Mock drills prepare perioperative professionals to manage a malignant hyperthermia event.
Photo source: Hommertzheim R, Steinke EE. Malignant hyperthermia--the perioperative nurse's role. AORN J. 2006, 83(1): 160.
Reprinted with permission from AORN, Inc,
Denver, CO.














 

Perioperative professionals need to be prepared to handle unexpected emergencies. While rare conditions like malignant hyperthermia may not be a risk that perioperative and perianesthesia nurses are necessarily looking for, experts say it should be.

"Malignant hyperthermia (MH) is something that most facilities believe they are prepared for as long as they have a supply of dantrolene sodium and a protocol for managing MH, but this preparation is worth little if all staff don't know exactly what is their role is in handling an MH event," said Dianne Daugherty, executive director of the Malignant Hyperthermia Association of the United States (MHAUS).

"'Do you know the early signs of MH? Do you have 36 vials of dantrolene sodium on hand? Do you know what solution should be used for mixing? These are some of the questions that need to be answered in order for a team to be prepared to get a patient through an MH event," Daugherty stressed.

Malignant hyperthermia is a rare genetic condition that can be triggered when an MH-susceptible patient is exposed to certain inhalation anesthetics. This exposure can cause the patient to experience a severe hypermetabolic state, which can lead to cardiac arrest, brain damage, internal bleeding and death.

"Because this condition is uncommon, it may not be a key concern for healthcare professionals during surgery, but that is exactly why everyone needs to be ready," Daugherty said. "MH is an all-hands-on-deck type of situation."

Know the signs
"It should always be in the back of your mind that malignant hyperthermia could happen, even if the patient has made it through surgery," stressed Mary Asher, MSN, CS, CPAN, an experienced perianesthesia nurse and clinical instructor at the University of Miami School of Nursing and Health Studies.

Asher speaks from experience. Several years ago she lost a patient to MH.

"He was a healthy, 39-year-old undergoing a simple surgical procedure. I was asked to make a bed available for this patient in the PACU, but the patient never came. I learned that as the surgeon left to tell the family that the surgery went as planned, the patient went into an MH-induced cardiac arrest and died on the table," she explained.

"When this happened I asked myself, 'if this patient had made it to my area and then exhibited symptoms of MH, would I have known what I needed to know to save his life?' I couldn't say for sure," Asher said.

So, she began researching malignant hyperthermia to understand the early warning signs and best practices for treating the condition. After gathering information from MHAUS and professional organizations like AORN, Asher developed her research into an MH in-service to share with local hospitals.

"Recognizing the early signs of MH is critical," she emphasized. "Use your observational skills. Look at increasing CO2 and masseter muscle rigidity. If the patient is tachycardic, but there is no reason for this, ask questions. The earlier you pick up MH symptoms, the better," she advised.

She also stressed that every perioperative professional, whether they work in pre-op, intra-op or post-op, needs to understand how to detect and treat MH.

Be prepared"Assessment is the real key. Nurses need to understand the critical role they play in determining the risk of MH," said Bonnie Denholm, RN, MS, CNOR, perioperative nursing specialist in AORN's Center for Nursing Practice.

Denholm and members of AORN's 2006-2007 Nursing Practice Committee worked closely with MHAUS to update AORN's Malignant Hyperthermia Guideline, which is published in the Perioperative Standards and Recommended Practices, 2008 Edition. Updates to the guideline include new information on the complete plan of care for an MH patient, beginning with preoperative nursing care.

According to the guideline, the perioperative nurse should ask patients and their families a series of questions to help screen for susceptibility to MH, such as

• Have you or a family member experienced a high fever while under anesthesia?
• Has anyone in your family died unexpectedly in the operating room?
• Have you or anyone in your family experienced sunstroke, heat stroke or exercise-induced muscle breakdown resulting in hospitalization?

"Asking questions in layman's terms can open discussion and help patients and family members talk about situations that relate to susceptibility for MH. Communicating this information to the surgeon and anesthesia care provider means steps can be taken to protect the patient," Denholm said.

