Episode #7 MH Preparedness and the APSF Research Program

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining me for another show. On the show today, I am so excited to talk about the APSF Grant Program.  This program supports clinical research designed to improve patient safety. In the Spring 1986 Newsletter, the APSF first announced the grant program. I will link to that article in the show notes.  The grant program was created to stimulate studies in anesthesia methods that will help to eliminate anesthesia accidents, misadventures, critical incidents, and morbidity.  The funded studies were expected to be completed within one year with a focus on anesthesia safety for healthy patients in particular based on existing medical knowledge, with a goal to create methods that can be incorporated into clinical practice and will lead to improved patient safety.

Now, that we reviewed the initial call for grant applications from 1986, let’s talk about what the APSF is doing now.  I hope that you will check out our website and click on the Grants and Awards page that I will link to in the show notes. Here you will find information about the several grant and award opportunities.  First, we have the APSF/FAER Mentored Research Training Grant which is a collaboration with APSF and the Foundation for Anesthesia Education and Research designed to develop the next generation of patient safety scientists. It is a 2 year, $300,000 award to help anesthesiologists develop skills and begin to collect data to develop into an independent investigator. Next up, we have the annual investigator initiated research IIR Grants which is our primary grant program designed to support enhancing anesthesia patient safety research from a wide variety of topics. These grants may be awarded for up to $150,000 for at most 2 years. Along with this grant is the Ellison C. Jeep Pierce Award in honor of the APSF founder, Ellison Jeep Pierce and his work towards improved anesthesia patient safety. This is an annual prize given to the highest ranked Investigator initiated research grant for $5,000 to the institution under the name of the primary investigator for unrestricted use.

Another program we have is the Safety Scientist Career Development Award which is a training grant that is awarded every one to two years for up to $75,000 each year for up to 2 years and combines career development and a mentored research project. The APSF also releases periodic request for proposals to investigate specific research areas as directed by the ASPF Executive Committee.

Here at the APSF, we also have several award programs to highlight premier projects designed to improve anesthesia patient safety. First up, we have the Ellison C. Pierce Patient Safety Award which is awarded for the best abstract in patient safety each year at the ASA Annual Meeting. Next up, we have the Trainee Quality Improvement Recognition Program. This program hosts tracts for student registered nurse anesthetists and anesthesiologist assistant graduate students in US and Canadian anesthesia programs to demonstrate their program’s work in patient safety and QI initiatives. The top projects in each tract are awarded APSF recognition and financial awards.

Finally, we have a safety recognition award that is awarded for best practices for safe medications administration during anesthesia care. We want to recognize organizations that have made significant advances in safe medication administration during anesthesia care including best practices in standardization, technology, pharmacy, and culture.  We recognize how important it is to develop practices with well-described processes that complement patient care workflow and integrate with the electronic medical records. We are looking for evidence of improved medication safety as well as qualitative evidence of process improvement for best practices that have been implemented.

There are so many wonderful opportunities with the APSF to support anesthesia patient safety research and programs. I hope that you will check it out and who know, I may be talking about your project on an upcoming podcast!!

It is my pleasure to announce the 2020 APSF Investigator Initiated Grant Recipient, Sheila Riazi, MD. She is an associate professor of anesthesiology at the University of Toronto for her project titled “A Minimally Invasive Diagnostic Test for Malignant Hyperthermia.” Riazi’s project also won the Ellison C. Pierce Jr MD Merit Award. This project is so exciting since it evaluates the calcium-induced calcium release test, the alternative test for Malignant hyperthermia susceptibility and compares the results to the current standard test for MH susceptibility, the caffeine-halothane contracture test. This project has huge implications for patient safety by validating the calcium-induced calcium release test against the caffeine-halothane contracture test which would provide a less expensive and minimally invasive test with the potential for increased testing for patients.

Since Riazi’s project involves malignant hyperthermia, let’s talk a little more about this disease.  In our June 2020 Newsletter, we published an article on MH called “Malignant Hyperthermia Preparedness: Stocking, Drilling, and Offsite Considerations” by Hamlin and Shukry. I will put the link to the article in the show notes as well. MH is a rare and life-threatening condition that we may see in patients receiving anesthesia care since it is triggered by anesthesia medications. By studying this condition, we have learned that early recognition and treatment can improve survival so it is something that we need to keep in mind when we are caring for patients. However, because it is a rare condition, you may have never had to treat a patient for MH, but when the time comes you want to be ready to provide appropriate treatment without delay.  In order to be prepared, the authors discuss the importance of a dedicated MH cart as well as simulated MH crisis scenarios for anesthesia providers as well as other staff who may be involved in helping to care for patients who receive anesthesia including pacu nurses and operating room nurses. Did you know that July 2020 is the 60th anniversary of a Letter to the Editor that described an inherited condition in a young man who received Halothane anesthetic with resultant metabolic derangements…a condition that we now know as MH. We have learned a lot in the past 60 years including that the prevalence of an MH crisis is approximately 1 in 100,000 anesthetics which means that as an anesthesia professional, you may only take care of 1 patient having an MH crisis in your whole career, but remember this is a life-threatening condition so we must be prepared in order to achieve our primary mission…that no person be harmed by anesthesia care.

There are 2 vital steps to be prepared to manage an MH crisis. First, stocking a dedicated MH Cart and Second, developing a mock MH drill that is multidisciplinary for your institution. Another very important consideration is that anesthesia professionals must be prepared to treat an MH crisis at offsite and remove locations.

