Succinylcholine Use and Dantrolene Availability: Reply
Marilyn Green LarachThomas T. KlumpnerBarbara W. BrandomMichelle T. VaughnKumar G. BelaniAndrew HerlichTae W. KimJanine LimoncelliSheila RiaziErica L. SivakJohn F. CapacchioneDarlene Mashman
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Abstract:
We thank Drs. Joshi, Desai, Valedon, and Gayer for their interest in our database analyses and systematic literature review of succinylcholine use and dantrolene availability for malignant hyperthermia treatment.1 Joshi et al. state that our analyses do not include data from Class B ambulatory care facilities. The American Association for Accreditation of Ambulatory Surgery Facilities (Gurnee, Illinois) defines Class B facilities as those that allow minimally or moderately invasive surgical, endoscopic and/or pain management procedures under moderate sedation with intravenous sedation, and/or parenteral sedation, and/or field and peripheral nerve blocks, and/or dissociative drugs excluding propofol.2 Because the Multicenter Perioperative Outcomes Group (Ann Arbor, Michigan) uses different classifications for its participating institutions, we do not know how many of the 24 freestanding ambulatory surgery centers captured in our study also might have been Class B facilities.Joshi et al. may have missed our systematic literature review of succinylcholine use for treatment of laryngospasm (appendix 2, query 5 and key words with combinations, supplemental digital content 3).1 Unfortunately, we found no published studies containing data on succinylcholine administration rate in ambulatory surgery centers for airway rescue.Joshi et al. are correct as regards our Multicenter Perioperative Outcomes Group investigation. We could not do a retrospective analysis of laryngospasm in the Multicenter Perioperative Outcomes Group database because laryngospasm is not reported in a consistent, discrete fashion across the millions of cases included in our study. We chose grades III/IV mask ventilation as a surrogate for airway rescue to facilitate examination of 6,938,341 anesthetic cases. Succinylcholine was administered in freestanding ambulatory surgery centers in 1,388 cases of documented grade III/IV airway (table 2). For all anesthetizing locations, the succinylcholine dose for the 560 grade IV (impossible to ventilate) mask ventilation cases with a recorded succinylcholine amount and weight was 1.2 mg/kg (first quartile, 0.97; third quartile, 1.44; range, 0.12 to 3.02 mg/kg).1Malignant hyperthermia cases triggered by low-dose succinylcholine without volatile anesthetic administration have been reported by Riazi. Two adult patients developed “almost certain” malignant hyperthermia after receiving 0.5 mg/kg and 0.8 mg/kg of succinylcholine to facilitate electroconvulsive therapy. Both of these patients had positive malignant hyperthermia diagnostic biopsies; one had a malignant hyperthermia causative mutation (supplemental digital content 6, reference 27 [table 3]).1Although Joshi et al. quote part of Dr. Hopkins’ statement, the remainder of his observations were omitted. We cite the entire paragraph with the omitted portions italicized. “Although the evidence presented in this article is insufficient to convince me that succinylcholine in the absence of volatile anesthetics can trigger a life-threatening progressive hypermetabolic response in MH-susceptible patients, the evidence is similarly insufficient to rule out that this is the case. My view, therefore, is that equipoise is retained on this issue, and while it remains, patient safety is served by mandating that dantrolene be stocked where succinylcholine is available.”3Although Joshi et al. state that there is a high likelihood of overdiagnosis of malignant hyperthermia, we cannot find evidence to support this comment. Also, we could not find data to support the statement that “offering the alternative to stocking succinylcholine without dantrolene is prudent from patient safety and cost-effective perspectives.”What will be included in a malignant hyperthermia drill for Class B facilities that have no dantrolene to administer? We reiterate that time to dantrolene administration affects the likelihood of complications including coagulation, heart, lung, liver, kidney, and brain dysfunction (reference 9 [table 6]). Malignant hyperthermia complications increase substantially with every 10-min delay in initiating dantrolene treatment. If clinicians wait more than 50 min, complications increase to 100% (reference 27 [fig. 1].1Drs. Joshi, Desai, Valedon, and Gayer emphasize the need for transfer arrangements at Class B Ambulatory Facilities. We agree that transfer arrangements are essential for all freestanding facilities so that appropriate care for unanticipated medical, anesthetic, and/or surgical issues may be obtained. In 2012, four physicians representing the Society for Ambulatory Anesthesia (Drs. Belani, Metz, Piccone, and Valedon) helped to create a guide for the transfer of care of the malignant hyperthermia patient from ambulatory surgery centers to receiving hospital facilities. These physicians agreed that IV dantrolene therapy should be initiated before patient transfer.4 Why is this guide no longer relevant to the care of ambulatory surgery center patients?We stand by our conclusion that our data support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used, even when succinylcholine is used solely for airway rescue.Many of the authors are unpaid volunteers for the nonprofit Malignant Hyperthermia Association of the United States (MHAUS; Sherburne, New York). They have served variously as directors of The North American Malignant Hyperthermia Registry of MHAUS and members of the board of MHAUS, the Professional Advisory Council of MHAUS, and/or the Malignant Hyperthermia Hotline of MHAUS. All of these positions are voluntary and unpaid. Many participated in the drafting of the current MHAUS recommendation for dantrolene availability in anesthetizing locations. Many of the authors have traveled to malignant hyperthermia conferences in the United States or Canada with MHAUS financial support. MHAUS receives funding support from MHAUS members, customers, medical associations and societies, foundations, and various corporations, including Eagle Pharmaceuticals (Woodcliff Lake, New Jersey), PAR Pharmaceuticals (Chestnut Ridge, New York), and U.S. WorldMeds, LLC (Louisville, Kentucky). Dr. Belani received several vials of Ryanodex from Eagle Pharmaceuticals, Inc., for use in a research study. Dr. Mashman has received a grant from Eagle Pharmaceuticals, Inc., for three vials of Ryanodex to bring on a medical mission trip. Dr. Riazi has received a consulting fee from Norgine Pharmaceuticals (Amsterdam, The Netherlands) and is also a member of the scientific advisory board of the RYR1 Foundation (Pittsburgh, Pennsylvania). Dr. Sivak has been a principal investigator for a Merck (Kenilworth, New Jersey) sponsored study of sugammadex (November 7, 2017 through August 3, 2018).Keywords:
Laryngospasm
Laryngospasm is an emergency situation that requires rapid identification and resolution of the obstructed glottis. Although there is a low incidence of laryngospasm, it is important to remember that any patient has the potential for post-extubation laryngospasm. Nurses must know about the causes, risk factors and treatment for this respiratory emergency. This includes the plan of care and possible medications administered to assist in restoring the patient's airway. Nurses must be able to respond quickly to avoid complications such as noncardiogenic pulmonary edema (NCPE) and respiratory arrest. The triggers, signs and symptoms, and treatment of NCPE are also reviewed. Due to the risk of laryngospasm recurring or NCPE presenting itself, any patient who has had laryngospasm needs close monitoring for two to three hours after the laryngospasm has resolved. It is important for nurses to review the interventions for laryngospasm and NCPE prior to caring for a patient with this respiratory emergency.
