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May 5, 2009 To Members of
the NJSSA: Click to view: What's Happening in Washington Now
Are You Prepared for Malignant Hyperthermia? Henry Rosenberg, MD The recent publicity concerning the death of a young patient from what appears to be malignant hyperthermia in a Florida outpatient surgery facility reminds us that this syndrome can appear suddenly and explosively whenever general anesthesia is administered and that deaths still occur from MH. In this case, the MH episode began during cosmetic surgery in an office based operating room. Even though MH was recognized after it had begun some time during the procedure and some amount of dantrolene was administered, by the time the patient was moved to the nearby emergency room, her body temperature was elevated to such an extent that DIC and death was inevitable. Over the next several weeks and months more details will emerge as to the sequence of events that transpired and what specific lessons may be learned from this tragedy. At Dr. Moss’ request, I will outline some of my recommendations concerning preparedness for managing a case of MH in any environment. However, before I do that I would like to point out that almost exactly one year ago a young woman expired under almost exactly the same circumstances in the Los Angeles area. Not to be an alarmist, we do hear regularly of patients who develop MH in the ambulatory or hospital setting who are treated and survive. According to the latest article on the risk of death from MH just published in this month’s issue of Anesthesiology based on data accumulated in the North American MH Registry of the MHAUS, the mortality from an MH is in the range of 2%. (Cardiac Arrests and Deaths Associated with Malignant Hyperthermia in North America from 1987 to 2006: A Report from The North American Malignant Hyperthermia Registry of the Malignant Hyperthermia Association of the United States. Marilyn Green Larach, M.D., F.A.A.P.; Barbara W. Brandom, M.D.; Gregory C. Allen, M.D., F.R.C.P.C.; Gerald A. Gronert, M.D.; Erik B. Lehman, M.S. Anesthesiology 108;603-611,2008). So while MH does not happen often and prompt recognition and treatment is the key to a successful outcome, nevertheless mortality from MH still does occur. Furthermore many of the patients who have a bad outcome are usually healthy young adults. This problem is far from solved.
If you are in a non hospital settings, there are some special issues: Make sure that the hospital where the patient will be transferred knows about MH, that the ED physicians have dantrolene available or at least know the basics of treating the disorder. Although it is tempting to move the patient as rapidly as possible to the hospital setting, the 20 or more minutes that that will take under the best of circumstances may lead to the MH event spiraling out of control. It is very difficult to be definitive on this issue e, but in my opinion, the patient should be stabilized, i.e. the ETC02 near normal, temperature at or below perhaps 101 F, tachycardia resolving before transfer. You may have to hold the EMS people at bay while this is happening. In addition, the most knowledgeable person(s) about MH should accompany the patient with dantrolene drawn up and ready to administer and the patient being monitored as thoroughly as possible. Blood specimens for CK, potassium, coagulation profile should be drawn and measured asap. Once stabilized, the patient should be given information about MH through MHAUS. Either the hotline consultant or one of the members of the MH professional advisory council will be able to give advice concerning recommendation for testing and confirming the episode. Over the past year or so, the MH hotline consultants and members of the professional advisory council have come to realize that our educational efforts need to be expanded from the anesthesia and surgical specialties to include Emergency and ICU physicians as well as EMS personnel who need to recognize that dealing with MH is not the same as dealing with many of the crises that they have been trained to manage. We hope to expand our training and education into those areas as soon as possible, but resources are always a problem. If you value the services of MHAUS and the 27 hotline consultants who volunteer their time as well as the members of the professional advisory council, do support MHAUS by becoming a member and /or donor. Visit the MHAUS web site www.mhaus.org for further details. The opinions expressed here are mine and do not necessarily represent the opinions of our hotline consultants or professional advisory council.
