Microsoft word - 1106 amra

The North American Malignant Hyperthermia Registry of MHAUS Report of Acute
ADVERSE METABOLIC OR MUSCULAR REACTION TO
ANESTHESIA
(AMRA Report)
INSTRUCTIONS
This form is to be filled out by an anesthesiologist or other health care provider.

1.
Complete this form each time you suspect a patient may have experienced an adverse metabolic
reaction to anesthesia or exercise, possibly related to malignant hyperthermia (MH).
Examples: hypercarbia, acidosis, tachycardia, rigidity, hyperkalemia, myoglobinuria, Please fill out as soon as patient is stable, preferably within 48 hours of the event. The attending anesthesiologist, or other physician, should review the completed form. The patient’s name should not be recorded on the form sent to the NAMH Registry. If a patient
wishes to be registered by name, they may contact the Registry directly. The toll free telephone
# of the NAMHR is 888-274-7899
Please make one (1) photocopy of the completed form, and send the forms as follows:
1.MH Diagnostic Center (if referred) The North American Malignant Hyperthermia Registry
For FULMINANT MH cases refer the patient and their physician to the genetic counselor, Deanna
Steele at # 800-454-8155 for consideration of the blood test that can help diagnose MH susceptibility in
other family members. The patient should call # 888-274-7899, the MH Registry, to discuss joining this
research registry.

AMRA Report Version 9.6
June 2011

DEMOGRAPHIC INFORMATION
( ) other (specify):___________________________________________________ ( ) Other (specify):_____________________________________________________ State or province of patient’s residence State or province of facility in which anesthesia was given Reporting physician’s name: (optional) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ ( ) Ambulatory Surgical facility located on hospital campus ( ) Free-standing ambulatory surgical facility ( ) Surgical Office other _____________________________________ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ number and/or email address: (optional) (__ __ __)-__ __ __-__ __ __ __ _________________________@______________
FAMILY HISTORY

12.
Before this episode, was the patient’s family history positive for: ( ) intraoperative death not thought to be MH ( ) sudden infant death syndrome or cot death ( ) sudden death from unknown cause at < 45 year >1.5 years ( ) exercise intolerance due to muscle pain, weakness or fever ( ) episodes of dark urine and muscle pain ( ) myopathies specify type; write unknown if not known:_____________________ ( ) idiopathic creatine kinase elevation ( ) Other (specify):_____________________________________________________
MEDICAL HISTORY

13.
Has the patient had any of the following? ( ) muscle weakness interferes with daily activity at least once/week ( ) muscle cramps or pain that interfere with daily activity at least once/week ( ) oral (or rectal/axillary equivalent) fever >38.8ºC or 101.4ºC at least 6 times/year If there was infection, how long ago was it? _ _ _ (days) ( ) recent use of cholesterol lowering drugs If so, which drug _ _ _ _ , and when was it last ingested? _ _ _ (days) ( ) a regular regimen of physical activity? If so, when was the last work-out? _ _ _ (days) ( ) ingestion of any medicine to improve muscular performance ( ) exercise intolerance due to muscle pain, weakness or fever ( ) Other (specify):_____________________________________________________ Has the patient ever had physical findings of: ( ) myopathy specify type; write unknown if not known:_______________________ ( ) kyphoscoliosis (moderate or severe; curve > 45º) ( ) other (specify):_____________________________________________________
ANESTHETIC HISTORY

15.
How many times was this patient anesthetized prior to this event? Year of most recent anesthetic (excluding present episode)? Were unusual metabolic or muscular responses noted during prior anesthetics? Was there delayed awakening from previous general anesthetics?
ADVERSE METABOLIC REACTION TO ANESTHESIA

Year of adverse metabolic or muscular reaction. a) abdominal b) pelvic c) other (specify) __________________________________ transplant type_____________________________ ( ) other (specify):_____________________________________________________ 22a. Did this adverse reaction occur without exposure to anesthetic? add details ______________________________________ 22b. Was the environment hot when this reaction occurred? If yes how hot? __ __ . __ C or __ __ __ . __ F Was any infection present at the time of this reaction? If infection was present, what organisms were known to be present? specify:__________________________________________________________ After adverse metabolic or muscular reaction was noted, the surgical procedure was: ( ) terminated before all scheduled procedures completed ( ) not applicable - patient in recovery or intensive care area at time of reaction ( ) patient was in transport at time reaction occurred Premedication and anesthetic agents utilized (before reaction occurred): ( ) sodium citrated citric acid (Bicitra) ( ) IM succinylcholine (Anectine)
( ) IV succinylcholine (Anectine)
( ) NO succinylcholine
( ) NO potent volatile anesthetic
( ) other (specify):______________________________________________________________ ( ) other (specify):_____________________________________________________ __ __ . __ (in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) Type of anesthetic prior to adverse metabolic or muscular reaction ( ) monitored anesthesia care (local standby) ( ) general anesthesia without endotracheal intubation
( ) general anesthesia with endotracheal intubation
elapsed time after the start of anesthesia tourniquet was inflated (in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) (in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) ( ) general anesthesia with a face mask ( ) general anesthesia with a larygneal mask airway
PATIENT MONITORING UTILIZED BEFORE THE REACTION

