Malignant Hyperthermia Association of the Volume 27 Number 4 United States and the North American Fall 2009 Malignant Hyperthermia Registry of MHAUS

by Henry Rosenberg, MD MHAUS President

How Well Prepared Are Operating Room & PACU Teams For An MH Crisis?

There is no doubt that over the past 30 Mortality From MH As A Measure years MH has gone from a virtually un- Of Preparedness known, highly fatal problem to one that One of the goals of MHAUS has been to not is well described in every textbook of an- only provide information about MH to health esthesia, surgery, medicine, and nursing. care professionals and the public but also to Reference to MH can be found, even if it’s assist the anesthesia and nursing communi- just in passing, in the curriculum of most ties to be prepared to act promptly and effec- training programs for health care profes- tively when a crisis arises. We have gener- sionals dealing with surgical patients. Since ally measured success in the management MH is not an extremely common problem, of MH based on declining mortality from MH. it is not surprising that the average physi- However, we realize that we are not aware cian or nurse would not know a great deal of all cases of MH. In some situations we about the intricacies of the syndrome, such might not be called when a patient dies from as its clinical manifestations, the underly- MH because there is an aversion to publiciz- ing pathologic changes and subtleties of ing a bad outcome. treatment. But everyone who has A study published in the very respect- studied some aspect of medicine able journal, Anesthesia and Analgesia, or nursing will be able to know found that the mortality from MH is closer where to find more information to 12% overall based on national data. The about the syndrome and also mortality ranges from 5% when the syn- to understand at the least that it drome occurs in a hospital to 20% when the may be fatal if not identified patient with MH has to be transferred into a and treated with dantrolene hospital. (1) This statistic causes concern, promptly. We would expect but again we questioned whether all those that anesthesia provid- cases called MH were really MH, or just ers and surgeons know a cases of high fever after surgery. Hard to good deal about MH and know since the individual case data are not particularly the steps in presented. treating the syndrome. As part of an epidemiologic study Recent studies provide some disturbing information about MH preparedness. continued on page 3 The Communicator is published four times each year by the Malignant Hyper- thermia Association of the United States (MHAUS) and is made possible by a generous grant from JHP Pharmaceuti- cals, manufacturers of Dantrium®. The Communicator is intended to serve the Notice Something Different In This information needs of MH-susceptible families, health care professionals, and others with an interest Issue Of The Communicator? in MH.

EDITOR Well, you should. We have and scientific understanding of MH Brian Kamsoke completely redesigned the front page and related disorders. (The Cana-

Editorial Advisory Panel of The Communicator. The new de- dian Malignant Hyperthermia Asso- Scott Schulman, M.D. sign, we believe, is much more styl- ciation closed its doors a few years Henry Rosenberg, M.D., CPE Barbara Brandom, M.D. ish and modern, and incorporates the ago). Cynthia Wong, M.D. “Faces of MH” (the father and son There are, of course, other Lena Sun, M.D. Ronald J. Ziegler image) which is also found on the organizations at work around the Sharon Dirksen, PhD MHAUS exhibit booth that we display globe, most notably the European FOR MHAUS at various meetings, as well as our Malignant Hyperthermia Group Henry Rosenberg, M.D., CPE President website and informational literature. (EMHG). MHAUS works with EMHG Our thanks to Michael J. and other groups, and communi- Ronald J. Ziegler Vice President Barker, President of Integrated cates with medical professionals Marketing Services, Inc., for the new around the world, from South Ameri- Sheila Muldoon, M.D. Vice President, Scientific Development look. ca to Southeast Asia. (MHAUS/NMSIS/Registry) This is the 27th year in which The Communicator remains Stanley Caroff, M.D. we’ve published The Communicator a vital component for distributing Vice President – Director of NMSIS newsletter. The Communicator is information; think of it as the hub of Steven V. Napolitano, Esq. aptly named; it is a primary source a wheel, with the spokes its informa- Secretary of information to medical profession- tion and resources distributed; in its Joseph R. Tobin, M.D. als and MH-susceptibles and their tracks it leaves heightened aware- Treasurer families. But it is not the only source ness and a better understanding of Dianne Daugherty Executive Director of information. MH. MHAUS manages a website Gloria Artist Hotline Coordinator www.mhaus.org and publishes and – The Editor distributes a multitude of informa- Sharon Dirksen, PhD Scientific Officer tional material: podcasts, brochures, pamphlets, videos, and poster. Much Correction Notice Fay Kellogg The article “Calsequestrin1 Fulfillment Administrator of this informational material can be accessed free-of-charge online, and (CASQ1): A New Gene For MH?” Nicole Viera in the summer 2009 issue of The Database Administrator other items, such as the In-Service Communicator (Vol. 27, No. 3, pg Michael Wesolowski Kit, can be purchased for a nominal Public Relations/Project Coordinator fee. 6) should have contained the name of the author Sharon Dirksen, PhD, Malignant Hyperthermia (MH) is an MHAUS is the only organiza- inherited muscle disorder which, when tion in the country (indeed, the only MHAUS Scientific Officer. We triggered by potent inhalation anesthet- apologize for the omission. ics and succinylcholine, may cause a organization in North America) whose life-threatening crisis. The incidence of MH is low, but, if untreated, the mortality mission is to promote optimum care rate is high. Since the advent of the an- tidote drug, dantrolene sodium, and with greater awareness of the syndrome, the mortality rate has decreased. Great ad- vances in our understanding of MH have The mission of MHAUS is to promote optimum care and been made since it was first recognized in the early 1960s, but the nature of the fundamental defect(s) is still unknown. scientific understanding of MH and related disorders.