Resolved: The NJSSA issues a statement in support of the NJ Sharing Network procedure for organ donation after cardiac death. Organ transplantation is a life sparing (preserving) procedure and as such deserves the support of the New Jersey Medical community. Over the last decade, the unfavorable balance of recipient and donor has left many patients in need of transplantation helpless and at risk of death. In an attempt to improve this situation, organ donation routinely performed after brain death, has now been extended to those donors after cardiac death. This donation takes place after detailed preparation of family and/or patient and is part of the end of life care. Withdrawal of life support, decided in advance of organ donation decision, is done in the operating room. This is the anesthesiologists domain and since anesthesiology is the practice of medicine, our specialty needs to lend a hand to this important endeavor. The proper preparation of patients and their families, medical and nursing staff are paramount to a smooth, ethical and successful transfer of care to the anesthesia team. The New Jersey Sharing Network has and will continue to support the clinicians throughout the process and see them to the conclusion of their task. Details on hospital as well as intradepartmental policies and procedure will be available on the NJSSA website for any department wishing to participate in this process. Questions and concerns can either be addressed to Aryeh Shander, MD, FCCP at aryeh.shander@ehmc.com or the NJ Sharing network at 841 Mountain Avenue Springfield, NJ 07081. Supreme Court Rules in Favor of The Board of Medical Examiners At 10 am on 6/29/05 the Supreme Court posted its decision on the Internet, as is their practice. The Supreme Court unanimously upheld the unanimous Appellate's Court's decision in favor of the Board of Medical Examiners office surgery and anesthesia regulations challenged by New Jersey CRNAs and supported by the AANA. Supervision requirement will remain in place. This has been an expensive defeat for the CRNAs whose ultimate goal was, in bringing their case to the Supreme Court, unsupervised practice. The NJSSA supported the BME as Amicus-Intervenor and the ASA and the Medical Society of New Jersey as Amicus Curiae (friends of the court). The AANA sent their lawyer who stressed that the issue was jurisdictional which turned out to be the view of the Court. The AFL/CIO wanted to join on the side of the nurses but were rejected, as was the Board of Nursing. The decision states that ANESTHESIOLOGY IS THE PRACTICE OF MEDICINE and that the Regulations fall squarely within the Board of Medical Examiner's jurisdiction. The Court did nor accept the CRNAs claim of equal education and ability by stating that "it is fundamentally reasonable that additional education and training would enable anesthesiologists administering or supervising anesthesia to better protect patients and to respond when complications occur. Thus the NJANA failed to overcome the presumption of validity of the regulations". The news of the decision spread across the nation through the Internet. Dozens of e-mails have been received praising the NJSSA, the BME, and the MSNJ for putting up the long fight and winning it. All recognize the precedent setting implications in the heart of the decision as quoted above. North Carolina is facing a similar challenge in their Supreme Court and will now use the New Jersey decision. The President of the ASA, Dr. Gene Sinclair, called me at home over the Holiday to congratulate us. Several past presidents sent their congratulations as well as numerous key ASA figures. The NJSSA and New Jersey again has reclaimed its role as a leader in patient safety. The implications of a loss would have been far reaching. At a meeting 2 weeks ago with the Commissioner of Health, Dr. Fred Jacobs, he stated that if the supervision requirements in the offices were overturned by the Court, he would amend the hospital and ASC regulations, in place since 1989, to conform to the office regulations. While a loss would have resulted, as expected, in an attack by the CRNAs on the supervision requirements in hospitals and ASCs, it was a shock to hear that changes by the Department of Health would be a giveaway to the nurse anesthetists. If the Court had acted in favor of the CRNAs, your practices in hospitals or ASCs would be forever changed. A copy of the Courts decision has been sent to Dr. Jacobs in the hope of averting any action on his part. As far as CRNAs becoming APNs by grand fathering by the Board of Nursing, he stated that it is within the power of the Board of Nursing to do so. At this time the cost of the victory has not been totaled. The ASA contributed $20,000 in cash while paying their law firm $36,000 dollars for two briefs. The MSNJ sent Bob Conroy to speak at both the Appellate Court and the Supreme Court with no charge to the NJSSA. We have not been billed by our attorneys as yet. Approximately 70% of the NJSSA membership contributed to the emergency legal fund with an average donation of $100. To the 30% who did not contribute, I ask that you do so now. You will reap the benefits and security on the backs of others. To everyone, it was the best investment you have ever made. If you wish to help in the expected shortfall by another contribution, we will not reject it. In the future we will see the CRNAs move to gain APN status including prescriptive authority and collaborative arrangement. Since the Supreme Court decision addressed only the Office Regulations, what is to prevent then from attacking the Hospital and ASC regulations next? New Jersey has become a thorn in the side of the AANA. The AANA does not like to lose. Therefore we should be prepared for further attacks upon a practice that has focused on patient safety. Of note is that the CRNA'S two court cases included a stay in office regulations lasting 10 months during which office patients were at risk. American Society of Anesthesiologists
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