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Guideline Summary
Guideline Title
Evidence-based patient safety advisory: malignant hyperthermia.
Bibliographic Source(s)
Gurunluoglu R, Swanson JA, Haeck PC, ASPS Patient Safety Committee. Evidence-based patient safety advisory: malignant hyperthermia. Plast Reconstr Surg. 2009 Oct;124(4 Suppl):68S-81S. [80 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Malignant hyperthermia

Guideline Category
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Anesthesiology
Plastic Surgery
Surgery
Intended Users
Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To review the current concepts pertinent to malignant hyperthermia in the outpatient setting, with particular emphasis on presurgical evaluation, identification of susceptible individuals and selection of the appropriate setting for these patients, appropriate anesthetic agents for susceptible patients, early diagnosis and management of acute malignant hyperthermia, and postoperative vigilance and care

Target Population

Patients at risk for malignant hyperthermia who are undergoing plastic or reconstructive surgery in the outpatient setting

Interventions and Practices Considered

Risk Assessment/Evaluation

  1. Patient assessment
    • Personal and family history of malignant hyperthermia (MH)
    • Personal and family history of adverse anesthesia reactions (unexplained fever or death during anesthesia)
  2. Diagnostic testing
    • Caffeine-halothane contracture test (CHCT)
    • In vitro contracture test is the standard
    • Genetic testing for mutations in the RYR1 gene

Treatment/Management

  1. Preoperative management
    • Refraining from use of MH-triggering anesthetics and muscle relaxants
    • Equipping surgical suite with drugs and supplies to manage MH
    • Establishing protocol for treating MH
  2. Anesthesia administration
    • Local or regional anesthesia
    • Monitored anesthesia care
    • General anesthesia using alternative regimens
    • Body temperature and capnographic monitoring
  3. Intraoperative management
    • Monitoring for clinical signs of MH
    • Protocol for emergency assistance (dantrolene, 100% oxygen, cooling patient, electrolyte testing)
    • Transfer of patient to an acute care facility when needed
Major Outcomes Considered
  • Sensitivity and specificity of diagnostic tests for malignant hyperthermia
  • Morbidity and mortality associated with malignant hyperthermia

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

PubMed and the Cochrane Library were searched. The search terms used were: malignant hyperthermia, surgery, genetics, genes, anesthesia, patient selection, preoperative assessment, physical examination, medical history, risk factors, diagnosis, management, dantrolene. No limits were set on publication dates in the searches. The searches included all types of published articles. However, articles that were critically appraised and rated for level of evidence were limited to systematic reviews, meta-analyses, randomized controlled trials (RCTs), clinical trials, comparative studies, case series and case reports.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Evidence Rating Scale for Studies Reviewed

Level of Evidence Qualifying Studies
I High-quality, multi-centered or single-centered, randomized controlled trial with adequate power; or a systematic review of these studies
II Lesser-quality, randomized controlled trial; prospective cohort study; or a systematic review of these studies
III Retrospective comparative study; case-control study; or a systematic review of these studies
IV Case series
V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or "first principles"
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

The supporting literature was critically appraised for study quality according to criteria referenced in key publications on evidence-based medicine. Depending on study design and quality, each reference was assigned a corresponding level of evidence (I through V) with the American Society of Plastic Surgeons (ASPS) Evidence Rating Scales and the evidence was synthesized into practice recommendations. (see "Rating Scheme for the Strength of the Evidence").

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations
Grade Descriptor Qualifying Evidence Implications for Practice
A Strong Recommendation Level I evidence or consistent findings from multiple studies of levels II, III, or IV Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
B Recommendation Levels II, III, or IV evidence and findings are generally consistent Generally, clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preference.
C Option Levels II, III, or IV evidence, but findings are inconsistent Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role.
D Option Level V; little or no systematic empirical evidence Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role.
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

The guideline was approved by the American Society of Plastic Surgeons Executive Committee on January 10, 2009.