Ensuring intraoperative preparedness for MH is also critical, she stressed.

Facilities may be concerned with the cost of keeping 36 vials of dantrolene sodium on hand, but during an MH crisis every second counts and all needed medication should to be available, she said, adding that expired dantrolene sodium can be used in mock drills to help nurses get a feel for mixing the medication.

Denholm, Asher and Daugherty all agree that mock drills for MH events are a good way to help each member of the OR team understand his or her role in treating a patient with malignant hyperthermia. MHAUS recommends MH mock drills every six months to maintain MH treatment skills and ensure that everyone is aware of protocols for communicating with the OR team and possibly transporting the patient.

Plan aheadTransfer of care for patients in MH crisis is an important issue MHAUS is currently working to address, particularly for ambulatory surgery centers that may need to transfer a MH patient to an inpatient facility.

"If an ASC plans to transfer patients in MH crisis to a nearby hospital, they need to make sure that facility is prepared to care for that patient with the necessary medication and resources," MHAUS's Daugherty noted.

She says MHAUS receives a number of questions regarding transfer of care and caring for an MH patient in an ambulatory setting. To address these concerns her association developed an ambulatory MH procedural manual in 2001.

In September 2007 MHAUS also organized a consensus meeting to address the needs and concerns ASCs may have about MH. Discussions from this meeting are currently being gathered to create a white paper, which MHAUS will distribute later this year.

AORN also addresses MH care in ambulatory surgery settings through the updated Malignant Hyperthermia Guideline. "The key is communication. We encourage all perioperative professionals to speak with colleagues and MH-susceptible patients to work together and determine options," said AORN's Denholm.

Work with patientsAORN and MHAUS both support the need to educate patients about malignant hyperthermia.

"Patients need to have a clear understanding of what malignant hyperthermia is and why they need to communicate with family members and health care providers if they are suspected to be MH-susceptible," Denholm explained.

Because malignant hyperthermia is a genetic condition, relatives of MH-susceptible patients have a chance of inheriting the susceptibility, so family members also may need to be tested before they undergo surgery.

The standard diagnostic test for determining MH-susceptibility is the caffeine-halothane contracture test, which involves taking a biopsy of muscle from the thigh and exposing the muscle in a controlled environment to a solution of caffeine and/or halothane (an anesthetic agent that can trigger MH). However, there are only a few biopsy centers in the United States and the patient must have the muscle biopsy done at the center.

Molecular genetic testing is a less expensive and less invasive alternative to the muscle contracture test that can be valuable to family members of MH-susceptible patients.

"We are now able to offer a person who is known to be MH-susceptible by a muscle contracture test or an MH episode a simple blood test to detect the genetic variants that are known to cause MH. Through the test, the known DNA variants that are causative for MH are searched for. If variants are found, the patient's children and relatives should also undergo genetic testing to determine if they also carry the same DNA variants as their parent," explained Daugherty.

"The catch with genetic testing is that we don't know all the variants that cause MH and, if the parent's variant is not found in the child, the only way to determine susceptibility is by the muscle biopsy test," she added.

This is why MHAUS supports the North American Malignant Hyperthermia Registry of MHAUS, which records all patients in the U.S. who report testing positive for genetic MH-susceptibility. Through the Registry, MH genetic variants are being compiled so more can be understood about malignant hyperthermia.

"The research end of what we do is very important," Daugherty stressed. She encourages anyone with a known MH-susceptibility to contact the Registry to assure their personal information is in the database.
 
Stay connectedDaugherty and AORN's Denholm both agree that staying current with new research and guidelines on malignant hyperthermia is the key to preventing an MH crisis.

"Nurses play a critical role in MH awareness and management," Daugherty acknowledged. "By working with AORN we are able to understand the needs of perioperative nurses who must face the risks of malignant hyperthermia in their daily practice and work together to develop resources that can lead to safer outcomes."

Additional resources

Malignant Hyperthermia Association of the United States

MHAUS Emergency Hotline
800-644-9737
(US and Canada)

+1-315-464-7079
(outside the US)

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