MHAUS advocates that all surgical patients undergoing general anesthesia should receive continuous temperature For more information or for materials on malignant hy- monitoring, that adequate supplies of dantrolene be stocked near the OR perthermia or MHAUS’ programs, call 607-674-7901; write and that thorough family histories be obtained. MHAUS, PO Box 1069, Sherburne, NY 13460; or visit us Copyright 2009 by MHAUS on the Internet at www.mhaus.org. 3

Continued from page 1 the emergency situations were part, because one of the ambula- quite good, but not for MH! Less tory center accrediting agencies than 20% of those handling the require such a drill every year. based on data from the state of crisis performed the key actions But we also know that others do NY from 2001-2005, a higher required to identify and treat MH not know how to develop such than expected mortality (about as opposed to a much higher a drill. Such questions as how 20%) was also identified in cer- percentage for all the other situa- many people need to be involved, tain situations. (2) This data will tions. (3) where does one get expired dan- soon be published in Anesthesia trolene to practice mixing the stuff, and Analgesia. My coauthors MHAUS’ Efforts In Simulation- how does one score the success on the study, Dr. Lena Sun, Dr. Based Education & Training of the drill, does a site require a Guohua Li and Ms. Joanne Brady A word is in order about the use manikin to carry out the drill or is of Columbia University and I will of simulation in training health there an alternative? soon be embarking on an in depth care professionals. Full scale Creation of a program to study of the specific cases that high fidelity manikins that may be assist hospital ORs, ambulatory were labeled MH in order to be programmed to respond to drugs centers and other places where sure that they really were MH and or situations with such physi- MH trigger agents are in use, in not a syndrome resembling MH. ologic responses as blood pres- developing a drill is tops on the sure, heart rate, respiration, even MHAUS project list. Our staff, con- Use Of Simulation Technol- muscle tone, and bleeding have sultants and other volunteers are ogy To Test Preparedness For rapidly become an important part committed to having a guideline Emergencies of training students and health for setting up and carrying out an These studies call into question care professionals. Such simula- MH drill in place soon. our comfort level that MH is recog- tion has been around for a while, So the answer to the ques- nized and treated appropriately in but it has reached the “tipping tion in the headline is that some greater than 95% of cases. Now point”, whereby it will soon be centers are very well prepared, another study looking at MH from a requirement that trainees and but there is still a need for im- an entirely different viewpoint, even experienced clinicians dem- provement. demonstrates that indeed when onstrate their abilities in a simula- faced with a crisis many anesthe- tion center. References: sia providers become confused In the future, we intend for (1) Rosero EB, Adesanyo AO and overwhelmed and do not MHAUS to assist in the develop- et al. Trends and outcomes of follow the standard treatment ment of simulator based education malignant hyperthermia in the procedures. They may waste time programs. However, to do it right US., 2000-2005. Anesthesiology changing an anesthesia machine, requires many hours of planning 2009;110:89-94 make a mistake in calculating the and development. Meanwhile (2) Brady, JE, Sun LS, Rosen- dose of dantrolene, have insuffi- we are approaching the need for berg H, Li G. .The Prevalence of cient personnel to do all the tasks preparation and training in suc- Malignant Hyperthermia Related required for management of MH, cessfully handling an MH crisis to Exposure to Anesthesia in New etc. using a different form of simula- York State, 2001-2005. Anesth Most interestingly, this tion: an MH drill. Analg 2009, in press. study was not aimed at determin- The Board and staff at (3) Henrichs BM , Avidan MS, ing how practitioners manage MHAUS have been delving deeply Murray DJ et al. Performance MH specifically. Rather it was a into what our “customers” need for of Certified Registered Nurse simulation-based study whereby better management of MH. One Anesthetists and Anesthesiolo- the anesthesiologists and nurse of the top requests is for the de- gists in a Simulation-based Skill anesthetists were confronted with velopment of a guide for carrying Assessment. Anesth. Analg. one of ten emergencies, such as out an MH drill (like a fire drill or a 2009;108:255-62 unexpected anaphylaxis (mas- response to a cardiac arrest). We sive allergic response) and were know that many hospitals and am- scored on how the response was bulatory surgery centers perform managed by independent ob- such a drill on a regular basis, in servers. The scores for nine of 4 Both MH-Mini Conferences Very Successful The MH mini-conferences held last month in City, OK and Latham, NY were very successful. There were 45 at- tendees at the Oklahoma City conference and 82 attendees at the Latham conference. Fay Kellogg, MHAUS Ful- fillment Administrator, helped or- ganize the events along with Lydia Friedman, head of the MHAUS Patient Liaison Committee. Both conferences followed the same format. Attendees at the conferences included nurses, fam- ily members, and medical doctors. This was the first year that two MH mini-conferences were held. MHAUS plans to hold more such conferences in the future. The conferences provide Highlights of the two mini-conferences included mixing dantrolene (be- updates by medical profession- low left), the MH muscle biopsy video, an MH mock drill, and panel dis- als on current MH research and cussion with guest speakers in Latham (above, left-to-right) Dr. Barbara testing, which includes the latest Brandom, Dr. Michael Adragna, and Deanna Steele, genetic counselor; on molecular genetic testing, as and in Oklahoma City (below, left-to-right) Dr. Tae Kim, Jennifer Geurts, well as addresses any questions genetic counselor, and Dr. Mohanad Shukry. posed by those attending. 5 Happy 30th Anniversary To Dantrium® IV That’s right, it’s been 30 for MH. Keith O. Ellis, PhD, one were later purchased by JHP years now that Dantrium® IV has of the scientists who worked at Pharmaceuticals, an integrated been on the market and saving Norwich Eaton Pharmaceuticals, specialty healthcare company that lives of those afflicted with malig- where the drug was being devel- acquires, manufacturers and dis- nant hyperthermia. How many oped, wrote “(Dantrium IV) was a tributes sterile injectable products lives has Dantrium® IV saved drug in search of a disease.” predominately to hospitals and in those years? It’s difficult to In the early 1970s, the clinicians in the USA and Puerto calculate. Suffice it to say, there drug was known as a skeletal Rico. With this, the story (and his- are countless people alive today muscle relaxant and was in clini- tory) of Dantrium® IV continues. thanks to this miracle drug. cal development for the treatment And yes, it can be (and of spasticity. It was around this Do you have an MH was) considered a miracle drug time that Dr. Ellis read about ma- survival story? Tell us when it gained FDA approval lignant hyperthermia, the skeletal based on 14 cases. Before Dan- muscle rigidity and pig model of about it and include a trium® IV, there was no cure for MH. He contacted investigators before and after picture. MH, an inherited muscle disorder working with MH pigs and later Visit the MHAUS website which, when triggered by certain sent samples of the drug for trial types of anesthetic agents used studies. The rest is history. at www.mhaus.org and during surgery in MH-susceptible Norwich Eaton Pharma- click on “Faces of MH” in individuals, may cause a life- ceuticals was later bought by the lower left of the patient threatening crisis. Procter & Gamble Pharmaceuti- or professional section, Coincidently, it was by cals, which took over the market- happenstance that Dantrium® IV ing and distribution of Dantrium® located just above the came to be known as the cure IV. The rights to Dantrium® IV “Facebook” link. 6 Activated Charcoal As An Alternative To Flushing To Prepare The Dräger Fabius Anesthesia