Recommendations

Major Recommendations

Definitions for the levels of evidence (I–V) and grades of the recommendations (A–D) are provided at the end of the "Major Recommendations" field.

Recommendations Supporting Evidence Grade
Patient Selection

During patient assessment, patients should be asked about personal and family history of:

  • Malignant hyperthermia (MH)
  • Adverse anesthesia reactions (unexplained fever or death during anesthesia)

Malignant Hyperthermia Association of the United States, "The ABC's of managing," 2008; Malignant Hyperthermia Association of the United States, "Emergency therapy," 2008; Larach et al., 1994

D

Patients with suspected MH should be referred for appropriate diagnostic testing:

Ording et al., 1997; Allen, Larach, & Kunselman, 1998

B
  • Caffeine-halothane contracture test (CHCT) or in vitro contracture test is the standard.
  B
  • Genetic testing for mutations in the RYR1 gene may be considered; however, it typically cannot replace contracture tests, as it has low sensitivity. Results do not always correlate with a positive contracture test, which suggests that there may be other loci involved with MH.

Ibarra et al., 2006; Sambuughin et al., 2001; Anderson et al., 2008

Patients susceptible to MH may undergo outpatient surgery, provided that nontriggering anesthetics are used. All office surgical suites should be equipped to manage an MH emergency. However, anyone identified with MH susceptibility should be referred to an accredited ambulatory surgical center or hospital for surgery.

Malignant Hyperthermia Association of the United States, "The ABC's of managing," 2008; Malignant Hyperthermia Association of the United States, "Emergency therapy," 2008

D
Preoperative Management

In patients susceptible to MH, do not use the following MH-triggering drugs:

Inhaled general anesthetics:

  • Desflurane
  • Enflurane
  • Halothane
  • Isoflurane
  • Sevoflurane

Depolarizing muscle relaxants:

  • Succinylcholine

Britt et al., 1980; Reed & Strobel, 1978; Flewellen & Nelson, 1982; Snoeck et al., 2000; Gallant, Godt, & Gronert, 1980; Louis et al., 1992

B

The surgical suite should be equipped to manage malignant hyperthermia.

Drugs and supplies should include:

  • Dantrolene sodium IV (36 vials)
  • Sterile water for dantrolene reconstitution
  • Sodium bicarbonate
  • Furosemide
  • Dextrose
  • Calcium chloride
  • Regular insulin (refrigerated)
  • Antiarrhythmics
  • A protocol for treating MH crisis. For additional information on how to treat a malignant hyperthermia crisis, consult the Malignant Hyperthermia Association of the United States (MHAUS) documents, Emergency Therapy for Malignant Hyperthermia or The ABC's of MH Management, both found on the MHAUS Web site: http://medical.mhaus.org/ External Web Site Policy.

Malignant Hyperthermia Association of the United States, "The ABC's of managing," 2008; Malignant Hyperthermia Association of the United States, "Emergency therapy," 2008

D
Anesthesia

Local or regional anesthesia and monitored anesthesia care are considered to be safe for individuals susceptible to MH; this includes spinal, epidural, and nerve block anesthesia using local anesthetics (e.g., lidocaine, bupivacaine).

Malignant Hyperthermia Association of the United States, "The ABC's of managing," 2008; Malignant Hyperthermia Association of the United States, "Emergency therapy," 2008

D

General anesthesia can be performed with alternative anesthetic regimens, including barbiturates (e.g., thiopental), propofol, nondepolarizing paralytic agents (e.g., vecuronium) and their reversal agents, nitrous oxide, and opioids (e.g., fentanyl) (anesthesia machine preparation: change circuits, disable or remove the vaporizers, flush the machine at a rate of 10 liters/min for 20 min).

Malignant Hyperthermia Association of the United States, "The ABC's of managing," 2008; Malignant Hyperthermia Association of the United States, "Emergency therapy," 2008

D

If general anesthesia will be used, patients should undergo body temperature and capnographic monitoring.

