Succinylcholine use and dantrolene availability for malignant hyperthermia treatment: Database analyses and systematic review

Marilyn Green Larach, Thomas T. Klumpner, Barbara W. Brandom, Michelle T. Vaughn, Kumar G. Belani, Andrew Herlich, Tae W. Kim, Janine Limoncelli, Sheila Riazi, Erica L. Sivak, John Capacchione, Darlene Mashman, Sachin Kheterpal, Thomas T. Klumpner, Barbara W. Brandom, Michelle T. Vaughn, Kumar G. Belani, Andrew Herlich, Tae W. Kim, Janine LimoncelliSheila Riazi, Erica L. Sivak, John Capacchione, Darlene Mashman, Sachin Kheterpal, Fabian Kooij, Janet Wilczak, Roy Soto, Joshua Berris, Zachary Price, Steven Lins, Peter Coles, John M. Harris, Kenneth C. Cummings, Mitchell F. Berman, Masakatsu Nanamori, Bruce T. Adelman, Christopher Wedeven, John Lagorio, Patrick J. McCormick, Simon Tom, Michael Aziz, Traci Coffman, Terri A. Ellis, Susan Molina, William Peterson, Sean C. MacKey, Wilton A. Van Klei, Adit A. Ginde, Daniel A. Biggs, Mark D. Neuman, Robert M. Craft, Nathan L. Pace, William C. Paganelli, Marcel E. Durieux, Bala J. Nair, Jonathan P. Wanderer, Scott A. Miller, Daniel L. Helsten, Zachary A. Turnbull, Robert B. Schonberger

Research output: Contribution to journalReview article

3 Citations (Scopus)

Abstract

Editor's Perspective What We Already Know about This Topic Dantrolene effectively treats malignant hyperthermia, but there are discrepant recommendations for dantrolene availability in facilities that stock succinylcholine for airway rescue but do not use volatile anesthetics. What This Article Tells Us That Is New The authors performed an analysis of data from three databases and a systematic literature review. Providers frequently use succinylcholine, including during difficult mask ventilation. Succinylcholine given without volatile anesthetics triggered 24 malignant hyperthermia events, 13 of which were treated with dantrolene. Fourteen patients experienced substantial complications, and one died. Delayed dantrolene treatment worsened patient outcomes. Background: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. Methods: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. Results: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. Conclusions: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

Original languageEnglish (US)
Pages (from-to)41-54
Number of pages14
JournalAnesthesiology
Volume130
Issue number1
DOIs
StatePublished - Jan 1 2019
Externally publishedYes

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Dantrolene
Malignant Hyperthermia
Succinylcholine
Databases
Anesthetics
Masks
Therapeutics
Morbidity
Mortality
Anesthesia

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

Larach, M. G., Klumpner, T. T., Brandom, B. W., Vaughn, M. T., Belani, K. G., Herlich, A., ... Schonberger, R. B. (2019). Succinylcholine use and dantrolene availability for malignant hyperthermia treatment: Database analyses and systematic review. Anesthesiology, 130(1), 41-54. https://doi.org/10.1097/ALN.0000000000002490

Succinylcholine use and dantrolene availability for malignant hyperthermia treatment : Database analyses and systematic review. / Larach, Marilyn Green; Klumpner, Thomas T.; Brandom, Barbara W.; Vaughn, Michelle T.; Belani, Kumar G.; Herlich, Andrew; Kim, Tae W.; Limoncelli, Janine; Riazi, Sheila; Sivak, Erica L.; Capacchione, John; Mashman, Darlene; Kheterpal, Sachin; Klumpner, Thomas T.; Brandom, Barbara W.; Vaughn, Michelle T.; Belani, Kumar G.; Herlich, Andrew; Kim, Tae W.; Limoncelli, Janine; Riazi, Sheila; Sivak, Erica L.; Capacchione, John; Mashman, Darlene; Kheterpal, Sachin; Kooij, Fabian; Wilczak, Janet; Soto, Roy; Berris, Joshua; Price, Zachary; Lins, Steven; Coles, Peter; Harris, John M.; Cummings, Kenneth C.; Berman, Mitchell F.; Nanamori, Masakatsu; Adelman, Bruce T.; Wedeven, Christopher; Lagorio, John; McCormick, Patrick J.; Tom, Simon; Aziz, Michael; Coffman, Traci; Ellis, Terri A.; Molina, Susan; Peterson, William; MacKey, Sean C.; Van Klei, Wilton A.; Ginde, Adit A.; Biggs, Daniel A.; Neuman, Mark D.; Craft, Robert M.; Pace, Nathan L.; Paganelli, William C.; Durieux, Marcel E.; Nair, Bala J.; Wanderer, Jonathan P.; Miller, Scott A.; Helsten, Daniel L.; Turnbull, Zachary A.; Schonberger, Robert B.

In: Anesthesiology, Vol. 130, No. 1, 01.01.2019, p. 41-54.

