Newly Published
Perioperative Medicine  |   November 2018
Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment: Database Analyses and Systematic Review
Author Notes
  • From The North American Malignant Hyperthermia Registry of the Malignant Hyperthermia Association of the United States, University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, Pennsylvania (2000 through 2017; M.G.L., B.W.B.); Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida (2018; M.G.L.); Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan (T.T.K., M.T.V., S.K.); Department of Nurse Anesthesia, University of Pittsburgh, Pittsburgh, Pennsylvania (2016 through 2018; B.W.B.); Department of Anesthesiology, School of Medicine (K.G.B., T.W.K., J.C.) and School of Public Health (K.G.B.), University of Minnesota, Minneapolis, Minnesota; Department of Anesthesiology, Children’s Hospital of Pittsburgh (E.L.S.), and Department of Anesthesiology (A.H.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Anesthesiology, Weill Cornell Medical College and New York−Presbyterian Hospital, New York, New York (J.L.); Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Canada (S.R.); Department of Anesthesiology and Pediatrics, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Egleston Hospital, Atlanta, Georgia (D.M.). Current positions: Dr. Larach is now at the Department of Anesthesiology, University of Florida, Gainesville, Florida. Dr. Sivak is now at the Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, Ohio.
  • Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
  • Beaumont Health, Dearborn, Michigan
  • Beaumont Health, Royal Oak, Michigan
  • Beaumont Health, Farmington Hills, Michigan
  • Beaumont Health, Grosse Pointe, Michigan
  • Bronson Healthcare, Battle Creek, Michigan
  • Bronson Healthcare, Kalamazoo, Michigan
  • CHOC Children’s Hospital, Orange, California
  • Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
  • Department of Anesthesiology, Columbia University Medical Center, New York, New York
  • Henry Ford Health System, Detroit, Michigan
  • Henry Ford Health System, West Bloomfield, Michigan
  • Holland Hospital, Holland, Michigan
  • Mercy Health, Muskegon, Michigan
  • Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
  • Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Medical Center, New York, New York
  • Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
  • St. Joseph Mercy, Ann Arbor, Michigan
  • St. Joseph Mercy Oakland, Pontiac, Michigan
  • St. Mary Mercy Hospital, Livonia, Michigan
  • Sparrow Health System, Lansing, Michigan
  • Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
  • Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
  • Department of Anesthesiology, University of Colorado, Aurora, Colorado
  • Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
  • Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania
  • Department of Anesthesiology, University of Tennessee Medical Center, Knoxville, Tennessee
  • Department of Anesthesiology, University of Utah, Salt Lake City, Utah
  • Department of Anesthesiology, University of Vermont, Larner College of Medicine, Burlington, Vermont
  • Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
  • Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
  • Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
  • Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina
  • Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri
  • Department of Anesthesiology, Weill Cornell Medical College, New York, New York
  • Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
  • Current positions: Dr. Larach is now at the Department of Anesthesiology, University of Florida, Gainesville, Florida. Dr. Sivak is now at the Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, Ohio.
    Current positions: Dr. Larach is now at the Department of Anesthesiology, University of Florida, Gainesville, Florida. Dr. Sivak is now at the Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, Ohio.×
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • *Members of the Multicenter Perioperative Outcomes Group are listed in appendix 1.
    Members of the Multicenter Perioperative Outcomes Group are listed in appendix 1.×
  • Submitted for publication May 19, 2018. Accepted for publication September 21, 2018.
    Submitted for publication May 19, 2018. Accepted for publication September 21, 2018.×
  • Correspondence: Address correspondence to Dr. Larach: The North American Malignant Hyperthermia Registry of Malignant Hyperthermia Association of the United States at the Department of Anesthesiology, University of Florida College of Medicine, P.O. Box 100254, Gainesville, Florida 32610-0254. mlarach@gmail.com. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Airway Management / Neuromuscular Diseases and Drugs / Patient Safety / Pharmacology
Perioperative Medicine   |   November 2018
Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment: Database Analyses and Systematic Review
Anesthesiology Newly Published on November 12, 2018. doi:10.1097/ALN.0000000000002490
Anesthesiology Newly Published on November 12, 2018. doi:10.1097/ALN.0000000000002490
Abstract

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.