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Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment: Database Analyses and
Marilyn Green Larach1, Thomas T Klumpner, Barbara W Brandom
1From The North American Malignant Hyperthermia Registry of the Malignant Hyperthermia Association of the United States, University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, Pennsylvania (2000 through 2017; M.G.L., B.W.B.) Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida (2018; M.G.L.) Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan (T.T.K., M.T.V., S.K.) Department of Nurse Anesthesia, University of Pittsburgh, Pittsburgh, Pennsylvania (2016 through 2018; B.W.B.) Department of Anesthesiology, School of Medicine (K.G.B., T.W.K., J.C.) School of Public Health (K.G.B.), University of Minnesota, Minneapolis, Minnesota Department of Anesthesiology, Children's Hospital of Pittsburgh (E.L.S.) Department of Anesthesiology (A.H.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Department of Anesthesiology, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, New York (J.L.) Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Canada (S.R.) Department of Anesthesiology and Pediatrics, Emory University School of Medicine, and Children's Healthcare of Atlanta, Egleston Hospital, Atlanta, Georgia (D.M.). Current positions: Dr. Larach is now at the Department of Anesthesiology, University of Florida, Gainesville, Florida. Dr. Sivak is now at the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio. Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands Beaumont Health, Dearborn, Michigan Beaumont Health, Royal Oak, Michigan Beaumont Health, Farmington Hills, Michigan Beaumont Health, Grosse Pointe, Michigan Bronson Healthcare, Battle Creek, Michigan Bronson Healthcare, Kalamazoo, Michigan CHOC Children's Hospital, Orange, California Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio Department of Anesthesiology, Columbia University Medical Center, New York, New York Henry Ford Health System, Detroit, Michigan Henry Ford Health System, West Bloomfield, Michigan Holland Hospital, Holland, Michigan Mercy Health, Muskegon, Michigan Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Medical Center, New York, New York Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon St. Joseph Mercy, Ann Arbor, Michigan St. Joseph Mercy Oakland, Pontiac, Michigan St. Mary Mercy Hospital, Livonia, Michigan Sparrow Health System, Lansing, Michigan Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands Department of Anesthesiology, University of Colorado, Aurora, Colorado Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania Department of Anesthesiology, University of Tennessee Medical Center, Knoxville, Tennessee Department of Anesthesiology, University of Utah, Salt Lake City, Utah Department of Anesthesiology, University of Vermont, Larner College of Medicine, Burlington, Vermont Department of Anesthesiology, University of Virginia, Charlottesville, Virginia Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Department of Anesthesiology, Weill Cornell Medical College, New York, New York Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut.
Dantrolene is crucial for treating malignant hyperthermia (MH) triggered by succinylcholine, even without volatile anesthetics. Prompt dantrolene availability is vital to reduce MH complications and mortality.
Area of Science:
- Anesthesiology
- Pharmacology
- Critical Care Medicine
Background:
- Dantrolene is the primary treatment for malignant hyperthermia (MH).
- Conflicting guidelines exist regarding dantrolene availability, particularly in ambulatory settings.
- The study addresses the use of succinylcholine and its association with MH events.
Purpose of the Study:
- To investigate succinylcholine use rates, including for airway rescue.
- To determine if succinylcholine alone can trigger MH requiring dantrolene.
- To analyze the relationship between dantrolene administration timing and MH morbidity/mortality.
Main Methods:
- Analysis of large perioperative outcome databases (2005-2016).
- Inclusion of North American MH Registry and Anesthesia Closed Claims Project data.
- Systematic literature review (1987-2017) and expert judgment on MH cases.
Main Results:
- Succinylcholine was used without volatile agents in 3.9% of cases and in 46% of difficult mask ventilation scenarios.
- Succinylcholine alone triggered 24 MH cases, with 13 requiring dantrolene.
- Delayed dantrolene treatment (over 50 minutes) correlated with 100% complication rates and 1-10% mortality.
Conclusions:
- Succinylcholine is frequently used, including for airway management, and can trigger MH.
- Dantrolene must be readily available wherever succinylcholine or volatile anesthetics are administered.
- Timely dantrolene administration is critical for mitigating MH severity and improving patient outcomes.
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