Machine For The MH-Susceptible Patient by Joel B. Gunter, M.D. particularly pronounced for the mounting a completely new ab- Professor, Clinical Anesthesia and Dräger Primus and Fabius plat- sorber assembly and connecting Pediatrics Department of Anesthe- forms, which required 65 min and several sensor and control cables sia, Children’s Hospital Medical 105 min, respectively, to achieve and hoses. Since failure to attach Center Department of Anesthesi- a residual anesthetic concentra- all the cables and hoses correctly ology, University of Cincinnati tion < 5 ppm(4,5). The Primus could result in breathing circuit Cincinnati, OH, USA and Fabius workstations employ a and/or ventilator malfunction, re- piston ventilator and share unique placement of the Fabius breathing Care of the malignant hyperther- circuit architectural features which system does not appear to be a mia-susceptible patient requires may have contributed to delayed task which should be undertaken avoidance of exposure to even clearance of residual anesthetics; by the unaided clinician. trace concentrations of residual however, even completely bypass- As an alternative to flush- halogenated anesthetics. This ing the Fabius ventilator failed to ing residual anesthetics from has typically been accomplished significantly accelerate anesthetic the Fabius breathing system, we either by the use of dedicated clearance (5). While the precise investigated the utility of adsorb- “clean” anesthesia machines mechanism of delayed clearance ing halogenated anesthetics onto which are never exposed to of anesthetics from the Primus activated charcoal placed between halogenated anesthetics or by and Fabius anesthesia machines the breathing system and the flushing residual anesthetics from remains unknown, the most likely patient(5). Mounting an Anecare anesthesia machines prior to use. explanation appears to be slow Quick Emergence Device (QED®, The flushing procedure consists of elution of absorbed anesthetics Anecare Laboraties, Salt Lake removing or disabling any vaporiz- from the synthetic components of City, UT) on the inspiratory port of ers, changing the CO2 absorbent, the breathing circuit and ventila- the breathing circuit made it pos- replacing any readily accessible tor(4-8). sible to reduce residual haloge- rubber or plastic parts (e.g., fresh With this mechanism in nated anesthetic concentration in gas hose or ventilator bellows) mind, Crawford et.al., accelerated the inspiratory limb of the breath- with dedicated “clean” compo- clearance of residual haloge- ing circuit to < 10 ppm within 10 nents, installing a clean breathing nated anesthetics from the Dräger min and to < 5 ppm within 15 min; circuit and breathing bag, and Primus by replacing the entire concentrations were maintained flushing the machine with oxygen breathing system and ventilator < 5 ppm for up to six hours, by 10 l/min for 20 min while the venti- rolling diaphragm with components which time the residual anesthetic lator cycles into a clean breathing which had been autoclaved to concentration within the breathing bag or test lung mounted on the remove any absorbed anesthet- system upstream of the QED® patient Y-piece. ics(3). Prepared in this manner, was < 5 ppm. A number of recent reports the Primus required less than 5 The preparation procedure have documented that this pro- min of flushing to reach a residual when using the charcoal filter is cedure may not be adequate in anesthetic concentration < 5 ppm. similar to that for a conventional many modern anesthesia work- Unfortunately, this approach is flush. Vaporizers are removed or stations, including the Siemens much less practical for the Dräger disabled, the CO2 absorbent is KION(1), Datex-Ohmeda AS/3(2), Fabius anesthesia machine; un- changed, and a clean breathing Dräger Primus(3,4), and Dräger like the Primus, whose integrated bag and circuit are mounted on Fabius(5) anesthesia machines. breathing system can be replaced the breathing system. The QED® The inadequacies of the conven- en bloc, replacing the breathing device is mounted on the inspira tional flushing procedure were system on the Fabius requires continued on page 5 7