Research output: Contribution to journalReview article

Larach, MG, Klumpner, TT, Brandom, BW, Vaughn, MT, Belani, KG, Herlich, A, Kim, TW, Limoncelli, J, Riazi, S, Sivak, EL, Capacchione, J, Mashman, D, Kheterpal, S, Klumpner, TT, Brandom, BW, Vaughn, MT, Belani, KG, Herlich, A, Kim, TW, Limoncelli, J, Riazi, S, Sivak, EL, Capacchione, J, Mashman, D, Kheterpal, S, Kooij, F, Wilczak, J, Soto, R, Berris, J, Price, Z, Lins, S, Coles, P, Harris, JM, Cummings, KC, Berman, MF, Nanamori, M, Adelman, BT, Wedeven, C, Lagorio, J, McCormick, PJ, Tom, S, Aziz, M, Coffman, T, Ellis, TA, Molina, S, Peterson, W, MacKey, SC, Van Klei, WA, Ginde, AA, Biggs, DA, Neuman, MD, Craft, RM, Pace, NL, Paganelli, WC, Durieux, ME, Nair, BJ, Wanderer, JP, Miller, SA, Helsten, DL, Turnbull, ZA & Schonberger, RB 2019, 'Succinylcholine use and dantrolene availability for malignant hyperthermia treatment: Database analyses and systematic review', Anesthesiology, vol. 130, no. 1, pp. 41-54. https://doi.org/10.1097/ALN.0000000000002490
Larach, Marilyn Green ; Klumpner, Thomas T. ; Brandom, Barbara W. ; Vaughn, Michelle T. ; Belani, Kumar G. ; Herlich, Andrew ; Kim, Tae W. ; Limoncelli, Janine ; Riazi, Sheila ; Sivak, Erica L. ; Capacchione, John ; Mashman, Darlene ; Kheterpal, Sachin ; Klumpner, Thomas T. ; Brandom, Barbara W. ; Vaughn, Michelle T. ; Belani, Kumar G. ; Herlich, Andrew ; Kim, Tae W. ; Limoncelli, Janine ; Riazi, Sheila ; Sivak, Erica L. ; Capacchione, John ; Mashman, Darlene ; Kheterpal, Sachin ; Kooij, Fabian ; Wilczak, Janet ; Soto, Roy ; Berris, Joshua ; Price, Zachary ; Lins, Steven ; Coles, Peter ; Harris, John M. ; Cummings, Kenneth C. ; Berman, Mitchell F. ; Nanamori, Masakatsu ; Adelman, Bruce T. ; Wedeven, Christopher ; Lagorio, John ; McCormick, Patrick J. ; Tom, Simon ; Aziz, Michael ; Coffman, Traci ; Ellis, Terri A. ; Molina, Susan ; Peterson, William ; MacKey, Sean C. ; Van Klei, Wilton A. ; Ginde, Adit A. ; Biggs, Daniel A. ; Neuman, Mark D. ; Craft, Robert M. ; Pace, Nathan L. ; Paganelli, William C. ; Durieux, Marcel E. ; Nair, Bala J. ; Wanderer, Jonathan P. ; Miller, Scott A. ; Helsten, Daniel L. ; Turnbull, Zachary A. ; Schonberger, Robert B. / Succinylcholine use and dantrolene availability for malignant hyperthermia treatment : Database analyses and systematic review. In: Anesthesiology. 2019 ; Vol. 130, No. 1. pp. 41-54.
@article{070ad35cca04427785752899f6a2ec26,
title = "Succinylcholine use and dantrolene availability for malignant hyperthermia treatment: Database analyses and systematic review",
abstract = "Editor's Perspective What We Already Know about This Topic Dantrolene effectively treats malignant hyperthermia, but there are discrepant recommendations for dantrolene availability in facilities that stock succinylcholine for airway rescue but do not use volatile anesthetics. What This Article Tells Us That Is New The authors performed an analysis of data from three databases and a systematic literature review. Providers frequently use succinylcholine, including during difficult mask ventilation. Succinylcholine given without volatile anesthetics triggered 24 malignant hyperthermia events, 13 of which were treated with dantrolene. Fourteen patients experienced substantial complications, and one died. Delayed dantrolene treatment worsened patient outcomes. Background: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. Methods: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. Results: Among 6,368,356 queried outcomes cases, 246,904 (3.9{\%}) received succinylcholine without volatile agents. Succinylcholine was used in 46{\%} (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37{\%}. Treatment delay increased complications every 10 min, reaching 100{\%} with a 50-min delay. Overall mortality was 1 to 10{\%}; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. Conclusions: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.",
author = "Larach, {Marilyn Green} and Klumpner, {Thomas T.} and Brandom, {Barbara W.} and Vaughn, {Michelle T.} and Belani, {Kumar G.} and Andrew Herlich and Kim, {Tae W.} and Janine Limoncelli and Sheila Riazi and Sivak, {Erica L.} and John Capacchione and Darlene Mashman and Sachin Kheterpal and Klumpner, {Thomas T.} and Brandom, {Barbara W.} and Vaughn, {Michelle T.} and Belani, {Kumar G.} and Andrew Herlich and Kim, {Tae W.} and Janine Limoncelli and Sheila Riazi and Sivak, {Erica L.} and John Capacchione and Darlene Mashman and Sachin Kheterpal and Fabian Kooij and Janet Wilczak and Roy Soto and Joshua Berris and Zachary Price and Steven Lins and Peter Coles and Harris, {John M.} and Cummings, {Kenneth C.} and Berman, {Mitchell F.} and Masakatsu Nanamori and Adelman, {Bruce T.} and Christopher Wedeven and John Lagorio and McCormick, {Patrick J.} and Simon Tom and Michael Aziz and Traci Coffman and Ellis, {Terri A.} and Susan Molina and William Peterson and MacKey, {Sean C.} and {Van Klei}, {Wilton A.} and Ginde, {Adit A.} and Biggs, {Daniel A.} and Neuman, {Mark D.} and Craft, {Robert M.} and Pace, {Nathan L.} and Paganelli, {William C.} and Durieux, {Marcel E.} and Nair, {Bala J.} and Wanderer, {Jonathan P.} and Miller, {Scott A.} and Helsten, {Daniel L.} and Turnbull, {Zachary A.} and Schonberger, {Robert B.}",
year = "2019",
month = "1",
day = "1",
doi = "10.1097/ALN.0000000000002490",
language = "English (US)",
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pages = "41--54",
journal = "Anesthesiology",
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TY - JOUR

