthesia, and his sister corrected him, about a sister who coded with most surgeries "high blood pressure and heart rate, possibly fever." The sister didn't quite remember since it had been 7 or so years. It actually happened a couple of times, and wasn't worked up, and she died after a surgery. I decided to just go ahead with a TIVA, and my attending told me it didn't sound suspicious enough for MH, so I didn't need to do TIVA, but I told him I already had it all set up.

When we got into the OR and after the case had started (hardware removal or something), another sister came to the hospital, and called in from day surgery and said she actually had MH. I was so relieved that I just gone ahead with the TIVA.

The weird thing was, the guy having the surgery had no idea of any of these problems. He didn't know why his sister died, apparently, he kept questioning his one sister in day surgery.

I do TIVA whenever I have doubt about MH family history. It's my arse on the line and the patient's life. Remember, your anesthesia machine may need special "flushing" time if it's German made.

http://journals.lww.com/anesthesiol...of_Modern_Anesthesia_Workstations_for.40.aspx

Don't forget to create an artificial lung out of a breathing bag and flush the ventilator as well. If your Medical Center has a Charcoal Filter then the preparation time is always fast.
http://www.ncbi.nlm.nih.gov/pubmed/19020141




In the first study by Prinzhausen et al.,7 they found the Primus required a maximum of 70 min to decrease the anesthetic concentration of isoflurane to 5 ppm when using a fresh gas flow rate of 10 l/min. As a comparison, an Ohmeda Excel 210 (GE Healthcare, Helsinki, Finland) attained a isoflurane gas concentration of 5 ppm in 7 min under the same conditions

 

[Ashers]

I do TIVA whenever I have doubt about MH family history. It's my arse on the line and the patient's life. Remember, your anesthesia machine may need special "flushing" time if it's German made.

That's been my policy so far, if it sounds vaguely like it could have been MH in someone closely related, I'll treat the person with MH precautions.

With this case, the timing was awesome. The surgeon had unexpectedly postponed the case start by 30min, so I had enough time to get the machine flushed and set up the TIVA. Worked out beautifully.

I think this machine was one of our newer ones, a Draeger Apollo, that's an older model compared to some of the awesome ones I saw at ASA this year.

 

[BLADEMDA]

That's been my policy so far, if it sounds vaguely like it could have been MH in someone closely related, I'll treat the person with MH precautions.

With this case, the timing was awesome. The surgeon had unexpectedly postponed the case start by 30min, so I had enough time to get the machine flushed and set up the TIVA. Worked out beautifully.

I think this machine was one of our newer ones, a Draeger Apollo, that's an older model compared to some of the awesome ones I saw at ASA this year.

You got lucky. The Apollo requires a LONG time to get the machine ready for an MH susceptible patient. Please be aware that 30 minutes probably isn't long enough for a true MH patient unless a charcoal filter is utilized.


http://www.asaabstracts.com/strands...64DF5A1E26C7FC5?year=2008&index=8&absnum=2007

 

[BLADEMDA]

The Apollo takes 29 minutes even using this SUPER FLUSH Method from Boston Children's Hospital:

The study washout time was tested by employing a series of 6 washouts on the same two Apollos used for the control. Identical priming and equipment replacement procedures were used but with the following changes: FGF was 20L/min with a 1:1 mix of oxygen & air; 3L bag was removed from the manual ventilation arm leaving the circuit open to atmosphere; the ventilator was placed in pressure mode with a PIP of 70cm H20 & a rate of 40 bpm

 

[BLADEMDA]

All 5 controls runs reached 5ppm in >52 min (median =78 min, range 52-84 min).

 

[BLADEMDA]

 

[BLADEMDA]

 

[BLADEMDA]

I'm just having some fun with the pictures. No malice or ill will was intended towards anyone.