Continued from page 4 must be mounted on the inspira- that a similar procedure can be tory port of the breathing system employed on any anesthesia ma- between the inspiratory valve and chine employing one-way valves tory port of the breathing system the breathing circuit. The inspira- and circle-absorber architecture. between the inspiratory valve tory port is usually identified by It is less clear that this procedure and the breathing circuit. Prepa- an arrow pointing away from the should be employed to rapidly ration then proceeds in three breathing system and toward the clean an anesthesia machine phases, each lasting five minutes patient and is typically in-line with during a malignant hyperthermic (the Five-Five-Five Flush). The the oxygen analyzer; any question crisis; in the absence of laboratory machine is first flushed for five regarding which is the inspira- data demonstrating equivalent minutes with oxygen 10 l/min with tory port should be addressed by outcomes for experimental ani- the ventilator cycling into a clean breathing through the system and mals whose management dur- breathing bag/test lung with the observing the one-way valves. ing MH crisis included the use of QED® in the OFF position; this The QED® must remain on the activated charcoal filters to scrub serves to remove bulk anesthetic inspiratory port and in the ON po- inspired gases, management from the circuit, reducing the con- sition throughout the anesthetic; of suspected MH crisis should centration in the breathing system mounting the QED® on the expi- continue to include switching to to around 100 ppm. The QED® ratory port or premature de-activa- a clean non-rebreathing system is then turned to the ON posi- tion or removal of the QED® will or a dedicated, clean anesthesia tion and the machine is flushed expose the patient to the residual machine. as above for an additional five concentration of anesthetic in the minutes; at this point the residual breathing system and ventilator, anesthetic concentration at the which may be much greater than REFERENCES patient Y-piece will be about 10 10 ppm. It is hoped that charcoal 1. Petroz GC, Lerman J. Preparation of the ppm. It is now possible to expose Siemens KION anesthetic machine for pa- filters designed specifically for tients susceptible to malignant hyperthermia. the patient to the machine, pro- this purpose will be marketed. Anesthesiology 2002;96:941-6. vided that the total fresh gas flow Such a device would not include 2. Schönell LH, Sims C, Bulsara M. is maintained at ≥ 10 l/min for the features of the QED® related to Preparing a new generation anaesthetic first five minutes of the anesthetic; machine for patients susceptible to malig- its intended function of speeding nant hyperthermia. Anaesth Intensive Care at the end of the third five minute emergence (the ON-OFF switch 2003;31:58-62. phase the anesthetic concentra- and expandable tubing) but not 3. Crawford MW, Prinzhausen H, Petroz GC. tion at the patient Y-piece will be Accelerating the washout of inhalational an- needed for this application, and esthetics from the Dräger Primus anesthetic < 5 ppm and the total fresh gas would include a clear housing workstation: effect of exchangeable internal flow can be reduced to as low as (to confirm presence of activated components. Anesthesiology 2007;106:289- 2 l/min. Delivered residual anes- 94. charcoal) and instructions and 4. Prinzhausen H, Crawford MW, O’Rourke thetic concentrations will remain markings on the housing to facili- J, Petroz GC. Preparation of the Dräger < 5 ppm for at least six hours. It tate proper use and placement on Primus anesthetic machine for malignant should not be necessary to re- the anesthesia machine. hyperthermia-susceptible patients. Can J place the QED® due to saturation Anaesth 2006;53:885-90. Use of activated charcoal 5. Gunter J, Ball J, Than-Win S. Preparation during even an extended anes- filters to remove halogenated of the Dräger Fabius anesthesia machine thetic, as the residual halogenated anesthetics from the inspiratory for the malignant-hyperthermia susceptible anesthetic concentration in the patient. Anesth Analg 