T1 - Succinylcholine use and dantrolene availability for malignant hyperthermia treatment

T2 - Database analyses and systematic review

AU - Larach, Marilyn Green

AU - Klumpner, Thomas T.

AU - Brandom, Barbara W.

AU - Vaughn, Michelle T.

AU - Belani, Kumar G.

AU - Herlich, Andrew

AU - Kim, Tae W.

AU - Limoncelli, Janine

AU - Riazi, Sheila

AU - Sivak, Erica L.

AU - Capacchione, John

AU - Mashman, Darlene

AU - Kheterpal, Sachin

AU - Klumpner, Thomas T.

AU - Brandom, Barbara W.

AU - Vaughn, Michelle T.

AU - Belani, Kumar G.

AU - Herlich, Andrew

AU - Kim, Tae W.

AU - Limoncelli, Janine

AU - Riazi, Sheila

AU - Sivak, Erica L.

AU - Capacchione, John

AU - Mashman, Darlene

AU - Kheterpal, Sachin

AU - Kooij, Fabian

AU - Wilczak, Janet

AU - Soto, Roy

AU - Berris, Joshua

AU - Price, Zachary

AU - Lins, Steven

AU - Coles, Peter

AU - Harris, John M.

AU - Cummings, Kenneth C.

AU - Berman, Mitchell F.

AU - Nanamori, Masakatsu

AU - Adelman, Bruce T.

AU - Wedeven, Christopher

AU - Lagorio, John

AU - McCormick, Patrick J.

AU - Tom, Simon

AU - Aziz, Michael

AU - Coffman, Traci

AU - Ellis, Terri A.

AU - Molina, Susan

AU - Peterson, William

AU - MacKey, Sean C.

AU - Van Klei, Wilton A.

AU - Ginde, Adit A.

AU - Biggs, Daniel A.

AU - Neuman, Mark D.

AU - Craft, Robert M.

AU - Pace, Nathan L.

AU - Paganelli, William C.

AU - Durieux, Marcel E.

AU - Nair, Bala J.

AU - Wanderer, Jonathan P.

AU - Miller, Scott A.

AU - Helsten, Daniel L.

AU - Turnbull, Zachary A.

AU - Schonberger, Robert B.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Editor's Perspective What We Already Know about This Topic Dantrolene effectively treats malignant hyperthermia, but there are discrepant recommendations for dantrolene availability in facilities that stock succinylcholine for airway rescue but do not use volatile anesthetics. What This Article Tells Us That Is New The authors performed an analysis of data from three databases and a systematic literature review. Providers frequently use succinylcholine, including during difficult mask ventilation. Succinylcholine given without volatile anesthetics triggered 24 malignant hyperthermia events, 13 of which were treated with dantrolene. Fourteen patients experienced substantial complications, and one died. Delayed dantrolene treatment worsened patient outcomes. Background: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. Methods: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. Results: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. Conclusions: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

AB - Editor's Perspective What We Already Know about This Topic Dantrolene effectively treats malignant hyperthermia, but there are discrepant recommendations for dantrolene availability in facilities that stock succinylcholine for airway rescue but do not use volatile anesthetics. What This Article Tells Us That Is New The authors performed an analysis of data from three databases and a systematic literature review. Providers frequently use succinylcholine, including during difficult mask ventilation. Succinylcholine given without volatile anesthetics triggered 24 malignant hyperthermia events, 13 of which were treated with dantrolene. Fourteen patients experienced substantial complications, and one died. Delayed dantrolene treatment worsened patient outcomes. Background: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality. Methods: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given. Results: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities. Conclusions: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

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JO - Anesthesiology

JF - Anesthesiology

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