Malignant Hyperthermia Association of the United States, "The ABC's of managing," 2008; Malignant Hyperthermia Association of the United States, "Emergency therapy," 2008

D
Intraoperative Management

Monitor for clinical signs of MH:

  • Signs of respiratory acidosis: end tidal carbon dioxide (ETCO2) >55 mmHg, partial pressure of carbon dioxide (PaCO2) >60 mmHg (with appropriately controlled ventilation); ETCO2 >60 mmHg, PaCO2 >65 mmHg (with spontaneous ventilation); inappropriate hypercarbia and/or tachypnea
  • Trunk or total body rigidity
  • Masseter muscle spasm or trismus
  • Sinus tachycardia; ventricular tachycardia; ventricular fibrillation
  • Rapidly increasing temperature, or inappropriately increased temperature (>38.8°C); may be a late sign
  • Signs of muscle breakdown: elevated serum creatine kinase after anesthetics that included succinylcholine (>20,000 International Units [IU]) or anesthetics without succinylcholine (>10,000 IU); cola-colored urine; excess myoglobin in urine (>60 µg/liter) and serum (>170 µg/liter); blood/plasma/serum K+ >6 mEq/liter (in absence of renal failure)
  • Other: arterial base excess <–8 mEq/liter; arterial pH <7.25; rapid reversal of MH signs of respiratory and/or metabolic acidosis with intravenous (IV) administration of dantrolene

Malignant Hyperthermia Association of the United States, "The ABC's of managing," 2008; Malignant Hyperthermia Association of the United States, "Emergency therapy," 2008; Larach et al., 1994

D

Treatment of MH Crisis

  • Call for help; summon emergency medical service.
  • Patient should be transferred to an acute care facility as soon as possible.
   
  • Administer dantrolene.

Kolb, Horne, & Martz,1982; Nelson & Flewellen, 1979

B
  • Hyperventilate with 100% oxygen.

Malignant Hyperthermia Association of the United States, "The ABC's of managing," 2008; Malignant Hyperthermia Association of the United States, "Emergency therapy," 2008

D
  • Cool the patient.
  • Check electrolytes, especially potassium.
  • For specific treatment recommendations, consult the MHAUS documents, Emergency Therapy for Malignant Hyperthermia or The ABC's of MH Management, both found on the MHAUS web site: http://medical.mhaus.org/ External Web Site Policy.
   

Definitions:

Evidence Rating Scale for Studies Reviewed

Level of Evidence Qualifying Studies
I High-quality, multi-centered or single-centered, randomized controlled trial with adequate power; or a systematic review of these studies
II Lesser-quality, randomized controlled trial; prospective cohort study; or a systematic review of these studies
III Retrospective comparative study; case-control study; or a systematic review of these studies
IV Case series
V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or "first principles"

Scale for Grading Recommendations

Grade Descriptor Qualifying Evidence Implications for Practice
A Strong Recommendation Level I evidence or consistent findings from multiple studies of levels II, III, or IV Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
B Recommendation Levels II, III, or IV evidence and findings are generally consistent Generally, clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preference.
C Option Levels II, III, or IV evidence, but findings are inconsistent Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role.
D Option Level V; little or no systematic empirical evidence Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role.
Clinical Algorithm(s)

Clinical algorithms are provided in the original guideline document for:

  • The surgeon to work up a patient with a family history of malignant hyperthermia
  • The management of masseter muscle spasm associated with or without generalized muscle rigidity in an anesthetized patient

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate treatment and management of malignant hyperthermia

