Published Aug 6, 2003
Here is a real situation for the anesthesia students and CRNAs. Perspective students feel free to comment, also.
When I made my pre-op phone calls for cataract surgery yesterday, one of the patients gave me a history of malignant hyperthermia. She had a family member die at 5 years of age durning tonsil surgery. She had a muscle biopsy which was positive for MH. She has had two surgeries, one under general with her temp being elevated and treated with Dantrolene. The second procedure was performed with regional anesthesia, without problem.
My question--would you do her in an ambulatory surgery facility, where general anesthesia is not performed? The is no dantrolene in the facility. The cataracts are performed with topical local by the surgeon and I administer small doses of versed and hold the patients' hand while monitoring them .
What would you do in this situation?
PS, I am in private practice, work alone with no medical direction.
Will be starting CRNA school later this month so obviously I have barely scratched the surface in this area.
Can versed cause MH? Or are you concerned about the local? Thought it was attributed to the gases and
sux. If so, have you considered ketamine / propofol mix? Link to a study that suggests this combo, although doesn't mention this type of surgery at University of North Carolina School of Medicine article http://www.unc.edu/~rvp/CVDocs/KetProp.html
As long as you don't use succs or the volatile anesthetics (Nitrous is ok) you should be just fine. Look here. This is what I was taught.
Is there a point in the surgery where you would have to use general anesthesia if something went wrong? If so, I would not put myself or the patient at risk.
Hi, Yoga. This is not a insignificant issue for out of hospital anesthesia. Maintaining dantrolene is a big expense, especially for a drug you never intend to use.
In all likelihood, this case would go fine in your ambulatory facility. But if it were me, I would refuse the case. The AANA standards of anesthesia in the office setting require dantrolene. I believe the agencies that accredit ambulatory care centers also require it.
So I think it would be tough to justify the decision to proceed without dantrolene, in the (incredibly unlikely) event of an episode. It might even look bad if some other, non-MH complication were to occur. I would take the "CYA" position, and turf this one to the big house.
I imagine this may not make your surgeon very happy. But he needs to realize that he doesn't need the potential liability, either.
Let us know how the story ends.
What did you decide to do about this case? How did it go?
I borrowed dantolene from another facility and had it handy. The patient only received versed 1 mg and a topical anesthetic by the surgeon. She did real well, but has to have the other eye done.
It was a little tricky because the nurses had no idea how to help if there was a problem. Of course, the surgeon would have also been useless--he had no idea what MH was.
I am still not sure I did the right thing by doing her in an ASC setting. I have always been a very lucky CRNA, but I want that luck to last.
By the way, I have had one MH in a plastic surgery office on a patient who had a rhinoplasty. She survived, but I will never forget that day.
Surely one MH event is enough for anyone's career lifetime! But you can't count on that, as of course you well know.
That was a great, innovative solution-to borrow the dantrolene. I would have completely supported that option, I just didn't think of it.
The dantrolene availability was the only concern I had. Additional help if a crisis hits is an issue in this setting, but not a "deal breaker", if you know what I mean. I am sure you would have taken charge, and gotten the job done, if the need had arisen.
Good solution, good outcome, everybody happy-just another day in the life of a CRNA. Congrats, and thanks for the update.
what worries me as much as anything is your statement that the nurses and surgeons wouldent know what to do?. are u telling me that u carried on knowing that your team were unprepared for an emergency?. I truly believe this patient should have been admitted to a facility where there were trained medical and nursing personnel to deal with and emergency if one had arisen. by admitting that you bought a patient into an environment where they were at risk from uninformed staff is so stupid i cant believe it. the least u should have done was to have educated your team. i do agree with part of your experience though. you were lucky!:
I did educate the team, showed the nurses how to mix the dantrolene, what to look for regarding patient vital signs and discharge criteria.
I must take exception to your attack regarding my practice. The teams I work with are excellent, but have little experience in dealing with such a rare disorder as MH. The have been very helpful to me in the past with difficult intubations, IV starts and positioning. I will stand by my statement that the surgeons are of little use in difficult anesthesia situations. The surgeon on that particular case is a very good ophthalmologist, but hasn't managed a patient outside of his field for years. That is what I am there for.
I practice in the "real world" in office and ambulatory surgery centers where having a lot of anesthesia experience is important to the good outcomes. The surgeons will try to operate on corpses (if they could collect from insurance) and it is up to us to set and follow standards that are both safe and economically sound.
I would love to know why you used the term "stupid" to describe my practice when you have no idea what it is like? Also, your grammer could use a little correcting.
Carcha, Why is it that you feel the need to slam someone's character when you know nothing about them. Almost every CRNA I have shadowed has taken the time to educate myself and others. I have seen them stand up to others when it was in the patient's interest and remain firm in their decision. If you had read Yoga's past posts, you would know Yoga is the same. Your post could have been asked much more appropriately.
We must all remember the purpose of this forum is to support each other, share information and have healthy debate. It is not about calling people names or making rude remarks.
I will happily share my knowlege with anyone because I know I will learn from all of you.
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