Succinylcholine use and dantrolene availability for malignant hyperthermia treatment: Database analyses and systematic review

Marilyn Green Larach, Thomas T. Klumpner, Barbara W. Brandom, Michelle T. Vaughn, Kumar G. Belani, Andrew Herlich, Tae W. Kim, Janine Limoncelli, Sheila Riazi, Erica L. Sivak, John Capacchione, Darlene Mashman, Sachin Kheterpal, Thomas T. Klumpner, Barbara W. Brandom, Michelle T. Vaughn, Kumar G. Belani, Andrew Herlich, Tae W. Kim, Janine LimoncelliSheila Riazi, Erica L. Sivak, John Capacchione, Darlene Mashman, Sachin Kheterpal, Fabian Kooij, Janet Wilczak, Roy Soto, Joshua Berris, Zachary Price, Steven Lins, Peter Coles, John M. Harris, Kenneth C. Cummings, Mitchell F. Berman, Masakatsu Nanamori, Bruce T. Adelman, Christopher Wedeven, John Lagorio, Patrick J. McCormick, Simon Tom, Michael F. Aziz, Traci Coffman, Terri A. Ellis, Susan Molina, William Peterson, Sean C. MacKey, Wilton A. Van Klei, Adit A. Ginde, Daniel A. Biggs, Mark D. Neuman, Robert M. Craft, Nathan L. Pace, William C. Paganelli, Marcel E. Durieux, Bala J. Nair, Jonathan P. Wanderer, Scott A. Miller, Daniel L. Helsten, Zachary A. Turnbull, Robert B. Schonberger

Research output: Contribution to journalReview articlepeer-review

17 Scopus citations

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.

Original languageEnglish (US)
Pages (from-to)41-54
Number of pages14
JournalAnesthesiology
Volume130
Issue number1
DOIs
StatePublished - Jan 1 2019

Bibliographical note

Funding Information:
Support for underlying electronic health record data collection by the Multicenter Perioperative Outcomes Group (Ann Arbor, Michigan) was provided, in part, by Blue Cross and Blue Shield of Michigan (BCBSM; Detroit, Michigan) and Blue Care Network (Southfield, Michigan) as part of the BCBSM Value Partnerships program for contributing hospitals in the State of Michigan. Although BCBSM and Multicenter Perioperative Outcomes Group work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. Although the Multicenter Perioperative Outcomes Group has collaborated in the authorship of this manuscript by providing data and statistical analysis, the opinions, beliefs, and viewpoints expressed by the authors of this manuscript do not necessarily reflect the opinions, beliefs, and viewpoints of the Multicenter Perioperative Outcomes Group. Support of the Anesthesia Closed Claims Project of the Anesthesia Quality Institute is provided, in part, by the American Society of Anesthesiologists (Schaumburg, Illinois). The North American Malignant Hyperthermia Registry (Gainesville, Florida), founded in 1987, became a wholly owned subsidiary of the Malignant Hyperthermia Association of the United States (Sherburne,New York) in 1995. North American Malignant Hyperthermia Registry administrative staff members have received salary support from the Malignant Hyperthermia Association of the United States. North American Malignant Hyperthermia Registry directors have never received financial support from the Malignant Hyperthermia Association of the United States. The opinions, beliefs, and viewpoints expressed by the authors of this manuscript do not necessarily reflect the opinions, beliefs, and viewpoints of the Malignant Hyperthermia Association of the United States. Apart from the above, only institutional or departmental sources supported the creation of this manuscript.

Publisher Copyright:
© 2018 the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc.

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