Early afternoon, about 51/2 years ago, a middle-aged man was admitted to the ICU at the University of North Carolina REX Healthcare facility to recover after an elective abdominal surgery. He was there for a little while when his muscles clenched and his temperature and heart rate spiked rapidly. The anesthesiologist assigned to the ICU quickly assessed the patient and determined he was probably having a malignant hyperthermia (MH) crisis.

But the primary ICU nurse didn't hesitate or freeze because she had a plan — or a checklist to be specific. The team assisted the ICU intensivist, who called for the anesthesia tech in the nearest OR to bring the MH cart. Like a baseball manager, the primary ICU nurse gave everyone their roles and they sprang into action. They administered the dantrolene and stabilized the patient — and he survived.

Our staff is trained to respond to a malignant hyperthermia event anywhere in our 7-floor hospital. OR, ER, ICU, everyone knows their role and the locations of our 5 strategically stationed MH carts. How about you? Would your team save an MH patient's life? Could they quickly identify the MH event and treat the patient with dantrolene? The faster you can diagnose and deliver the antidote, the greater the likelihood of having a successful outcome.

How we got there

We didn't always have a protocol to follow. In 2012, I approached the anesthesia department to help me establish a protocol for the circulating nurse that clearly defined her role during an MH event. I got straight to the point. The very first thing I asked anesthesia was, "What does the circulating nurse need to do to assist you in response to the MH crisis?" I knew that, first and foremost, the circulating nurse should assist the anesthetist during an event.

But what else? We needed to ensure a predictable, reliable response. Our answer: a checklist that lists step-by-step instructions outlining who does what during a MH crisis. The MH Circulating Nurse Checklist hangs on the side of every MH cart and in a binder in every OR. We also created an MH cart policy so that we always had ready access to the many supplies you need in an MH crisis.

Many of the steps on the checklist will be familiar to anyone who has ever gone through an MH drill. But there are a couple aspects that I should highlight that are specific to our institution and are key to our quick response.

Our 5 MH carts

The MH cart is the first thing that needs to get to the bedside. Like tanks on a battlefield, we positioned our 5 MH carts in strategic locations throughout the facility. We perform surgery in 3 separate locations, so we placed a cart in each surgery wing. We have a cart in the ER and another cart in the pharmacy, a rover that can respond anywhere in the hospital.

Each cart covers a territory that's listed on a laminated chart attached to the cart. For example, the MH event happened in the ICU so the ICU intensivist called the anesthesia tech in OR East to bring over that MH cart. We update the anesthesia techs every year on which cart responds to where in the facility.

Our MH carts are all set up the exact same way. Each drawer is labeled clearly with what's inside. In the top drawer we keep all the drugs and lab supplies. The test tubes needed for labs are separated into Ziploc bags labeled 'mandatory' and 'optional.' In the other 2 drawers are supplies that anesthesia determined we needed, including a bladder irrigation set, Foley catheters and esophageal sensors.

The cart also has a fridge on the bottom with cold saline, insulin and cold packs. The cart is always plugged in when not in use and is hooked up to a computer that monitors the temperature all day. It can be unplugged quickly and wheeled down the hall during a MH crisis.

Once the cart is bedside, the circulating nurse starts assigning roles like getting ice, inserting the Foley catheter and calling the MH hotline. We noticed that during our MH drills things got pretty loud, so the carts include laminated role cards attached to the side that she can just hand out to people as they respond. As time is of the essence, she also assigns multiple nurses to start mixing the dantrolene. On top of the cart is a dosing chart that lists for a given patient's weight, the number of vials of dantrolene we need to open, the amount of mg to give the patient and the amount of dantrolene to administer once it's reconstituted.

The labs

Labs are a necessity during a MH crisis and you need the results STAT. But it can be a process to order labs. You have to go through your EHR to get the right lab order, print out the labels and send the vials off properly identified. In order to save time and confusion, I worked with the lab coordinator and their IT staff to develop a specific order set for MH labs. I first asked anesthesia which labs were mandatory during a MH crisis and which labs were optional depending on the patient's medical history or other factors. Then I contacted our surgical lab and respiratory IT employees to determine the fastest way to have all the MH order sets available electronically. IT made an order set so we just have to type in "MH" or "malignant hyperthermia" into the search box and all the lab work comes up automatically. So all you have to do is press a button and the correct labels print. This is a huge time saver and I recommend working with your institution to automate this process as best you can.

Going global

In the beginning, we only implemented the MH protocol in our 3 surgical services departments, but as our own event showed, MH isn't confined to surgery. A few years ago, we went global with our MH checklist and carts. We have to be ready to respond to a MH crisis anywhere in the hospital.

Since our facility is so large, we created a task force made up of representatives of several departments to make sure everyone was on the same page and aware of our MH protocol. The departments and people you include on your task force will vary depending on your facility, but anesthesiology should lead the way and your OR champion should be coordinating with the different departments to make sure everyone has what they need and follows MHAUS-recommended guidelines.

Our annual drills keep us ready to respond and let us see if there are any areas that need improvement in our protocol. Anesthesia is in charge of our drills and decides when they will take place. Generally they occur around the first quarter and we hold them in the morning during our in-service time. Anesthesia begins with a lecture on MH and the metabolic processes that occur during an event. Then, I go over our checklist and cart, and we get ready for our drill. Our Anesthesiology High Reliability Organization develops a scenario where a team is in the middle of surgery and the patient begins developing signs of MH. We do the drill in the OR and use a mannequin or one of the OR personnel if the mannequin isn't available. We have to make it as real as possible.

Staff roleplay as the people who'd respond to a MH event — the OR circulating nurse, the surgical scrub RN or tech, CRNA, anesthesia tech and surgeon. The OR circulating charge nurse assigns roles to the different OR personnel — a few to mix the dantrolene, someone to get the ice, someone to insert the Foley tube, someone to pretend to call the MH hotline. Of course every drill results in an excellent outcome. We debrief at the end and give all a chance to ask anesthesia questions.

We've refined this protocol year after year. After we drill, we talk about what went well and where we can improve. If there are areas of concern, we adjust the protocol to address them. We all do better in a crisis with a standard protocol to follow. We've updated our checklist 3 times, but the basic protocol hasn't changed: assess, get the cart, know your role and stabilize the patient. OSM