HANDS-ON APPROACH Using expired vials to practice reconstituting dantrolene adds realism to drills and familiarizes staff with the time-sensitive task of preparing the drug for administration.

Today might be the day you get called into the OR to help save a patient stricken with malignant hyperthermia. Does that thought fill you with a jolt of panic or calm confidence in knowing your staff will be well on their way to stabilizing the patient by the time you arrive?

It's estimated that malignant hyperthermia occurs once in every 100,000 surgeries, but don't let that low incidence rate fool you. MH can strike at any time, without warning, and when it does, it comes on quickly and progresses even faster. Your surgical team must react like seasoned professionals who've responded to MH before and know precisely what to do and where to be in an emergency. If you conduct regular and realistic MH management drills, they'll be ready to spring into action when seconds count and a patient's life hangs in the balance.

What better way to assess your staff's baseline understanding of MH than with a quiz? Based on how well your team scores, you can tailor your subsequent training to fill in identified knowledge gaps. (Quick tip: Have each staff member identify their quiz with a unique symbol, so they can view their corresponding scores anonymously when you post the results.) Here's a variety of questions to consider asking:

What causes MH? MH is a rare genetic disorder marked by severe responses to anesthesia. Not all anesthetic agents will trigger susceptible patients. Some, though, like isoflurane, desflurane, sevoflurane, and the muscle-relaxant succinylcholine, can cause life-threatening reactions.

What are the early warning signs? Your staff should be able to recognize changes in a patient's condition that indicate the onset of an episode, including muscle rigidity, flushed skin, rising end-tidal CO₂, tachycardia and rapid breathing. MH can strike at any time in anesthetized patients, including when the patient is in recovery, so recovery area nurses should be aware of the possibility and remain vigilant.

DO YOUR JOB Assignment cards tell staff members where to be and what to do during each phase of an emergency response.

What are the treatment options? Three formulations of dantrolene, which specifically combats muscle contractions caused by MH, are currently available: Dantrium, Revonto and Ryanodex. Dantrium and Revonto come in 20 mg vials and require 60 ml of sterile water for reconstitution. Ryanodex, a newer formulation, comes in 250 mg vials and should be reconstituted with 5 ml of sterile water. You must stock 36 vials of Dantrium or Revonto. You only need to stock 3 vials of Ryanodex to administer the initial 2.5 mg/kg stabilizing dose. While you can reconstitute Ryanodex in less time than Dantrium and Revonto, it costs more than twice as much as the other treatment options. It'll cost you $2,500 for Revonto, $2,340 for Dantrium and $7,500 for Ryanodex, per the companies.

What should be stored in MH carts? In addition to the vials needed for the initial dantrolene dose, stock sodium bicarbonate, dextrose, calcium chloride, regular insulin, lidocaine for injection and sterile water to mix with dantrolene. The cart should also contain syringes that can be used to reconstitute dantrolene, IV catheters, NG tubes and Toomey irrigation syringes. Include charcoal filters, which can be attached to the inspiratory and expiratory ports of anesthesia machines during cases involving MH-susceptible patients to flush the breathing circuit and reduce the concentration of delivered anesthetic gases.

Practice to perfection
After tallying the results of the quiz, present an MH-response lesson based on your staff's educational needs. Epidemiology, symptoms and treatment of MH were areas of focus at our hospital.

The Malignant Hyperthermia Association of the United States (MHAUS) can offer plenty of useful resources for your educational efforts — including posters and script cards for everyone involved in an emergency response — that detail how to communicate, what needs to be done and when to do it (mhaus.org). We tabbed anesthesia providers and surgeons to take charge during MH emergencies, while the OR nurses and surgical techs took on their own responsibilities. Here are some suggestions for how to divvy up the assignments:

Surgeons should end the procedure as quickly as possible and help with response protocols.

Anesthesia providers should discontinue inhalational agents, hyperventilate the patient with 100% oxygen, lavage the patient with cool saline solution and oversee the response efforts.

Circulating nurses can ask for help from all available employees, retrieve the MH and crash carts, prepare dantrolene for administration, assist the anesthesia provider in treating secondary symptoms — including metabolic issues such as acidosis, hyperkalemia and rhabdomyolysis — and patch the OR through to the MHAUS hotline (800-644-9737).

EASY ACCESS Stock MH carts with enough dantrolene to administer the initial dose and the many supplies needed to help save a life.

OR nurses can assist in reconstituting dantrolene and call 911 to get the stabilized patient transferred to an intensive care unit as quickly as possible.

Surgical techs and additional staff members can retrieve and restock bags of ice that are used to cool the patient, and support other members of the response team as needed.

Discuss as a group how to reconstitute dantrolene, where to obtain bags of ice to pack around the patient, how to properly document an event and the protocols for working with responding emergency medical technicians to transfer patients to a local hospital for follow-up care. MHAUS can also be a valuable resource during your team's drills. We called the hotline during our practice session and listened as one of the organization's experts helped walk us through proper response protocols and answered questions we had during the exercise. With the expert's steady pacing over the 15-minute exercise and reiteration of how and when to run the commands noted on the script cards, our first drill went off as smoothly as possible.

Reconstituting dantrolene quickly and efficiently was a particular challenge for our team. Revonto and Dantrium expire in 36 months, and Ryanodex expires in 24 months, so we used outdated vials to provide staff with the opportunity to work through the reconstituting process. The hands-on practice gave them a real sense of how the process works and the coordination that's needed among team members to prepare the drug for administration. With additional guidance from the MHAUS expert, we maintained clear communication and maintained a good pace, and we're confident we can match our performance during a real-life event.

After the drill, discuss what worked, what didn't, and how to address areas of needed improvement. Also distribute a post-evaluation test identical to the quiz your staff took before the educational sessions and drill. If my staff's performance is any indication, you'll likely find that their knowledge of MH and how to respond to emergencies will improve across the board.

Always be prepared
The rarer the event, the more important simulated drills are for response preparedness. Adding variety and complexities to sample scenarios used during your annual drills will keep staff engaged and constantly learning. For example, running a drill based on the rescue of a pediatric patient is one way to raise the stakes and reinforce the importance of having response protocols down cold.

Thankfully I've never had to deal with an actual MH event, but knowing how to react to a crisis gives our staff the confidence they need to save a life. Even general awareness of MH makes them more cautious in their approach to surgery and, because they understand that MH is a genetic disorder, they realize the importance of properly screening for susceptibility and how to proceed in the care of at-risk patients. They also understand that you can never be certain when MH will strike, and they realize that knowing how to respond quickly and calmly when it does is a life-saving skill every surgical team member should have. OSM