 

[IlDestriero]

You got lucky. The Apollo requires a LONG time to get the machine ready for an MH susceptible patient. Please be aware that 30 minutes probably isn't long enough for a true MH patient unless a charcoal filter is utilized.


http://www.asaabstracts.com/strands...64DF5A1E26C7FC5?year=2008&index=8&absnum=2007

We use the filters.
As for not doing a TIVA on that patient, your attending is an imbecile. You don't F around with possible MH susceptibility. A TIVA takes all of 5 min to set up, and with the filters, you'll be ready by the time you're set up. The patient's sibling had multiple post anesthesia complications and DIED of an unknown cause, and they don't want to wait 5 min to set up a TIVA? It's really unbelievable.

 

[W222]

My case went like this (note: I still to this day don't know if this was true MH, but it was weird): 40 yo AA male with hx of obesity, HTN, OSA not on CPAP who was going for bilateral repair of ruptured quadriceps tendon. We got the guy in the room, monitors on, pre-ox, and then induced with propofol and then pushed rocuronium after we knew we could ventilate, then turned on desflurane, and waited for the roc to kick in. I tried to open his mouth and his jaw was locked shut. I waited another minute and then was able to get him open and intubate. We got him positioned and I put a temp probe down with the NG tube. Temp probe shot up to 38.5 and kept going. From the floor notes his temp was never higher than 37.0. We also noticed his CO2 went through the roof, hovered between 55 and 65 and his O2 consumption went up. We told the surgeon we were aborting, placed and Aline, got a gas, and started TIVA w/propofol while we waited for the ICU bed. Gas showed metabolic acidosis. His temp went from around 38.7 to 37 in 30 minutes, we hydrated the hell out of him but didn't give dantrolene. He was extubated in the ICU after about 5 hours. I called the hotline the next day and they didn't think it was MH, my attending was pretty sure it was though.

 

[sevoflurane]

The Apollo takes 29 minutes even using this SUPER FLUSH Method from Boston Children's Hospital:

The study washout time was tested by employing a series of 6 washouts on the same two Apollos used for the control. Identical priming and equipment replacement procedures were used but with the following changes: FGF was 20L/min with a 1:1 mix of oxygen & air; 3L bag was removed from the manual ventilation arm leaving the circuit open to atmosphere; the ventilator was placed in pressure mode with a PIP of 70cm H20 & a rate of 40 bpm

Nice. Thanks for sharing. I don't know about the charcoal filters... Is it just activated charcoal instead of amsorb/sodalime/baralyme in the canister? or is it activated charcoal fileter in the circuit?

 

[sevoflurane]

Inspiratory limb of the breathing circuit.

http://www.ncbi.nlm.nih.gov/pubmed/19020141

Cool. I learned something today.

 

[Ashers]

The references are great. Thanks!

 

[OB1🤙]

we hydrated the hell out of him but didn't give dantrolene. He was extubated in the ICU after about 5 hours. I called the hotline the next day and they didn't think it was MH, my attending was pretty sure it was though.

Why no dantrolene if the attending was so sure?

 

[dhb]

was going for bilateral repair of ruptured quadriceps tendon.

Perfect for a muscle biopsy

 

[Arch Guillotti]

Your attending sounds like a fool.

I haven't seen it yet (fortunately), but I have done a bunch of TIVA this year for MH precautions, one could have potentially led to an MH case. I went to talk to this guy before the case, and his sister was there. The guy said his family had no problems with anesthesia, and his sister corrected him, about a sister who coded with most surgeries "high blood pressure and heart rate, possibly fever." The sister didn't quite remember since it had been 7 or so years. It actually happened a couple of times, and wasn't worked up, and she died after a surgery. I decided to just go ahead with a TIVA, and my attending told me it didn't sound suspicious enough for MH, so I didn't need to do TIVA, but I told him I already had it all set up.

When we got into the OR and after the case had started (hardware removal or something), another sister came to the hospital, and called in from day surgery and said she actually had MH. I was so relieved that I just gone ahead with the TIVA.

The weird thing was, the guy having the surgery had no idea of any of these problems. He didn't know why his sister died, apparently, he kept questioning his one sister in day surgery.