Labor anelgesia

[EpiEMS]

Not a CRNA or anything fancy (), but PubMed had some useful write-ups. While incidence (# MH cases/# surgeries)seems low, susceptibility is pretty high. The review I skimmed cited incidence of 1:10,000 to 1:250,000 anesthetic administrations, but susceptibility between 1:400 and 1:3000 people.

That said, incidence of death (or cardiac arrest but not death) is in the single digits (small n study though) for MH. Looks like temperature monitoring is the best method to prevent problems (unsurprisingly).

Pretty crazy stuff!

 

[E tank]

.....incidence of 1:10,000 to 1:250,000 anesthetic administrations, but susceptibility between 1:400 and 1:3000 people.

That said, incidence of death (or cardiac arrest but not death) is in the single digits (small n study though) for MH. Looks like temperature monitoring is the best method to prevent problems (unsurprisingly).

Pretty crazy stuff!

One to two cases a week in North America, 1 to 2 deaths per year. Low death rate because of quickly accessible curative drug (dantrolene) and awareness of everyone that works in the OR. BUT, there are rare cases of non anesthetic related triggered patients. Basically, anyone you treat for severe heat exhaustion/heat stroke should be assessed for an MH susceptible gene. BTW, succs is a triggering agent as well. Not sure how common that is in EMS these days. But if there was an MH concern with that, there should be with Penthrane as well.

Tiny numbers we're talking about here, but devastating consequences.

 

[VentMonkey]

succs is a triggering agent as well. Not sure how common that is in EMS these days.

TMK, it's still fairly common with most prehospital-RSI formulary. It's our primary RSI paralytic. Roc is our back up, or second option.

Aside from perhaps an intraocular injury coupled with the need to induce, I like Succs because of its shorter length of duration. It (IMO) allows the receiving docs a chance to better assess our patients neurological status sooner rather than later as our transport times to our ED's works with our push dose sedative/ analgesics combos, typically.

We have Vec as a post-RSI option as well. And yes, when learning about these drugs, MH was mentioned (mirroring what you and Remi have said thus far) with regards to Succs administrations; right down to its precursors.

I just wondered how frequently you guys deal/ dealt with it, as I realize while very serious, is quite rare.

The FP-C loves to throw a-"what's the reversal agent for a suspected MH patient."-question in almost without fail, why? I have no clue.

 

[E tank]

TMK, it's still fairly common with most prehospital-RSI formulary. It's our primary RSI paralytic. Roc is our back up, or second option.

I just wondered how frequently you guys deal/ dealt with it, as I realize while very serious, is quite rare.

The FP-C loves to throw a-"what's the reversal agent for a suspected MH patient."-question in almost without fail, why? I have no clue.

Gotcha, thanks. There has been some controversy in succs being able to trigger on it's own (without being given with another trigger) but it absolutely can and has. As far as how often I deal with it, I've had one patient so far and the general incidence per anesthetist is roughly 1:15,000 performed anesthetics and I'm way, way over due for my second.

 

[Handsome Robb]

So knowing how dangerous MH is but also how uncommon it is does every patient who undergoes anesthesia with meds that are triggering agents receive continuous temperature monitoring?


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[E tank]

So knowing how dangerous MH is but also how uncommon it is does every patient who undergoes anesthesia with meds that are triggering agents receive continuous temperature monitoring?


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For cases that last an hour or more, the very strong recommendation is continuous electronic core (not skin) temperature monitoring every single time.

 

[Carlos Danger]

So knowing how dangerous MH is but also how uncommon it is does every patient who undergoes anesthesia with meds that are triggering agents receive continuous temperature monitoring?

Yes.

Thought according to some, Etc02 monitoring provides earlier warning in most cases.

 

[Nova1300]

Interesting point. For those outside the US using penthrox - do you screen for MH before use?

 

[para40s]

Interesting point. For those outside the US using penthrox - do you screen for MH before use?

Longtime lurker, regular penthrane administer-er

We ask prior to administration something along the lines of "have you had any prior problems with anaesthetic medications or have heard of something called MH..?" More specifically I'll also ask pt's if they've used the 'green whistle' before and if they've had any problems or side effects plus effects on their pain..the latter to decide if another analgesic might be more suitable.

In terms of analgesia for maternity pt's I've probably only given it maybe five times, maybe moderate effectiveness, even with good compliance. We did carry nitrous which was abandoned a few years ago mainly due to the cost from the supplier to supply and maintain the cylinders, regs, etc...I don't know how much was being spent, but when compared to pentrhane which costs $25-40 per dose and is given out like candy, I don't know if there was much to be saved. As good as penthrane is in terms of ease of use and low side-effects, I would love to have nitrous back for maternity pt's, extended transport times, and reduction of fractures especially.

As for MH, I've only come across one pt who ?had a hx which we found noted in a hospital discharge summary. Treatment had already been commenced and was stopped with no adverse effects. Anyways, I've never heard of any cases of MH pre-hospitally and even after scanning a bunch of literature where penthrane was used in a number of clinical settings I haven't found any reports of MH occurring including published case studies

 

[jwk]

Honestly much ado about nothing with the methoxyflurane discussions. MOF, Penthrane, Penthrox et al has been unavailable commercially in the US for probably 20 or more years. About the only place penthrox inhalers have been used is down under. It's clinical use in the US and most other first-world countries was abandoned because of nephrotoxicity, and because much safer and more reliable agents came along. I doubt you ever see it because there won't be anyone in the US willing to sell it due to the potential risks involved. I haven't checked, but I wouldn't be surprised if it is no longer FDA approved.

As far as ketamine for labor analgesia - if any hospital in the US is using it routinely for labor analgesia, I'm not aware of it. I know some of you think ketamine is the greatest thing to come along in EMS in decades, but it does have it's downsides. Trust me, you don't want to deal with a whacked out primip and there's no way to screen whether or not someone will have a hugely dysphoric reaction to it or not. Most mommies either want to go natural or they want an epidural. Our L&D unit gives IV fentanyl on occasion that's about it for IV pain meds.

 

[E tank]

As far as ketamine for labor analgesia - if any hospital in the US is using it routinely for labor analgesia, I'm not aware of it. I know some of you think ketamine is the greatest thing to come along in EMS in decades, but it does have it's downsides. Trust me, you don't want to deal with a whacked out primip and there's no way to screen whether or not someone will have a hugely dysphoric reaction to it or not. Most mommies either want to go natural or they want an epidural. Our L&D unit gives IV fentanyl on occasion that's about it for IV pain meds.

Not for labor analgesia per se, but ketamine works great for a spotty epidural for c section or even the occasional episiotomy or tear repair. 10-20 mg usually is plenty and moms do pretty well.