The north american malignant hyperthermia registry

The North American Malignant Hyperthermia Registry Report of Anesthesia in a
MH BIOPSY NEGATIVE PATIENT
(“MHN Report”)
INSTRUCTIONS
This form is to be filled out by an anesthesiologist or other health care provider.

1.
Complete this form each time you anesthetize a patient who has had a negative MH
biopsy (caffeine halothane contracture test).
The attending anesthesiologist should review the completed form. If the patient has been registered previously in the NAMH Registry, please ask the patient for his Registry identification number and record it in the space provided. A copy of this report may be given to the patient. Please send the original completed
form to the NAMH Registry.
The North American Malignant Hyperthermia Registry North American MH Registry Number (for office use) MHN REPORT

PATIENT IDENTIFICATION
1. Any previous North American MH Registry numbers associated with the patient. That is, the
Registry number of this patient on a Biopsy Report, AMRA, or AKA or the Registry number’s of a close relative’s reports, etc. a. ____ ____ ____ ____ ____ Comment ___________________________ ____ ____ ____ ____ ____ Comment ___________________________ ____ ____ ____ ____ ____ Comment ___________________________ Has consent been obtained to enter patient's name into the Registry? If yes, please complete a-g on following page. Note: DO NOT COMPLETE IF CONSENT HAS NOT BEEN OBTAINED
_______________________ ___________________________ __________________ _______________________ ___________________________ __________________ ________________________________________________________________________ _______________________ ___________________________ ____________________ (Work) (_____) _____ - _______ Patient e-mail address _______________________________________________ DEMOGRAPHIC INFORMATION

4.
Year of patient’s birth __ __ __ __ (data utilized for demographic purposes only) ( ) other (specify):___________________________________________________ ( ) Other (specify):_____________________________________________________ State or province of the patient’s residence State or province of the facility in which anesthesia was given. Reporting physician’s name (optional) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ ( ) Ambulatory Surgical facility on hospital campus ( ) Free-standing ambulatory surgical facility __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Anesthesia Department telephone number and/or email address (optional) (__ __ __) - __ __ __ - __ __ __ __ _________________@_____________
ANESTHETIC HISTORY

15.
Patient’s anesthetic history is positive for: ( ) positive calcium uptake test (performed in Boston) ( ) other (specify) _____________________________________________________ How many times was this patient anesthetized prior to this evaluation? Indicate the number of anesthetics with the following agents: __ __ volatile agents without succinylcholine __ __ volatile agents with succinylcholine __ __ succinylcholine without other known triggering agents Year of negative MH muscle biopsy (caffeine halothane contracture test) __ __ __ __ ( ) Presbyterian University Hospital (Pittsburgh) ( ) other (specify):_____________________________________________________ ANESTHETIC MANAGEMENT
21.
( ) other (specify) _______________________________ ( ) other (specify):_____________________________________________________
MONITORING UTILIZED

24.
( )other (specify):_____________________________________________________ ( ) monitored anesthesia care (local with anesthesia stand-by) ( ) general anesthesia with a face mask only ( ) general anesthesia with a laryngeal mask airway
( ) general anesthesia with endotracheal intubation
( ) general anesthesia with volatile agents (potent inhalation anesthetics)
Pre-medication and anesthetic agents utilized: ( ) sodium citrated citric acid (Bicitra) ( ) IM succinylcholine (Anectine)
( ) IV succinylcholine (Anectine)
( ) NO succinylcholine
( ) NO potent volatile anesthetic
( ) other (specify): _____________________________________________________ Total duration of potent inhalation anesthetic administration: __ __.__ (in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) Was a barbiturate given prior to the potent inhalation anesthetic? Was a non-depolarizing neuromuscular blocker given during the potent inhalation anesthetic? Maximum observed perioperative temperature and end-tidal pCO2 : Were any signs of MH noted during this anesthetic? Abnormal signs felt to be inappropriate in the judgment of the attending anesthesiologist (a number may be used more than once if signs 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):____________________________________________________ fill in the blank, write unknown if results not known most abnormal arterial blood gas after MH was suspected __ __ __ Time (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 MH
reaction suspected
check all treatments utilized; fill in the blanks ( ) Intraoperative or postoperative dantrolene given __ __ __ Time required (after anesthetic induction)
(in hours, express parts of an hour using decimal points) (example – 3 minutes = 0.05) __ __ __ __ Total dose given after induction (mg) Method (specify) ______________________________ Fluid type (specify) ____________________________ ( ) Other (specify):________________________________________________________
COMMENTS ON PATIENT
Optional
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Source: http://www.mhaus.org/public/registry/1006MHN.pdf