SUPPORT GROUP Call all available hands to the patient's bedside during an MH event.

Our facility's medical director squared off against malignant hyperthermia twice in his career. He once helped rescue a child when the condition's warning signs were noticed early enough to intervene. He was also involved in a case that didn't have a similar happy ending. Having seen both positive and negative outcomes of this potentially deadly event, he's hammered home the importance of screening for high-risk patients, rapid emergency response and targeted treatment when every second counts. Here's how to be sure you have effective MH prevention and response protocols in place.

WITHIN ARM'S REACH

MH Kit Essentials

Keep a malignant hyperthermia response kit in your anesthesia workroom or in an easily accessible location. It should contain:

• 36 dantrolene vials
• mini spikes for dantrolene vials
• sterile water IV bags
• syringes (60ml)
• IV tubing and bag spikes
• stopcocks
• supplies for drawing blood
• illustrated MH treatment algorithms
• drug dosing calculation and charting forms
• Malignant Hyperthermia Association of the United States' hotline (800-644-9737)

Note: Also wheel in your crash cart during MH emergencies for accessing medications to treat arrhythmias, acidosis and electrolyte disorders.

— Rachel Shulkin, RN, BS

Know the risks
Ask patients if they or anyone in their family has experienced MH or other anesthesia-related complications. MH is an inherited musculoskeletal disorder, so ask patients who've never undergone anesthesia if any close family members have histories of MH. Patients with immediate family members who've suffered an MH event are at greatest risk. (MH risk is also heightened for patients with distant relatives who've suffered the disorder.) Patients with personal histories of MH or close family members with the condition aren't candidates for surgery in freestanding facilities without access to adequate emergency backup personnel and equipment.

Recognize warning signs
Monitor patients' vital signs, blood pressure, respiratory rate, pulse, EKG, O2 saturation, capnography (end-tidal CO2) and body temperature during surgery, watching for signs of serious reactions to anesthetics. The first warning sign of MH is typically tachycardia. This can happen for many reasons, but when it occurs along with a rapid doubling or tripling of end-tidal CO2 values without a known cause, MH is likely occurring. When ETCO2, heart and breathing rates, oxygen saturation and core temperature change unexpectedly, always suspect MH.

In addition to close patient monitoring, look for MH's other early warning signs, including muscle rigidity, masseter spasm and flushing. An increase in core temperature is an obvious red flag, but typically occurs after you should have recognized the start of an event. MH can also present post-operatively, so continue to monitor patients in recovery until they're ready for discharge.

DOWN THE LINE Teamwork is essential for reconstituting dantrolene and charting how much is administered.

Tout teamwork
Conduct annual MH in-services. Include education on MH's basic pathophysiology, how to conduct pre-op screenings, symptoms to look for during and after surgery, and how to effectively treat the condition (see "When MH Strikes"). Make sure the surgical team knows where your MH kit is stored and how to use its contents (see "MH Kit Essentials").

Dantrolene, the rescue agent used to treat MH, must be reconstituted before being administered. The reconstituting process is labor intensive, so be sure your in-services train nurses on calculating accurate doses and working as a team to mix the drug rapidly and administer it effectively.

Make training as realistic as possible by staging mock MH events. Have your physicians, nurses and surgical techs rotate through each response role: mixing drugs, monitoring the patient's vital signs, calculating drug dosages and charting how the emergency response unfolds.

React and reassess
Transfer stricken patients to a nearby hospital as soon as possible. Members of your staff must continue MH treatments during transport. Patients will be admitted to the ICU for at least 24 hours for continued treatment with dantrolene and constant monitoring. Patients and their families will also be counseled about MH and further precautions needed during recovery and before future surgical care.

After an MH event, follow up with patients to ensure they receive needed post-event care. Also break down each step of the emergency and how your staff responded to assess what they did well and what they could improve upon the next time they're faced with this life-threatening emergency.

EMERGENCY RESPONSE

When MH Strikes

ACTION HEROES Assign clinical staffers to specific response roles for quick and efficient treatment.

1. Get help. Call the entire clinical staff to the patient's bedside, activate your facility's emergency response protocols and call 911. Also call the hotline of the Malignant Hyperthermia Association of the United States (800-644-9737). MH experts man the hotline 24 hours a day to offer guidance during MH crises or to answer pre-, post- or intraoperative anesthesia questions.
2. Stop anesthesia. Discontinue the administration of volatile anesthetic agents and succinylcholine, change the anesthesia breathing circuit, hyperventilate the patient with 100% O2 and notify the surgeon to halt the procedure or finish as rapidly as possible.
3. Mix dantrolene. This is where emergency response training pays off and teamwork is essential. Assign roles to each staff responder so someone retrieves the MH response kit, reconstitutes and administers dantrolene, calculates doses and charts how much is administered throughout the event. Your MH kit should contain 36 dantrolene vials, which totals 720mg of the drug. Dantrolene is given at 2.5mg/kg per dose, with a maximum dose of 10mg/kg. Having 36 vials on hand provides a little more than the amount needed to administer the maximum dose to a 70kg patient.
4. Apply cooling measures. While medications are being administered, and if the patient's core temperature has already risen, apply ice packs to body surfaces, substitute cold 0.9% normal saline for the IV infusion, and irrigate the stomach, bladder, rectum and any open body cavity with ice water.
5. Transfer. If you run a freestanding surgery center, it's extremely important to transfer the patient to a local hospital as soon as possible. Call for an ambulance the moment MH is recognized, and continue MH treatments on the way to the hospital. Send an anesthesia provider and nurse with the patient so they can continue administering dantrolene and monitoring the patient's ETCO2, core temperature and vital signs until the hospital's ER staff takes over.

— Rachel Shulkin, RN, BS