EDITOR’S PERSPECTIVE What We Already Know about This Topic Dantrolene effectively treats malignant hyperthermia, but there are discrepant recommendations for dantrolene availability in facilities that stock succinylcholine for airway rescue but do not use volatile anesthetics. What This Article Tells Us That Is New The authors performed an analysis of data from three databases and a systematic literature review. Providers frequently use succinylcholine, including during difficult mask ventilation. Succinylcholine given without volatile anesthetics triggered 24 malignant hyperthermia events, 13 of which were treated with dantrolene. Fourteen patients experienced substantial complications, and one died. Delayed dantrolene treatment worsened patient outcomes. Background Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. Methods The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. Results Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. Conclusions Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.
Typically, a patient's intraoral condition is not a chief perioperative concern. The need for proper dental care is often unmet prior to a surgical procedure. Consequently, patients presenting for surgery may possess untreated decayed teeth and/or periodontal disease. These individuals may be harboring a
A literature search was performed which identified many possible common and uncommon sources of fever. Some of these sources are quite relevant to the anesthesiologist. Other sources had potential relevance in obscure cases.
SummaryWe studied the incidence of fasciculations and postoperative myalgias in 100 Key wordsComplications; fasciculations, myalgias. Neuromuscular blocking agents; tubocurarine, suxamethonium, vecuronium.Postoperative myalgias (POM) are common among patients who receive suxamethonium; the reported incidence ranges from 0.2-89%.1-7 Myalgias occur more frequently after minor operative procedures in women and in outpatients.',2+7 Muscle fasciculations are also common after suxamethonium administration and have been associated with the development of POM.8,9 Various pretreatment regimens have been used in an attempt to decrease the incidence of fasciculations and POM. These include a small dose of a non-depolarising muscle r e l a~a n t , ' ,~,~.~,~~'~ a benz~diazepine,'~-~~ lignocaine,21,22 and suxamethonium it self. 23, 24 The purpose of this study was to determine whether pretreatment with a small dose of vecuronium or midazolam would attenuate fasciculations and (or) POM after suxamethonium in female patients who have laparoscopy as outpatients. The study was subsequently extended to determine whether myalgias after laparoscopy were associated with the use of suxamethonium. MethodsWe first studied 80 ASA physical status 1 and 2 female patients, after Institutional Review Board Ethics Committee approval and written informed consent was obtained. The patients had received no premedication and were scheduled to undergo laparoscopy on an outpatient basis. Each patient was assigned to one of four pretreatment groups, in a prospective, double-blind, randomised study to receive: group 1, saline; group 2, tubocurarine 0.05 mg/kg; group 3, vecuronium 0.006 mg/kg; and group 4, midazolam 0.025 mg/kg. All patients were monitored with ECG, noninvasive blood pressure (Dinamap, Critikon Inc., Tampa, FL, USA), pulse oximetry, mass spectrometry, and an oesophageal temperature probe. Fentanyl 100 pg and droperidol 1.25 mg were administered intravenously after insertion of an intravenous cannula, followed, at time zero, by the pretreatment drug according to group. Anaesthesia was induced 1.75 minutes later with sodium thiopentone 4 mg/kg. Suxamethonium 1.5 mg/kg was given at 3 minutes to facilitate tracheal intubation. An observer, blinded to the patient's pretreatment, then rated the fasciculations on a scale of &3, where 0 = none; 1 = mild fasciculations of eyes, face, neck or fingers without limb movement; 2 = moderate fasciculations involving limbs and/or trunk; and 3 = severe vigorous motion requiring restraint of limb^.'^.'^ Anaesthesia was maintained with N,O (60%) in 0, and isoflurane 0.5-1.5% end-tidal concentration as measured by mass spectrometry (Perkin-Elmer
Regression of onset type on pretreatment variables indicated that a small but statistically significant proportion of pretreatment variability (8.7%) could be accounted for by onset. Both traumatic and nontraumatic onset groups showed positive outcomes following treatment. No significant differences between groups were found for any of the clinical or self-reported outcome measures with the exception that a significantly higher percentage of the trauma group reported using pain medication at follow-up. These findings are in contrast with previous suggestions that post-traumatic TMD patients show poorer response to treatment than nontrauma TMD patients.
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