Page 63 - TNFlipTest

Toronto Notes 2019 Uncommon Complications
Prevention
• suspectMHinpatientswithafamilyhistoryofproblems/deathwithanesthetic
• avoidalltriggermedications,usevapourfreeequipment,useregionalanesthesiaifpossible • central body temp and ETCO2 monitoring
Malignant Hyperthermia Management
(Based on Malignant Hyperthermia Association of the U.S. [MHAUS] Guidelines, 2008)
1. notify surgeon, discontinue volatile agents and succinylcholine, hyperventilate with 100% oxygen at
flows of 10 L/min or more, halt the procedure as soon as possible
2. dantrolene 2.5 mg/kg IV, through large-bore IV if possible
■ repeat until there is control of signs of MH; up to 30 mg/kg as necessary
3. bicarbonate 1-2 mEq/kg if blood gas values are not available for metabolic acidosis
4. cool patients with core temperature >39oC
■ lavage open body cavities, stomach, bladder, rectum; apply ice to surface; infuse cold saline IV
■ stop cooling if temperature is <38oC to prevent drift to <36oC
5. dysrhythmias usually respond to treatment of acidosis and hyperkalemia
■ use standard drug therapy except Ca2+ channel blockers as they may cause hyperkalemia and cardiac arrest in presence of dantrolene
6. hyperkalemia
■ treat with hyperventilation, bicarbonate, glucose/insulin, calcium
■ bicarbonate 1-2 mEq/kg IV, calcium chloride 10 mg/kg or calcium gluconate 10-50 mg/kg for life-
threatening hyperkalemia and check glucose levels hourly
7. follow ETCO2, electrolytes, blood gases, creatine kinase (CK), core temperature, urine output/colour
with Foley catheter, coagulation studies
■ if CK and/or potassium rises persistently or urine output falls to <0.5 mL/kg/h, induce diuresis to >1
mL/kg/h urine to avoid myoglobinuric renal failure
8. maintain anesthesia with benzodiazepines, opioids, and propofol
9. transfer to ICU bed
Abnormal Pseudocholinesterase
• pseudocholinesterasehydrolyzesSChandmivacurium
• individualswithabnormalpseudocholinesterasewillhaveprolongedmuscularblockade
• SChandmivacuriumarecontraindicatedinthosewithabnormalpseudocholinesterase
• ifSChormivacuriumaregivenaccidentally,treatwithmechanicalventilationuntilfunctionreturns
to normal (do not use cholinesterase inhibitors rebound neuromuscular blockade once drug effect is terminated)
Anesthesia A29
Basic Principles of MH Management
“Some Hot Dude Better Get Iced Fluids Fast” Stop all triggering agents, give 100% O2 Hyperventilate
Dantrolene 2.5 mg/kg every 5 min Bicarbonate
Glucose and insulin
IV fluids; cool patient to 38oC
Fluid output; consider furosemide Tachycardia: be prepared to treat VT