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Didactics #2
Malignant Hyperthermia
| Question | Answer |
|---|---|
| How many cases of MH per year in the US result in death? | 10 |
| Which medication causes a faster onset of MH? | Succinylcholine |
| MH causes what type of metabolic state? | Intense hypermetabolic |
| Body temp may exceed? in intense cases | 46C |
| pH can reach 6.8 in what time frame? | 30 minutes |
| MH is a hypermetabolic state of what muscle type? | skeletal |
| What gas is the most potent trigger of MH | Halothane |
| What type of acidosis is seen with MH | both metabolic and respiratory |
| 50% of patients with susceptibility for MH usually develop it after how many exposures to anesthetics? | on the 2nd or 3rd exposure |
| The incidence of MH is higher in which gender? | Male |
| What is the ratio of MH occurrence in children? | 1/15,000 |
| Ratio with succinylcholine? | 1/60,000 |
| Ratio with volatile anesthetics? | 1/220,000 |
| Where are the cases of MH reported? | North American MH Registry |
| What type of inherited trait is MH? | Autosomal dominant |
| Mortality when 1st described? | 80% |
| Mortality today with early diagnosis & treatment? | 2% |
| What is the treatment for MH? (There are 2 questions like this, different answers) | Dantrolene IV/ Dantrium |
| Mortality is directly related to what? | Time delay in diagnosis and treatment |
| What other medical condition, that Dan mentioned, has similar symptoms? | Hyperthyroidism, thyroid storm |
| What are the 2 groups of triggering agents? | 1. potent inhaled volatile anesthetics 2. depolarizing NMB |
| Which group has a more gradual onset of MH symptoms? | Inhaled agents |
| When the skeletal muscle is depolarized by the MH triggering agent, what happens? | Release of Ca++ from SR, massive increase in intracellular concentration. |
| What attempts to return the Ca++? | ATP-dependent pumps |
| As the body attempts to return the Ca++ to the SR, what occurs? patho? | large consumption of O2, production of CO2, and generation of heat as by-product. |
| How many milligrams of dantrolene are in a vial? | 20mg |
| What is the only diluent that can be used to reconstitute Dantrolene? | Bacteriostatic free sterile water. 60ml |
| What is the dose range for Dantrolene? | 2.5mg/kg up to 10mg/kg. some sources say 20mg |
| What receptor is defective in MH? | Ryanodine receptor |
| How much mannitol is in 1 vial of Dantrolene? | 3 grams or 3000mg |
| What is the pH of Dantrolene when reconstituted? | 9.5 |
| What intracellular contents leak into the blood? | Creatine Kinase, Myoglobin, Potassium, and Ca++ |
| Skeletal muscle constitutes what % of body weight? | 40% |
| Describe the clinical presentation of MH? Described as a cascading cycle of: | hypermetabolism, hypercarbia, hyperthermia, & muscle rigidity. |
| Unexplained increase in ETCO2 and Tachycardia is part of the clinical presentation of MH? | True |
| What occurs in 70% of the cases that are associated with a predisposition to MH? | Masseter muscle rigidity & generalized muscle rigidity. |
| Why do arrhythmias occur? | 2ndary to pH and electrolyte abnormalities |
| If pt is spontaneously breathing, what type of respirations would you see? | Tachypnea |
| What is a normal CK level? | 22-198 units/L |
| What would the CK level be in an MH diagnosis? | >20,000 |
| What is the myoglobinuria from? | Rhabdomyolysis |
| What are the increments of core temperature rise? | >2C per hour >0.5C in 15minutes Severe cases 1C Q5min until 46C is reached |
| Dantrolene is rapid acting T/F? | True |
| Mortality is directly r/t what? It reflects the severity of contracture & muscle ischemia. | Absolute increase in CK levels. |
| What develops in the late stages of MH? | DIC & Renal failure |
| Are MH known/suspected pt's usually the 1st or last case of the day? | 1st |
| How do you clean an anesthesia machine? | change soda lime new circuit flush the machine |
| How much O2 & how long do you flush the anesthesia machine? | 10-15L for 20-30 minutes |
| What do you do with the vaporizers? | remove them |
| What is the 1st thing you do when MH suspected? | turn off the gas |
| 2 types of treatments? | specific- Dantrolene Symptomatic-correct hyperthermia, acidosis & hypercarbia |
| When do you stop treatment with Dantrolene? | When all symptoms dissipate, then run an infusion. |
| What is the rate for a Dantrolene infusion & how long do you run it? | 1-2 mg/kg for 1-3 days |
| What are the arrhythmias treated with? | beta adrenergic blockers, lidocaine or procainamide (3mg/kg up to 15mg/kg IV over 30 min.) |
| How does Dantrolene work? | Blocks the Ryanodine receptor. Stops additional Ca++ from being released. |
| Does Dantrolene rid the cells of the excess Ca++? | NO |
| MH patients will need what invasive lines/tubes? | arterial, CVP, foley,NGT |
| What labs are drawn? | ABGs, Coags, Hemoglobin & Myoglobin, CK, Ca++ & K+ |
| What is given to correct metabolic acidosis? pH <7.1 | Sodium Bicarb 8.4% 2-4ml/kg IV |
| What techniques are used to cool the pt? | Ice packs, ice NSS lavage, cooling blankets, cold IV NSS 15ml/kg Q10minutes x3 |
| When is cooling dc'd? | When core temp falls below 38C |
| What solutions should not be used to cool the pt via IV? | solutions containing K or lactate |
| How do you treat the Hyperkalemia? | Glucose & regular insulin. Drives K back into the cell |
| What is the dose of Glucose & insulin? | glucose 0.5g/kg insulin 0.5 units/kg |
| Diuresis with mannitol or lasix to maintain U/O of what? Why is this done? | >2ml/kg/HR prevent myoglobin precipitation in renal tubules |
| How long is the pt observed for reoccurence? | 24-48 hours |
| Why is the pt susceptible to DIC? | Thromboplastin release in shock, or loss of cell contents from hyperthermia |
| Comatose pt require ICP monitoring to manage cerebral edema. This edema is 2ndary to what? | severe acidosis or hyperthermia |
| What is an AMRA? | Adverse Medical Reaction to Anesthesia |
| Pt's must register with the North American MH registry? | TRUE |
| Dantrolene affects myocardial and smooth muscle cells T/F? | FALSE |
| What is the onset of Dantrolene? | 6 minutes |
| What is the shelf life of Dantrolene? | 2-3 years |
| NAme the gold standard MH test? | CHCT Caffeine Halothane Contracture Test |
| Elimination Half life? | 7-12 hours |
| How many vials of Dantrolene are stocked on MH cart? | 36 vials |
Created by:
MicheleK
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