31.
Monitoring utilized (before reaction occurred): ( ) arterial catheter ( ) central venous catheter ( ) pulmonary artery catheter temperature probes: ( ) other (specify):_____________________________________________________ If a liquid crystal temperature probe was used, did it accurately trend with core temperatures? Was a forced air or I.V. warming device in use?
SIGNS NOTED DURING THE REACTION

34.
Abnormal signs judged to be inappropriate by the attending anesthesiologist or other physician: RANK in order of appearance. NUMBER do not check. WRITE ZERO if sign did not occur.
(a number may be used more than once if signs were noted simultaneously)
___ masseter spasm: mouth cannot be fully opened, but direct laryngoscopy possible ___ masseter spasm: jaw clamped shut, intubation via direct visualization impossible ___ other (specify):________________________________________________________ time first adverse sign noted (after induction)
(in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) time second adverse sign noted (after induction)
(in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) maximum temperature noted (°C) OR
time maximum temperature noted (after induction)
(in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) time noted (after induction)
(in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) Type of ventilation used at the time hypercarbia was first observed: LABORATORY TESTS UTILIZED

37. Laboratory
Fill in the blanks for all lab tests obtained. Write unknown if results are not known. Most abnormal arterial blood gas after MH was suspected: (after induction)
(in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) * recommended intervals for creatine kinase determination are 0, 6, 12, 24 hours after the adverse reaction
PATIENT MONITORING UTILIZED AFTER THE REACTION
38.
Monitoring utilized (after reaction occurred): ( ) other (specify):_____________________________________________________ TREATMENT GIVEN

39.
Treatment given for possible or fulminant MH __ __ __ time (after induction)
(in hours, express parts of an hour using decimal points) Time of first dose (after induction)
(in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) Total dose (mg) - including maintenance therapy Time of last dose (after induction)
(in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) Method (specify) _________________________________________ Fluid type (specify) _______________________________________ ( ) other ( specify):_____________________________________________________ Mark any of the following that were noted after dantrolene was given: ( ) Decrease in end-tidal carbon dioxide or carbon dioxide tension in blood. If none were noted, please skip to question 42 How many minutes after dantrolene administration was the maximum change in this sign noted and what was the magnitude of the maximum change? ( _ . _ ºC) or ( _ . _ ºF ) (change in temperature) Were any problems noted with the dantrolene administration? If no, please skip to question 44 What were the observed dantrolene complications? ( ) other (specify):_____________________________________________________ After Adverse Metabolic or Muscular Reaction was noted:
( ) sodium citrated citric acid (Bicitra) ( ) NO succinylcholine
( ) NO potent volatile anesthetic
( ) other (specify):______________________________________________________________
PATIENT OUTCOME

45.
Did the patient develop any of the following complications? ( ) change in consciousness level and/or coma ( ) disseminated intravascular coagulation ( ) other (specify):_____________________________________________________ Did the patient survive the initial reaction? ( ) unknown because of transfer of case during treatment If no, please skip to question 51 Did the patient develop additional signs or symptoms after initial adequate treatment (recrudescence)? ( ) unknown because of transfer to another facility If no, please skip to question 54 __ __.__ hours after anesthetic induction (in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) Signs of recrudescence that were judged to be inappropriate by the attending RANK in order of appearance. NUMBER do not check. WRITE ZERO if sign did
not occur A number may be used more than once if signs were noted simultaneously.
___ masseter spasm: mouth cannot be fully opened, but direct laryngoscopy possible ___ masseter spasm: jaw clamped shut, intubation via direct visualization impossible (specify):_____________________________________________________ Did the patient survive both the initial reaction, the recrudescence, if any, and recover? ( ) unknown due to transfer to another hospital If the patient died, what was the primary cause of death? ( ) other (specify):_____________________________________________________ ( ) death > one month after the MH episode If the patient died, was an autopsy performed? ( ) no ( ) yes specify principal findings____________________________________________ _______________________________________________________________________ Was tissue from the deceased examined for a specific genetic defect? If so what was found? specify:_____________________________________________________________ 53a. In what tissue (check all that apply)? ( ) Other (specify) _______________________ CLINICAL IMPRESSION

54.
Patient experienced (opinion of attending anesthesiologist): ( ) adverse metabolic reaction that was not related to MH ( ) possible MH - may include masseter spasm (MH diagnostic center referral ( ) fulminant MH (family counseling, MH diagnostic center referral recommended) ( ) other (specify):_____________________________________________________ Were the patient and his/her family referred to a MH diagnostic center? If referred to a MH diagnostic center, check identity of center: ( ) Ottawa Hospital Civic Campus .Ottawa, ON ( ) Wake Forest University .Winston-Salem, NC ( ) Uniformed Services University .Bethesda, MD ( ) University of California at Davis .Davis, CA ( ) University of Minnesota .Minneapolis, MN ( ) University of Toronto .…………………………………….Toronto, ON Were the patient and the family also referred to MHAUS?
COMMENTS ON PATIENT
(Optional)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please make photocopies and distribute according to instructions on cover sheet.
The North American Malignant Hyperthermia Registry
MH DIAGNOSTIC CENTER DIRECTORY

Kevin Nolan, M.D.
Department of Anesthesia/Pain Management

Source: http://www.mhreg.org/Forms/1106AMRA.pdf