Let’s take a look inside the MH Cart.  The medications and supplies need to be available for administration  within 10 minutes of an MH crisis and this recommendation stems from the Malignant Hyperthermia Association of the United States since the likelihood of complications increases 1.6 times for every 30 minute delay in Dantrolene administration. The authors report that the complication rate skyrockets to 100% when Dantrolene administration does not occur within 50 minutes of the crisis. Thus, the MH cart needs to be well-stocked in a known and close-by location. When you take a look into the cart, you would like to see an area designated for medications, which should include Dantrolene in the top drawer, as well as an area for supplies to help treat the crisis. There are two formulations of Dantrolene including Dantrium or Revonto which is 20mg of dantrolene sodium in 60mls following reconstitution in sterile water. The newer formulation is Ryanodex which is an injectable suspension of dantrolene sodium providing 250mg of dantrolene sodium in 5mls following reconstitution with sterile water. This newer formulation is a welcome addition since it requires less storage space, less staff to mix it, and increased speed to mix and then administer to the patient. Besides Dantrolene, what else do we need in the cart? Since we will be treating a hypermetabolic condition with acidemia, hyperkalemia, cardiac arrhythmias, and severe hyperthermia, the cart should contain calcium chloride, 50% dextrose, regular insulin, as well as lidocaine and amiodarone to treat arrhythmias. The MH cart may also contain refrigerated one-liter saline bags for cooling if the cart contains a refrigerator.

Moving to the supply side to help with temperature management, patient monitoring, and laboratory testing, the MH cart will need to have syringes for dilution of the Dantrolene, 2 pairs of activated charcoal filters which can be attached to the inspiratory and expiratory ports of the anesthesia machine to reduce the concentration of gas to less than 5parts per million. Keep in mind that these filters need to be replaced after one hour of use to continue to maintain the effectiveness. Other supplies include IV catheters for peripheral, central, or arterial access and a large sterile drape to cover the surgical wound. Remember, these patients will be hyperthermic and with increasing temperatures there is an increased risk of death. The steps that we can take to treat the patient include discontinuing the triggering agent and giving Dantrolene. Following this, additional treatment includes strategic ice packing, forced air cooling, circulating cool water blankets, cold IV fluids, and ice-water immersion. Additional considerations include administration of cold saline on a pressure bag to aid cooling. During the MH crisis accurate and reliable monitors are vital including temperature monitoring, central and arterial lines, and a Foley catheter with a urometer to monitor urine output to help prevent acute renal injury from myoglobinuria.

The next piece of this crisis management includes laboratory supplies and frequent testing with rapid turnaround time. Important labs include blood gas analysis as well as creatinine kinase, myoglobin, comprehensive metabolic panel, lactate, complete blood count, coagulation studies, and urine myoglobin levels.

Let’s turn our attention to the mock MH drill and what this means for patient safety. This is the ideal time to use simulation since an MH crisis is a rare event and the simulated environment gives us a chance to become familiar with the management of these very sick patients. In fact, MHAUS recommends that teams perform MH drills yearly and these drills can be scheduled or unscheduled!  What are you doing at your institution? The authors of this article offer a several considerations to optimize the MH drills at your institution.

First, use a clinical scenario that reflects the patient population that the team cares for and that may even be based on prior experiences at the institution. It is also helpful to have a leader or facilitator to achieve buy-in from all of the team members and the other health care team members will look for leadership during the crisis from an anesthesia professional. Are you ready to start the drill? The authors reports that the focus should be on rapid recognition of MH and coordinating the team by assigning roles to the participants. Throughout the drill, the logistics of providing care are important such as where is the MH cart, what’s in the cart, who is responsible for reconstituting the Dantrolene, who is getting ice, who is calling the MH hotline (which I will include in the show notes!). In addition, if the crisis occurs away from the main hospital, there will need to be a plan for transport of the patient to an ICU when they are stable enough to do so. Finally, a debriefing session is vital following an MH drill to discuss what worked and what didn’t work and answer any questions and provide information.

Before we wrap up this discussion on MH, I want to talk about MH and Offsite Anesthesia locations. MHAUS provides recommendations for free-standing surgical facilities that stock and administer any triggering agent, such as succinylcholine even without volatile agents, that Dantrolene should be immediately available. For a different perspective, the society for Ambulatory Anesthesia, (SAMBA,) has a position statement on the use of Succinylcholine for Emergency Airway Rescue that allows for class B locations that stock succinylcholine for airway rescue without Dantrolene in situations when there is no volatile agents present and in use. Keep in mind that research has determined that succinylcholine administration even without volatile anesthetics can be a trigger for MH. Having well-established protocols that will lead to rapid recognition and treatment is paramount for patient safety in these offsite and remote locations. The authors wrap up their article with a call to action for patient safety during an MH crisis to remember that rapid recognition and treatment is a must to improve patient survival and save lives and being prepared means having a well-stocked MH cart with adequate supplies of Dantrolene and practicing simulated MH drills.

Congratulations to Riazi and her team and we are looking forward to following your research project.

If you are interested in more information about applying for an APSF sponsored grant to study patient safety and further advance the field, please see the show notes where I will link more information.  I will continue to introduce grant and award winners in future shows.

Thank you so much for joining me today on this journey towards improved patient safety. If you have any questions or comments from today’s show, please email me at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2020, The Anesthesia Patient Safety Foundation