2008;107:1936-45. limb of the breathing circuit makes 6. Eger EI, Larson CP, Severinghaus JW. breathing system will be < 5 ppm it possible to prepare the Dräger The solubility of halothane in rubber, soda after six hours at a total fresh gas Fabius anesthesia machine for the lime and various plastics. Anesthesiology flow of 2 l/min. malignant hyperthermia-suscep- 1962;23:356-9. When preparing the 7. Lowe HI, Titel JH, Hagler KJ. Absorp- tible patient in less than 15 min; tion of anesthetics by conductive rub- Dräger Fabius anesthesia ma- the approximate $40 cost of the ber in breathing circuits. Anesthesiology chine in this fashion, several pre- device is easily offset by recoup- 1971;34:283-9. cautions must be observed in or- 8. Targ AG, Yasuda N, Eger EI. Solubility of ing OR time which would other- I-653, sevoflurane, isoflurane, and halo- der to avoid inadvertent exposure wise be lost to a prolonged con- thane in plastics and rubber composing a of the malignant hyperthermia- ventional flush. Although it has conventional anesthetic circuit. Anesth Analg susceptible patient to halogenated not been formally tested, it is likely 1989;69:218-25. anesthetics. The QED® device 8 MH Hotline Activity: July – October 2008 by Mohanad received dantrolene prior to important sign of an MH reac- Shukry M.D. the Hotline call. Calls came tion. Thirteen patients in this from 26 states, and 2 calls group displayed some rigidity. During the from Canada. The callers’ in- Some had isolated jaw rigid- months of July hospital locations varied from ity and some patients had through October operating rooms, recovery body or limb rigidity. Some of 2008, 14 volun- room, preoperative clinics, to the surgical procedures were teer physicians answered 71 intensive care units. cancelled when the rigidity calls to the MH Hotline. Fifty- Many of the no event occurred before the surgical four of these calls involved calls were regarding the as- incision. Others continued clinical situations where signs sociation of MH and muscle with the operative procedure and symptoms indicated the diseases such as central core and switched to non-triggering potential for the occurrence of disease (CCD), strabismus, anesthetic technique. a MH event. Seventeen calls limb girdle dystrophy, and One phone consult involved only questions about muscular dystrophy. Of the concerned a MH susceptible MH or follow up calls about a true congenital myopathies, patient receiving a kidney previous MH event. CCD and the related multi- transplant. The caller was Consultants working minicore disease, as well as concerned that the donor had the Hotline during this pe- the myopathy of King-Denbor- been exposed to sevoflurane riod included Drs. Brandom, ough syndrome, are the only and residual of the gas in the Gronert, Litman, Melton, Mill- myopathies known today to donated kidney might trigger man, Parness, Rosenbaum, have a definite relationship an MH episode in the recipi- Rosenberg, Skoog, Shukry, with true MH. ent. The consultant assured Tobin, Watson,Weglinski, Many of the calls had the caller that the surgeon and Wong. Seven of the calls an initial elevation of exhaled usually flushes the harvested were thought to be prob- carbon dioxide (CO2). El- kidney with saline and that ably or definitely MH by the evated CO2 is an early sign should dissipate the sevoflu- consultants. There were no of MH and the skeletal muscle rane. Additionally, the caller deaths reported from this is the source of the CO2. The was assured that the almost group. Seven calls were from release of excess amount negligible amount of sevoflu- a hospital setting and none of calcium from the skeletal rane in a transplanted kidney from outpatient surgery cen- muscle causes increased me- should not trigger an MH ters. Only five of the probable tabolism producing extraordi- episode. or definite cases received narily large amounts of CO2 A call was received by dantrolene while twelve of the and respiratory acidosis. non-MH or unlikely MH calls Muscle rigidity is an Continued on page 9 In the U.S. and Canada, the MH Hotline is 1-800-MH-HYPER (1-800-644-9737) Outside the U.S., call 1-315-464-7079 9

