1. What went well? Could anything have been improved?
What went well? To begin, a history is obtained from the parents. He has not had previous operations and no previous exposure to anesthesia. After getting permission to proceed with the operation on patient C’s leg. After the reaction to succinylcholine, the patient is cooled with external cold packs applied to the groin and axilla areas. The leg wound is dressed to prevent further contamination during the resuscitative efforts Another thing that went well, when patient C goes into cardiac arrest, the anesthesiologist immediately stops the anesthesia and administers 100% oxygen and administers dantrolene.
I believe patient C should have continued to receive dantrolene. According to Glahn et al., 2020, A key component in the treatment of an MH reaction is an appropriate dose of i.v. dantrolene, administered as soon as possible after the diagnosis has been made (Glahn et al., 2020). Glahn et al., recommends that the initial dose of dantrolene should be repeated every 10 min (or as often as possible if the administration takes >10 min) until the signs of MH regress (Glahn et al., 2020).
Malignant Hyperthermia is a rare but life-threatening pharmacogenetic disorder (Simmons et al., 2020). The most important immediate treatment of acute intraoperative MH is discontinuing MH triggering agents, hyperventilation, and administration of dantrolene (Simmons et al., 2020). The initial dosing of dantrolene is 2.5mg/kg IV (Simmons et al., 2020). After the acute MH crisis, maintenance of dantrolene should be continued 1 mg/kg every 4-6 hours while monitoring for signs of recrudescence (Simmons et al., 2020).
Malignant hyperthermia is a severe reaction to particular anesthetic drugs that are often used during surgery and other invasive procedures (medlineplus.gov, 2020). This reaction occurs in response to some anesthetic gases, which are used to block the sensation of pain, either given alone or in combination with a muscle relaxant that is used to temporarily paralyze a person during a surgical procedure (medlineplus.gov, 2020). If given these drugs, people at risk of malignant hyperthermia may experience a rapid increase in heart rate and body temperature (hyperthermia), abnormally fast breathing, muscle rigidity, breakdown of muscle fibers (rhabdomyolysis), and increased acid levels in the blood and other tissues like acidosis (medlineplus.gov, 2020).
Without prompt treatment and cessation of the drugs, the body’s reaction can cause multiple organs to be unable to function, including cardiac arrest and renal failure (medlineplus.gov, 2020). People at increased risk of this disorder are said to have malignant hyperthermia susceptibility (medlineplus.gov, 2020). Affected individuals may never know they have the condition unless they have a severe reaction to anesthesia during a surgical procedure or they undergo testing (medlineplus.gov, 2020). Malignant hyperthermia may not occur every time anesthesia is used; Many individuals who develop a severe reaction have previously been exposed to a triggering drug and not had a reaction (medlineplus.gov, 2020). Succinylcholine doses require calculation following a thorough patient assessment and evaluation (Hager, 2020). Dosing is patient-specific and calculated based on current total body weight in conjunction with the overall physical condition (Hager, 2020). Hyperkalemia is the most common adverse effect of succinylcholine administration (Hager, 2020). The therapeutic index is the measurement range of drug safety among the average age groups (Hager, 2020). The range for adults is 0.3 to 1 mg/kg, with a recommended dose of 0.6 mg/kg administered intravenously (Hager, 2020). Patients who have received succinylcholine chloride should be on continuous cardiac monitoring in conjunction with end-tidal carbon dioxide monitoring (Hager, 2020).
3. Do you think that the patient’s fracture was stabilized and repaired? What will need to happen during subsequent surgical procedures for this patient?
To answer this question, I do think the patient’s fracture was stabilized, but not repaired. The leg wound was dressed to prevent further contamination during the resuscitative efforts. It is noted that patient C is subsequently stabilized and transferred to the ICU, where he remains for 72 hours, but it is not mentioned that his fracture was repaired. Perhaps before being transferred to ICU, the fractured was repaired, but because interventions were implemented to stable patient C after she had a reaction to Succinylcholine.
Glahn, K. P., Bendixen, D., Girard, T., Hopkins, P. M., Johannsen, S., Rüffert, H., … Urwyler, A. (2020). Availability of dantrolene for the management of malignant hyperthermia crises: European Malignant Hyperthermia Group guidelines. British Journal of Anaesthesia, 125(2), 133–140. https://doi.org/10.1016/j.bja.2020.04.089
Hager, H. H. (2020, November 16). Succinylcholine Chloride. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK499984/.
Malignant hyperthermia: MedlinePlus Genetics. medlineplus.gov. (2020, August 18). https://medlineplus.gov/genetics/condition/malignant-hyperthermia/.
Simmons, W., Feng, D., Ma, Z., Gu, X., & Huang, J. (2020, August 25). MH Survival without Dantrolene. Anesthesia Patient Safety Foundation. https://www.apsf.org/article/mh-survival-without-dantrolene/.