Is your staff prepared for MH? It's probably the key to saving lives
Cause of death confirmed in FL case, draws attention to ASCs
The cause of death in the case of a Florida teen having breast surgery has been confirmed as malignant hyperthermia (MH),1 and the eyes of the nation have turned to outpatient surgery providers and their preparation to handle an MH episode.
In the recently released autopsy report, the Palm Beach County Medical Examiner's Office said Stephanie Kuleba, 18, died earlier this year of MH after she had an "idiosyncratic reaction to anesthesia."1 She was having surgery to correct an inverted nipple and asymmetrical breasts. The surgeon and anesthesiologist are being accused by the family's attorney of not responding appropriately.2
The family has created an online memorial web site (www.stephaniejudekuleba.org), which says, "We believe that something positive must come from the loss of Stephanie's life. Through our terrible experience, our family is determined to create awareness about MH as well as educate people surrounding choices regarding anesthetics and surgical settings. Much will be told regarding the voids and inadequacies of the current system regarding certain ambulatory surgical centers (ASC), and how physicians' decisions regarding profit are compromising patient safety."
That issue is receiving attention at the state level. In Arizona, the state medical board said earlier this year that physicians in office-based surgery centers no longer can use any drug that could trigger MH.3 (See list of drugs that could trigger MH from a national association, below.)
Potential Malignant
Hyperthermia Triggering Agents
Source: Malignant Hyperthermia Association of the United States, Sherburne, NY. |
For Debra Merritt, CRNA, MSN, the liaison from the American Association of Nurse Anesthetists to the Malignant Hyperthermia Association of the United States (MHAUS), the issue of preparing for MH is personal. Her husband, who is "MH-positive," had a reaction under anesthesia in 1984 but survived because his providers quickly diagnosed and treated it, she says.
Today, Merritt touts the importance of being prepared for such episodes. "With anesthesia being provided in so many locations, being prepared is probably the key to saving someone's life," she says. When a provider says, "This is an MH case," your team members needs to know how to respond immediately because they've already participated in MH drills, she says. "It's not going to take just one or two people," Merritt points out.
At Ponte Vedra (FL) Plastic Surgery, expired dantrolene is used for walk-through drills so nurses have the opportunity to experience mixing up the medication, says Kelly Wilson, RN, surgery center administrator. Even the anesthesiologists have practiced mixing up the drug, she says. "Mixing is peace of mind, because it gets your hands on it and you know what it's like." To draw medication from a large vial takes a significant amount of work because it is so constituted, Wilson adds.
MHAUS officials point out that expired dantrolene should be clearly marked, used for training purposes that doesn't include dosing to humans, and should be destroyed after the drills.
Consider these additional steps:
- Have dantrolene on hand.
A recently published article in the The Wall Street Journal (WSJ) says that as many as 1 in 3,000 might be genetically predisposed to MH under inhaled anesthesia.3
Dantrolene is the drug used to treat MH. Although dantrolene traditionally cost up to $5,000, you might be able to obtain a generic form, approved late last summer, for about $2,500, sources say. Jeffrey Jacobs, MD, an anesthesiologist at Cleveland Clinic in Weston, FL, says, "That's a small amount to pay, considering what you pay in equipment and insurance, and considering your profit margin." Also, you must consider the value of a patient's life, he adds.
Jacobs has heard of centers and offices that share doses of dantrolene. However, providers should consider what's right for the patient, he says. "All it takes is one crisis, and not being prepared, to cause a catastrophe," Jacobs says. Having dantrolene available is part of the cost of doing business, he maintains. "It's just like the electric bills and plumbing," he says. "It needs to be there."
The Ponte Vedra center has a shelf designated for MH supplies, Wilson says. In addition to the dantrolene, that shelf includes an extra Foley catheter and an extra nasogatric tube, she says.
- Educate your staff.
Don't assume that your staff, even those who came from the emergency department, have been educated about MH, Wilson says.
Ponte Vedra includes MH education as part of new employee training, she says. Additionally, Wilson has included information about MH in the staff's monthly newsletter, which goes to everyone, including the receptionist. That staff member is likely to receive questions from patients about the center's MH preparation, due to the publicity of the Kuleba case, she says.
"It seems incomprehensible that a health young teen can go in for surgery and not come out, and it can happen anywhere," Wilson warns. Patients such as Kuleba are American Society of Anesthesiologists (ASA) Class 1 patients, she points out. "You don't see it coming, so you need to be prepared," Wilson says.
References
- Sarmiento G. Autopsy confirms Boca Raton cheerleader died of rare genetic ailment. The Palm Beach Post; May 30, 2008. Accessed at www.palmbeachpost.com/localnews.
- DeNardo C. West Boca High cheerleader got fraction of drug needed, lawyer charges. The Palm Beach Post; April 1, 2008. Accessed at www.palmbeachpost.com/search.
- Landro L. A fresh focus on a rare risk of anesthesia. The Wall Street Journal; April 30, 2008:D1. Accessed at online.wsj.com/public.
Resources
- The Malignant Hyperthermia Association of the United States (MHAUS) has the following resources:
— Ambulatory Surgery Center MH Procedure Manual. MHAUS says this resource could cut your response time by 50%. The cost is $265 including shipping and handling. Go to www.mhaus.org and click on "place order." Under "browse by category," click on "MH Procedure Manuals with Video."
— A free poster describing how to perform emergency therapy to treat MH is available at medical.mhaus.org.
— The MH Emergency Hotline is (800) MH HYPER [(800) 644-9737] in the United States and Canada. Outside those areas, call 001-1-315-464-7079.
— At press time, MHAUS was in the final stages of a report regarding the needs of surgery centers regarding MH and transfer of care. The organization plans to develop the report into an educational format by fall 2008.
The Ambulatory Surgery Center Association has an article on malignant hyperthermia posted at ascassociation.org/hyperthermiaarticle.pdf. The cause of death in the case of a Florida teen having breast surgery has been confirmed as malignant hyperthermia (MH),1 and the eyes of the nation have turned to outpatient surgery providers and their preparation to handle an MH episode.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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