Continued from page 8 Challenge a hotline consultant regarding rigidity and dantrolene was Yourself With a patient with severe sclero- not recommended. During an derma, a tissue disease that online discussion among the The MH Case makes the skin and tissue hotline consultants, they all underneath it inflexible. The agreed with the conclusion Of The Month patient has been sedated by a and thought that such a pa- radiologist when she stopped tient could have been better Have you challenged breathing. When the anes- sedated by a more skilled yourself with the MH thesiologist tried to insert a sedation physician such as breathing tube, the procedure an anesthesiologist to prevent Case of the Month? Visit turned out to be very difficult her from such an event. www.mhaus.org and due to what the anesthesiolo- Although a significant go to the Home or Pro- gist thought was jaw rigidity. percent of calls handled by The blood gas later showed the hotline consultants are fessional’s Info Center a respiratory acidosis. The thought unlikely to be related pages to decide the cor- consultant informed the caller to MH, the callers appreciate rect way to proceed with that he did not believe that the guidance and the oppor- these actual MH cases. the patient was experiencing tunity to have an expert avail- an MH episode or rigidity. The able to help them determine Answers with narratives consultant believed that the the best course of action. are provided for the pre- tissue inflexibility mimicked vious month’s cases.

Meet This Issue’s Hotline Consultant

ing year he completed his Center Children’s Hospital transitional year residency of Pittsburgh in Pittsburgh, at Razi Hospital in Damas- PA, from July 2004 to June cus, Syria. He completed his 2005. Dr. Shukry is cur- preliminary year residency rently the Director of the in General Surgery at the Pediatric Pain Service and University of Virginia Health the Clinical Director of the System in Charlottesville, VA, Operating Room at The from July 2000 to June 2001, Children’s Hospital in Okla- then completed his Residency homa City. Dr. Shukry received in Anesthesiology at Tulane Dr. Shukry has been his MD in 1997 from Da- University of Medicine in New published in Pediatric An- mascus University Faculty Orleans, LA, from July 2001 esthesia, has received of Medicine in Damascus, to June 2004. He received honors and awards for his Syria, where he also in- a Fellowship in Pediatric research, and has given nu- terned from July 1996 to Anesthesiology at the Uni- merous lectures both inter- June 1997. The follow- versity of Pittsburgh Medical nationally and nationally. 10 JHP Pharmaceuticals Introduces A The Lila & Jerry Dantrium® IV (dantrolene sodium for Lewis Memorial injection), Rapidly Mixing At 20 Seconds Fund JHP Pharmaceuticals, LLC Stuart Hinchen, co-founder There are many special people (“JHP”) announced today that it and President of JHP said, “We who take the time each year to had developed, and received ap- are excited about the dramatic en- remember their loved ones in proval by the FDA for Dantrium® hancements we have been able to a way that helps MHAUS. The IV (dantrolene sodium for injec- make to Dantrium® IV. The stun- people below have made gifts tion), a rapidly mixing product. ning improvement in reconstitu- during FY 08-09 (July 2008 - ® June 2009) in memory of Lila Dantrium IV now reconstitutes in tion time represents breakthrough and Jerry Lewis. We are most approximately 20 seconds, which innovation that significantly height- grateful for their support and is 4 times faster than before, sav- ens the life-saving characteristics special tribute gifts. ing valuable time and effort during of a drug 30 years after its suc- a malignant hyperthermia (MH) cessful introduction. Life Benefactors emergency. “During fulminant MH, Dorothy Glassman Dantrium® IV, the rapidly mix- Gregory Lewis Glassman when a patient’s core temperature Jacey Lila Glassman ing product, has the following can increase by as much 1 degree Steve & Mickey Lewis essential benefits: Centigrade every 5 minutes and Dr. Joseph Sugerman 1.) Reconstitutes in approximately time is obviously a crucial factor, Bob & Dianne Winters 20 seconds with noticeably less Dantrium® IV can now be recon- vigorous shaking required to com- stituted 4 times faster than before. Patrons plete the reconstitution process Taking into account the 36 vials Brad & Julie Shames 2.) Easier and faster introduction that are recommended by MHAUS ® Sponsors of diluent into the Dantrium IV (Malignant Hyperthermia Asso- Arline A. Hammer vial ciation of the United States) and Barry & Beverly Kurtz JHP has also introduced often needed to stabilize a patient Gloria Leonard two new features in the Dantri- with MH, Dantrium® IV, the rapidly Lenny Roberts um® IV vial; an easy-to-open flip- mixing product, saves up to 36 Mark Zamel off vial cap and an easy-to-identify minutes of mixing time.” Donors red vial cap and red vial label. Larry & Linda Blumenfeld Allen Jacobs Sheldon & Doreen Querido Bill & Linda Rouse NEW Manual Promotion Les & Diane Surfas Starting November 1st Friends Lois Soter MH Procedure Manuals in three versions: Hospital, George & Miriam Trustman Ambulatory Surgery Center, and Office-Based. Honoraria The procedure manuals consist of: a large flowchart that outlines the tasks Honor of Marilyn Glassman of each staff member who may treat an MH episode; laminated checklist by Lenord Roberts worksheets for each role; an instructional videotape demonstrating a mock Honor of the Marriages of episode, response plan, and explanation of how to utilize the manual. Jacey Glassman & Dan Hayes The MH Hospital Manual is specifically customized for each facility. A and Greg Glassman & Court- questionnaire will be faxed to obtain pertinent information (i.e., location of ney Grenfell MH cart, colors of test tub tops, important phone numbers). The customiza- by Diane & Bob Winters tion results in a unique and complete manual for your facility. The MH ASC Honor of the 60th Birthdays of Manual and Office-Based Manualcontain the same kind of information Judy Levine & Steve Lewis yet is more generic in nature to better fit the facility’s needs. by Marilyn Glassman ONLY $180 (includes S&H) To order, visit www.mhaus.org 11