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • Practice advisories are strategies for patient management, developed to assist physicians in clinical decision-making. This practice advisory, based on a thorough evaluation of the present scientific literature and relevant clinical experience, describes a range of generally acceptable approaches to diagnosis, management, or prevention of specific diseases or conditions. This practice advisory attempts to define principles of practice that should generally meet the needs of most patients in most circumstances. However, this practice advisory should not be construed as a rule, nor should it be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the appropriate results. It is anticipated that it will be necessary to approach some patients' needs in different ways. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of all the circumstances presented by the patient, the diagnostic and treatment options available, and available resources.
  • This practice advisory is not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all the facts or circumstances involved in an individual case and are subject to change as scientific knowledge and technology advance, and as practice patterns evolve. This practice advisory reflects the state of knowledge current at the time of publication. Given the inevitable changes in the state of scientific information and technology, periodic review and revision will be necessary.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Gurunluoglu R, Swanson JA, Haeck PC, ASPS Patient Safety Committee. Evidence-based patient safety advisory: malignant hyperthermia. Plast Reconstr Surg. 2009 Oct;124(4 Suppl):68S-81S. [80 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Oct
Guideline Developer(s)
American Society of Plastic Surgeons - Medical Specialty Society
Source(s) of Funding

American Society of Plastic Surgeons

Guideline Committee

American Society of Plastic Surgeons Patient Safety Committee

Composition of Group That Authored the Guideline

Committee Members: Phillip C. Haeck, M.D. (Chairman); Stephen B. Baker, M.D., D.D.S., Georgetown University Hospital, Washington, D.C.; Charles W. Bailey, Jr., M.D., J.D., Austin, Texas; C. Bob Basu, M.D., M.P.H., Center for Advanced Breast Restoration and Basu Plastic Surgery, Houston, Texas; Lynn A. Damitz, M.D., University of North Carolina, Chapel Hill, North Carolina; Felmont F. Eaves, III, M.D., Charlotte Plastic Surgery, Charlotte, North Carolina; Paul D. Faringer, M.D., Kaiser Permanente, Honolulu, Hawaii; Scot Bradley Glasberg, M.D., Lenox Hill Hospital and Manhattan Eye Ear and Throat Hospital, New York, New York; Lawrence S. Glassman, M.D., Nyack Hospital, Nyack, New York; Karol A. Gutowski, M.D., North Shore University Health System and University of Chicago, Evanston, Illinois; Elizabeth J. Hall-Findlay, M.D., private practice, Banff, Alberta, Canada; Ronald E. Iverson, M.D., Stanford University Medical School, Palo Alto, California; Linda J. Leffel, M.D., Bend, Oregon; Dennis J. Lynch, M.D., retired, Scott and White Healthcare, Texas A&M University, Temple, Texas; Noel B. McDevitt, M.D., Pinehurst Surgical, Pinehurst, North Carolina; Michael F. McGuire, M.D., David Geffen UCLA School of Medicine, Los Angeles, California; Patrick J. O'Neill, M.D., Medical University of South Carolina, Charleston, South Carolina; Neal R. Reisman, M.D., J.D., St. Luke's Episcopal Hospital and Baylor College of Medicine, Houston, Texas; Gary F. Rogers, M.D., Children's Hospital Boston, Boston, Massachusetts; Loren S. Schechter, M.D., Morton Grove, Illinois; Maria Siemionow, M.D., Ph.D., D.Sc., Cleveland Clinic, Cleveland, Ohio; Robert Singer, M.D., University of California, San Diego, La Jolla, California; Gary A. Smotrich, M.D., Lawrenceville Plastic Surgery, Lawrenceville, New Jersey; Rebecca S. Twersky, M.D., M.P.H., SUNY Downstate Medical Center, Brooklyn, New York; Amy G. Wandel, M.D., Mercy Medical Group, Sacramento, California; Ronald H. Wender, M.D., Cedars-Sinai Medical Center, Los Angeles, California; and James A. Yates, M.D., Grandview Surgery Center, Vista Surgery Center, Plastic Surgery Center, and Holy Spirit Hospital, Camp Hill, Pennsylvania

Financial Disclosures/Conflicts of Interest

The authors have no commercial associations that might pose or create a conflict of interest with the information presented in this article.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American Society of Plastic Surgeons Web site External Web Site Policy.

Print copies: Available from the American Society of Plastic Surgeons, 444 East Algonquin Road, Arlington Heights, IL 6005-4664

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on June 9, 2010. The information was verified by the guideline developer on August 31, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Copyright ©2009 by the American Society of Plastic Surgeons

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