Laryngospasm
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Laryngospasm is a common and often serious adverse respiratory event encountered during anesthetic care of children. We examined, in a case control design, the risk factors for laryngospasm in children.The records of 130 children identified as having experienced laryngospasm under general anesthesia were examined. Cases were identified from those prospectively entered into the Mayo Clinic performance improvement database between January 1, 1996 and December 31, 2005. Potential demographic, patient, surgical and anesthetic related risk factors were determined in a 1 : 2 case-control study.No individual demographic factors were found to be significantly associated with risk for laryngospasm. However, multivariate analysis demonstrated significant associations between laryngospasm and intercurrent upper respiratory infection (OR 2.03 P = 0.022) and the presence of an airway anomaly (OR = 3.35, P = 0.030). Among those experiencing laryngospasm during maintenance or emergence, the use of a laryngeal mask airway was strongly associated even when adjusted for the presence of upper respiratory infection and airway anomaly (P = 0.019). Ten patients experienced postoperatively one or more complications whereas only three complications were observed among controls (P = 0.008). No child required cardiopulmonary resuscitation and there were no deaths in either study cohort.In our pediatric population, the risk of laryngospasm was increased in children with upper respiratory tract infection or an airway anomaly. The use of laryngeal mask airway was found to be associated with laryngospasm even when adjusted for the presence of upper respiratory tract infection and airway anomaly.
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麻酔管理を安全に遂行する上で気道確保はこの上なく重要である. 日々の臨床麻酔の中で喉頭痙攣はいつでも遭遇する可能性があり, いったん起これば急激な低酸素血症, それに引き続く多臓器障害へと進行していく. しかしながら今日までその病態, 頻度, 予防, 治療などを含めた系統的な総説がなかった. 今回, 研究方法(調査研究と比較研究), 麻酔の導入と覚醒, 気管チューブとラリンジアルマスク, 抜管のタイミングなどごとにそれぞれまとめた. また, 麻酔に伴う喉頭痙攣の迅速な診断, 確実な予防法・治療法を文献的考察とともに記述した.
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Airway obstruction
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Malignant hyperthermia
Laryngospasm
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Laryngospasm
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Purpose of review The purpose of this review is to discuss the risk factors associated with laryngospasm and the techniques used for prevention and treatment. We also summarize the prevention and treatment modalities in organized algorithms. Recent findings According to recent endoscopic studies, laryngospasm is always complete, thus airway management and intravenous therapy are indicated. Parental history of children having upper respiratory infection is associated with increased risk of laryngospasm. Anesthesia administered by a pediatric anesthesiologist is associated with lower incidence of laryngospasm. Intravenous anesthesia is associated with lower incidence of laryngospasm than inhalational anesthesia. In tracheal intubation, the use of muscle relaxants decreases laryngospasm. Deep laryngeal mask airway removal is associated with lower incidence of laryngospasm in sevoflurane or isoflurane anesthesia. In no intravenous line situation, laryngospasm can be treated with succinylcholine administration by intramuscular, intraosseous and intralingual routes. Summary Identifying the risk factors and taking the necessary precautions are the key points in prevention of laryngospasm. An experienced anesthesiologist is associated with lower incidence of laryngospasm. Airway management is the most essential part of treatment of laryngospasm. Drugs can be used as an adjunct in treatment of laryngospasm, especially when anesthesia is administered by beginners.
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Laryngospasm is a potential complication encountered during anesthesia using a laryngeal mask airway (LMA). We report a case in which laryngospasm resulted in unsuccessful placement of an LMA ProSeal Airway (Teleflex Inc), and we discuss the various causes of unsuccessful placement of this type of airway device. Laryngospasm causes increased resistance to gas flow by inducing closure of vocal cords, aryepiglottic fold, and periglottic tissue. In this case report, the laryngospasm-induced increased resistance to gas flow was manifested by exaggerated outward movement of the LMA ProSeal following its connection to gas flows and thus resulted in failed airway placement. The possibility of laryngospasm as a cause of failed placement of an LMA ProSeal must be considered in clinical practice.
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