Have you visited us Every MH-Susceptible Should Wear lately? Log on to A Medical ID Tag www.mhaus.org MHAUS has help available for the MH-susceptibles who have no insurance or cannot afford to purchase a to get the latest medical ID tag. The Sandi Ida Glickstein Fund was established for information on MH, the purpose of providing free ID tags for MH-susceptible patients who qualify. order materials, To take advantage of this program, please send us a letter indicating why you would like MHAUS to provide post a message to you with a complimentary ID tag. the bulletin board The goal of the free ID tag program is to ensure the safety of MH-susceptibles during an emergency situation or learn about the and to prevent a tragic outcome from MH. For further information, please contact MHAUS at “Hotline Case of P.O. Box 1069, Sherburne, N.Y. 13460-1069; call 607- 674-7901, or visit www.mhaus.org. the Month.”

I want to support MHAUS in its campaign to prevent MH tragedies Yes! through better understanding, information and awareness.

A contribution of: ❑ $35 ❑ $50 ❑ $100 ❑ $250 ❑ $500 ❑ $1000 (President’s Ambassador)

or ❑ (other amount) $ ______, will help MHAUS serve the entire MH community.

Please print clearly:

Name: ______

Address: ______

City: ______State: ______Zip: ______

Please clip out this Phone: ______E-mail: ______handy coupon, or feel ❑ I am MH-Susceptible ❑ I am a Medical Professional free to photocopy if you prefer to keep Please charge my ❑ Visa ❑ Mastercard ❑ Discover ❑ American Express your issue intact, then Name on card: ______mail to: MHAUS, PO _ Box 1069, Sherburne, Credit Card Number: ______NY 13460-1069 Expiration: ______MHAUS Happenings, Events and Notices ❑ THANKS! MHAUS is Pittsburgh, PA on April 23- able until December 31, 2009. grateful for the financial sup- 24, 2010. After that date you will receive port of the following State a Course Completion Certifi- Societies of Anesthesiol- ❑ Special Promotion for cate. Completed tests can be ogy: , , New and Renewing Mem- mailed to MHAUS office at . Our appreciation also bers. Get the In-service Kit P. O. Box 1069, Sherburne, goes to the following state for half price when you are NY 13460 or can be taken components of the American a new or renewing mem- online at the MHAUS website Society of PeriAnesthesia ber! The In-service DVD at www.mhaus.org Nurses: , , includes a presentation on and . Call the MHAUS MH recognition and man- ❑ Visit the MHAUS website office to ask how your group agement, information relat- for a video clip which demon- can join their ranks! ing to suggested dantrolene strates the mixing and injec- mixing, patient safety, risk tion of dantrolene. The DVD, ❑ MHAUS will attend the management material, and “Malignant Hyperthermia: ASA in New Orleans on a mock drill to reinforce the Knowing Your Role,” is avail- October 17-21. We hope to quick response time neces- able in three different quality see you there! sary in an MH event. The formats to match your Internet kit includes a test booklet connection speed. ❑ The next MHAUS Scien- offering 1 CEU upon suc- tific Meeting will be held in cessful completion is avail-

MHAUS P.O. Box 1069 Sherburne, NY 13460-1069 www.mhaus.org