ASCs need to develop policies for management of malignant hyperthermia

As the number of surgical procedures performed outside hospitals continues to increase, ambulatory surgical centers (ASCs) need to develop policies for managing malignant hyperthermia—a rare but serious reaction to anesthetics, according to an expert panel report in the January issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS).

The report includes a guide for ASCs to follow in developing specific plans for transferring patients with malignant hyperthermia (MH) to a nearby hospital for advanced care. The lead author of the expert panel report was Dr Marilyn Green Larach of Penn State College of Medicine, Hershey, Pa.

ASCs Must Have a Plan for Managing Rare Complication
Malignant hyperthermia is a rare condition in which genetically susceptible people develop rapid increases in body temperature and muscle rigidity in response to certain anesthetics and other drugs. Once MH is recognized, it can be avoided by substituting other anesthetics. However, susceptible patients generally go unrecognized until they (or a family member) experience an episode of MH.

When patients develop MH, they need immediate transfer to a hospital capable of providing critical care crisis management. Recent years have seen rapid growth increase in surgical procedures performed at ASCs—which don't have the facilities needed to manage these potentially life-threatening reactions. The guide was developed by a panel of 13 experts representing the Malignant Hyperthermia Association of the United States along with experts in anesthesia, ambulatory surgery, emergency medicine, and nursing.

The panel concluded that every ASC must develop its own specific plan for managing MH, based on individual circumstances. However, all ASCs must be prepared to administer emergency medication—the muscle relaxant dantrolene, given intravenously—before the patient is transferred. Research shows that, for every 30-minute delay in dantrolene treatment, the risk of significant complications of MH doubles.

The guide includes a list of potential problems and treatment for each ASC to consider in developing its unique MH transfer plan. Key issues include the capabilities of the transport team and transfer hospital, indicators of patient stability, making the decision to transfer, and coordinating communications.

Estimated 50 Cases of MH per Year at ASCs
Malignant hyperthermia is rare: one study estimated that it occurs in 1 out of every 300,000 surgical procedures performed in ASCs. However, given that the number of procedures performed in ASCs each year is in the millions and growing, it's inevitable that some cases of MH will occur in out-of-hospital surgeries. The panel estimates that nearly 50 MH events may occur each year in "standalone" ASCs (not attached to hospitals).

The panel calls on each ASC to develop, review, and/or revise its MH transfer plan. Dr Larach and her fellow panel members hope their guide will help ASCs to "achieve optimal streamlined care with particular attention to the unique medical requirements of the surgical/medical patient with an MH crisis." The guide may be relevant to other non-hospital settings where anesthetics potentially causing MH are used—for example, surgical or dental offices.