We'll always remember that day. Our surgical team had just anesthetized a patient for spine surgery when the anesthesiologist noticed the end-tidal CO2 readings were rising and signaled to everyone in the room to initiate our malignant hyperthermia response protocols. The team members sprang into action like they had done it countless times before, because in fact they had through regular drills and education sessions.

We were prepared, and executed the response plan to perfection. The patient was stabilized and transferred to the ICU, where he eventually recovered.

Our efforts to save the patient's life that day began months earlier when we heard that regulatory surveyors had asked other facilities to demonstrate their responses to an MH crisis. We decided to initiate regular sessions for our team to review the contents of our MH cart, and simulate a response to an emergency situation. Additionally, we wanted our staff to know the correct responses to the following 5 questions.

The Malignant Hyperthermia Association of the United States (MHAUS) says about 1 out of every 2,000 to 3,000 people are genetically susceptible to MH, but many carriers are often unaware of the risk they face in surgery. Although rare — ?MH is estimated to occur in 1 out of every 100,000 surgeries, according to MHAUS — ?you must be prepared to respond to an episode during every case. MH is triggered by commonly used inhalational anesthetics and succinylcholine, a neuromuscular blocker and paralyzing agent. Cardiac arrest, brain damage, internal bleeding and failure of body systems can result. The cause of death is usually secondary cardiovascular collapse.

First, make sure the cart is easily accessible. We keep our cart in the middle corridor, a few feet from the back door of the OR. We also hung 7 task cards on one of the cart's handles; The charge nurse passes them out to staff members who arrive to help stabilize the patient (see "Task Cards Organize Response Efforts").

MHAUS provides a comprehensive list of supplies and medications that should be stored on the MH cart (osmag.net/C4EjrK). During our debriefing after the case involving the spine surgery patient, a nurse said she had trouble getting to the anesthesia cart, where the supplies needed to start IVs were located, because there were so many people in the room. We have since added the supplies to the MH cart based on that observation.

Immediately place calls to your facility's main desk (or whoever can alert the entire staff about the emergency) and the MHAUS Hotline (800-644-9737) for real-time access to an MH expert who will guide you through the response protocols. You can put the expert on speakerphone or have a staff member stay on the line to relay the patient's condition to the expert and the expert's advice back to the OR staff. We place a magnet with the MH hotline number on each anesthesia cart in every OR.

Follow the standard MH algorithm, which outlines each step of the response protocols. At our facility, the algorithm is adhered to the top of the MH cart. The critical first step is to start reconstituting the dantrolene as soon as possible.

Stop the flow anesthesia immediately and begin hyperventilating the patient with 100% oxygen. It's also a good idea to attach activated charcoal filters to the anesthesia machine's breathing circuit to remove traces of the volatile anesthetic that triggered the event. Reconstitute dantrolene for administration as soon as possible. Pack ice under the patient's armpits, around his neck and on his groin. Also obtain cold isotonic saline for IV infusion and for irrigating the surgical wound.

This depends on which of the 2 currently available formulations you choose to stock. Dantrium (Par Pharmaceutical) and Revonto (US WorldMeds) come in 20 mg vials that require 60 ml of sterile water to reconstitute. You should stock 36 vials of each formulation to have enough on hand to stabilize the patient. Ryanodex (Eagle Pharmaceut-icals) comes in 250 mg vials that require 5 ml of sterile water to reconstitute. You should stock 3 vials of the drug to stabilize the patient. Store enough vials on the MH cart to deliver the initial stabilizing dose an initial dose at 2.5 mg/kg ?within 5 minutes of MH being diagnosed, but have a plan in place to obtain more vials as needed.

Ideally, we assign 3 or 4 nurses to reconstitute the dantrolene. They use IV spikes instead of needles to infuse the vials with sterile water, because the spikes have a larger gauge and can deliver higher volumes of fluid more quickly.

When the spine patient exhibited symptoms of MH, everyone on our staff responded perfectly and followed our response plan exactly as we had hoped. The team was extremely proud of their success and was inspired to refine our protocols even more for the next emergency. We're ready to save a life. Are you? OSM