MOCK DRILL Throw some curves into your MH drills.

The most fortunate among us will never have to deal with a case of malignant hyperthermia. I've been a nurse for 15 years, and I never have. I fervently hope it stays that way. But hoping isn't enough. I want to be prepared, and I want my team to be prepared. After all, those who fail to prepare — and who end up having to live with the consequences — are among the least fortunate among us.

The next level
Complacency is Enemy No. 1 when it comes to preparations for MH. It used to be that we watched an MH video once a year and took a test afterward. I didn't think that was enough. A lot of actions have to be taken when MH strikes, and they have to be done quickly and correctly. It's asking a lot to expect a group of people who watched a video 11 months earlier to be able to act as a cohesive unit during a life-and-death crisis in which every second counts.

So one of the first things I did was add a mock drill to our yearly training regimen. Nothing in the real world is textbook. You hear about all the signs and symptoms when MH strikes, but you may not actually have all the signs — you may only have a couple. It can be confusing. So I try to throw some curves into the mock drills. Maybe the patient doesn't have all the generic symptoms. Maybe in the middle of an MH attack, the patient has a cardiac arrest. Maybe the pharmacy didn't stock enough dantrolene. What are you going to do in those situations?

The first time we did a drill, we learned some things we couldn't have gotten from watching a video. For example, our chilled fluids are locked up in a Pyxis system, so we couldn't ask a scrub tech to go get them. We had to have a nurse be responsible for that job. Also, a lot of people didn't know where our ice machine was. Those are key concerns that you should address ahead of time, not during a real emergency.

Although there were some rough spots, fortunately our major processes were in order. A big reason for that was another improvement I implemented.

IF MH STRIKES Pre-printed instructions spell out each staff member's job during an emergency response.

All spelled out
If an MH emergency happens, everyone will know exactly what her specific duties are. I've printed out ID tags with instructions for every role that's involved, and I have the tags in lanyards.

So now if the circulator gets a code and people start rushing in to help, instead of having to say, "Go get this, go get that," she can simply pass out the code cards. If you're the cooling nurse, for example, you get your card and you immediately know the first thing you need to do is retrieve the cold IV and bottled sterile saline from the refrigerator. Nothing is left to chance or memory.

There are 8 kinds of cards in total. They cover anesthesia, the charge nurse, the circulating nurse, the cooling nurse, the dantrolene nurses (at least 3 people should be mixing dantrolene), the medication nurse, the recorder and additional runners. The recorder is in charge of the paperwork that needs to be done and the runners are there in case anything additional is needed — labs or extra ice, for example.

In an outpatient facility, one of the most important duties is to call 911 and begin preparations for transferring the patient to a hospital. You should have a standard transfer protocol in place and make sure everyone knows where and what it is. The anesthesia provider should decide when the patient is stable enough to begin the transfer.

IN BRIEF
4 Fast Facts About MH

WELL-STOCKED Your MH cart should contain 36 vials of dantrolene sodium.

• MH is triggered in susceptible individuals primarily by the volatile inhalational anesthetic agents isoflurane and desflurane and by the muscle relaxant succinylcholine.
• A telltale sign of MH is masseter muscle rigidity —a severe, sustained contraction of the jaw muscle you might see after you administer succinylcholine.
• Stock an MH cart containing dantrolene and the necessary supplies to help reverse the process. Have 36 dantrolene vials (containing 20mg/vial) available wherever you administer general anesthesia.
• With aggressive treatment, the mortality rate of MH is less than 5%. Without prompt and appropriate treatment, patients can die as a result of cardiac arrest, hypoxia or internal hemorrhaging.

Having those pre-printed instructions makes it a lot less chaotic. They're an easy reference at a time when it would be both easy and potentially catastrophic to forget something.

The cards can also help keep people from being overwhelmed. If you're on call and there are only 4 of you, you may have to double up on some of the assignments, and do the best you can. Note, however, that the dantrolene nurses should have one job only. We stress that that's the first thing that needs to happen — you need to get that cart in the room and start mixing up your dantrolene.

The best treatment
We follow the recommendations of the Malignant Hyperthermia Association of the United States (MHAUS) and stock our MH cart accordingly. And once a month we go through all our supplies to check expiration dates. You should also have their 24-hour MH hotline number (800-644-9737) posted in your ORs. MHAUS recommends having the anesthesia provider use a cell phone to call them, rather than tying up the only phone line to the room.

Of course the best way to treat MH is to prevent it from happening at all. Every patient's history and physical should include questions that can indicate a propensity for the condition: Have you or a family member ever had a bad reaction to anesthesia? Have you or a family member ever been hospitalized with heat stroke? Do you, or does anyone in your family, have a neuromuscular disorder?

MH-susceptible patients can still have outpatient procedures, but the anesthesia provider needs to be aware that all known MH triggers are off limits, including most inhaled general anesthetics, such as isoflurane, desflurane and sevoflurane. Nitrous oxide is not a triggering agent. Nor is propofol or ketamine. Avoiding triggering agents is the best prophylactic approach, but you should still be hyper-vigilant with potentially susceptible patients. Have dantrolene and the MH cart at the ready, and monitor the patient closely for early signs of MH. Some of the initial signs of MH are unexpected tachycardia or tachypnea, generalized muscle rigidity and hypertension.