Okay, so a few months ago I was in the ENT room at my clinical site doing some peds cases. A 2 yr. old presents for BMT (ear tubes), otherwise healthy besides seasonal allergies and freq. ear infections. Upon reviewing the anesthesia pre-op assessment that was completed in pre-admission testing, it is noted that the child has a questionable family history of malignant hyperthermia. Supposedly, the child's aunt has been diagnosed with MH. The child himself has never had anesthesia and has never been tested. The child's mother recently had a lap chole but does not have access to her records and is unaware if she was given a non-triggering anesthetic. The anesthesiologist I am with would like to cancel the case and have the child tested for MH before proceeding, but the parents become very upset and insist that the procedure be completed because the child is miserable and having very severe hearing difficulties. Unfortunately, this is not the first case of the day and the questionable history of MH has not been picked up by the physician assistant in PAT. So, what now?
Questions:
Would you proceed with the case, and if so, how would you proceed?
Great job, wtbcrna, for not even being an official SRNA yet!!
This is what we ended up doing: The kid already had p.o. Versed on board, but was still kinda squirmy, so we gave some IM Ketamine (I can't remember the exact dose we gave but I was told that a good sedation dose would be to give an IV induction dose IM). My peds rotation is my very last one so you can understand how freaked out I was at this whole situation because I hadn't even done peds yet! Anyhoo, we changed the soda lime on the machine, removed the vaporizers so we wouldn't accidently use them, and flushed the machine at 10 liters for about 15 min. or so. We then started an IV and used a Prop gtt. The case turned out fine it was just a lot of extra work. And of course, we monitored EtCO2 and temp. the whole time just in case. Which leads me to another question: What is the FIRST indicator of MH, and what is the most SENSITIVE indicator of MH?
And whoever posted this is right, the Halothane contracture test is only done at like 6 centers in the U.S so I imagine getting tested is difficult for some people.
" The unanticipated double or tripling of end-tidal carbon dioxide is one of the earliest and most sensitive indicators of MH" Morgan, Mikhail, & Murray
ketamine will potentially interfere with determining whether MH is occurring. It causes tachycardia that can be profound....
I remember in the 80s it was also thought to be a triggering agent.
Oral or nasal versed is a good preop, then IV, the propofol...safest course.
Ketamine does not trigger malignant hyperthermia in susceptible swine
M Dershwitz, FA Sreter and JF Ryan
Department of Anaesthesia, Massachusetts General Hospital, Boston 02114.
The use of ketamine in individuals susceptible to malignant hyperthermia (MH) is controversial. We describe our experience with ketamine used for induction and/or maintenance of anesthesia in our herd of swine inbred for susceptibility to MH. A total of 76 MH- susceptible swine were given a total of 112 general anesthetics using ketamine as the induction drug. In 34 of these anesthetics, anesthesia was also maintained with ketamine. Signs of MH did not develop in response to ketamine in any of the pigs.
jer_sd
369 Posts
I was under the impression that MH could be triggered by Versed.... is this only with IV administration?