Are You Ready for an MH Emergency?

Anesthesia

By: Kimberly Macasieb

Published: 7/27/2020

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Realistic training ensures staff act quickly and confidently during a real crisis.


Our annual training for malignant hyperthermia (MH) emergencies used to be expected and ordinary. We sat through classroom learning, watched an educational video and clicked through a PowerPoint. It was boring and no one was engaged. It seemed like we tolerated training just to check a box to say we did it. We knew it could be better. Given the stakes, it had to be better.

MH is a potentially fatal, inherited disorder usually associated with the administration of triggering agents such as general anesthetics and/or succinylcholine. If an MH crisis isn't treated promptly, the patient can suffer severe complications such as cardiac arrest, brain damage, internal bleeding or failure of other body systems, according to the Malignant Hyperthermia Association of the United States (MHAUS). MH occurs in about one in 100,000 surgeries in adults and in one in 30,000 surgeries in children, according to MHAUS.

Most OR teams will never experience an MH crisis, so when it does happen, it can be hard to recognize and cause panic. Given the life-or-death nature of MH, we needed to better prepare staff for the real deal and decided to transition to simulation training. Practicing response protocols and teamwork in a tense, realistic situation gives staff the practice needed to feel confident they'll react appropriately and promptly during a real crisis, when every second counts.

1. Find the time

Simulation training is most effective when the drill is unexpected. Your staff won't be surprised if you conduct an MH in-service one day and simulation training the next. Space out the learning. Conducting an unannounced simulation 60 days after didactic learning will let you determine how much knowledge your staff has retained and gauge how they'd genuinely respond to an MH crisis. You can get a mock drill kit on the MHAUS website (mhaus.org) or use AORN's simulation scenario to help guide your training.

The most important thing you can do to develop and implement MH simulation training is get buy-in from anesthesia providers, who are key members of response protocols. Our providers were very involved and supportive of the project, but it was hard to get our schedules aligned. Luckily, our surgical department sets aside an hour two mornings each month for training. We used one of these time slots for the simulation. Anesthesia providers were excused from their normal meetings so they could join us.

2. Draw names

HOLD THE PHONE! During the simulation, one OR staffer stayed outside the operating room and acted as an MH hotline operator.   |  VA Southern Nevada Healthcare System

Members of our OR team were hesitant to be put on the spot during the simulation — they generally aren't outgoing when it comes to volunteering in front of a large group. To ensure individual staff members don't feel singled out, draw names to determine who will participate in the simulation. When a staff member's name is drawn, they get to draw the next name. Drawing names gives team members a sense of control. Once they get over the initial stage fright and the simulation begins, they'll assume their roles and get to work.

We drew four names out of a bucket to act the roles of RN Circulator #1, RN Circulator #2, surgical technician and runner. The remaining staff observed. Have the four staff members whose names were drawn stand outside the OR and inform them of the simulated situation. In our case, we told the staff a patient was undergoing a laparoscopic appendectomy and informed them of the patient's health history and baseline vital signs. When the staff members entered the OR, they found a patient with a simulated IV on the operating table and staff acting as the anesthesia provider, surgeon and resident.

A few minutes into the procedure, the anesthesia provider announced the patient was showing the early warning signs of MH. The circulators recognized the problem and jumped into action.

3. Add to the realism

STARRING ROLE After names are drawn from a bucket at random, they are assigned roles —— RN Circulator #1, RN Circulator #2, surgical technician and runner —— for the simulation.   |  VA Southern Nevada Healthcare System

Make a simulation as realistic as possible to ensure the OR staff treats the exercise as if it were the real thing, making it an effective learning experience. We had a staffer from another department act as the patient. He laid on the OR table, wore a patient gown, held an ET tube in his mouth that was connected to the anesthesia circuit, had a Bair Hugger blanket on and a back table was set up as it would normally be for surgery. We also set up an IV that ran a drainage pack that hid under the patient to simulate administering medications. We even worked with our hospital's pharmacy department to fill empty medication vials with simulated dantrolene powder, which we made by adding orange Crystal Light to water. It was important for OR staff to see that the simulated dantrolene was orange because they must reconstitute the real medication to an orange-colored uniform suspension.

During the simulation, an OR staffer stayed outside the operating room and acted as an MH hotline operator. We noted that staffer's cellphone number on a sticky note and stuck it over the MH hotline number posted on the MH cart. OR staff could call the cellphone number and simulate the experience of talking to someone on the hotline. The six most important steps in an MH crisis are:

  • recognizing the signs and symptoms,
  • calling for help from staff,
  • retrieving the MH cart,
  • administering the dantrolene,
  • packing the patient in ice and
  • calling the MH hotline.

Staff had to accomplish these objectives before our simulation ended.

It's vital to time the simulation so you can note how long it takes your staff to complete the critical steps of a response —— such as when they first recognized the signs and symptoms of a crisis and retrieved the MH cart. Our staff brought the MH cart into the OR in an average of 3.67 minutes from the onset of signs (that weren't obviously MH), which was fast. Then they administered the dantrolene in an average of 8.6 minutes, which met our goal to have this task completed in 10 minutes or less.

Essential Drugs of the MH Cart
Do you stock all of these key items?

In the rare event your OR staff finds itself facing a true malignant hyperthermia (MH) emergency, instant access to life-saving drugs and solutions is of paramount importance.

According to the Malignant Hyperthermia Association of the United States (MHAUS), the following drugs, solutions and agents should be on all MH carts:

  • Dantrolene — To treat an MH episode, an initial dose of dantrolene at 2.5 mg/kg is recommended.
  • Sterile water for injection USP (without a bacteriostatic agent) — It is mandatory to get dantrolene sodium to its effective site, the skeletal muscle.
  • Sodium bicarbonate (8.4%) — 50 ml x 4
  • Dextrose (50%) — 50 ml vials x 2
  • Calcium chloride (10%) — 10 ml vial x 2
  • Regular insulin — 100 units/ml x 1 (refrigerated)
  • Lidocaine for injection (2%) — 100 mg/5 ml or 100 mg/10 ml in preloaded syringes (3). Amiodarone is also acceptable. ACLS protocols, as prescribed by the AHA, would be followed when treating all cardiac derangements caused by MH.
  • Refrigerated cold saline solution — A minimum of 3,000 ml for IV cooling.

To view the full list of items (supplies, equipment, etc.) that should be included on your MH cart, visit: osmag.net/NqPXo3

— Outpatient Surgery Editors

4. Debrief and discuss

Gather the team after the simulation to reinforce teachable moments. What went well? What improvements can be made? What did they like about the simulation and what would they do differently if they could do it again? Process improvements are identified and staff share valuable insights during these discussions.

Only two out of the 24 OR nurses who attended the simulation had ever experienced a real MH emergency.

The rest of the staff learned a great deal. When you read about an MH crisis or watch a video about one, it's not nearly the same as practicing response protocols in a realistic setting.

During the simulation, staff said they felt a sense of urgency to treat the patient as quickly as possible. If our staff ever does experience an MH crisis, the simulation provides them with the muscle memory of tasks necessary to save the patient.

A better way to learn

We first conducted an MH simulation in 2018, and we've now made it part of our annual training. Our staff is much better equipped to deal with the rare instance of an MH emergency. We're now looking into using simulation training for other potential complications such as local anesthesia systemic toxicity (LAST), which we believe is another critical topic to cover. Simulation training is a more effective way to learn and we've found that staff enjoy participating in a dynamic training session. Having the surgical team practice the skills needed to respond to an MH emergency was the single greatest benefit of the simulation training. Our team told me afterward an MH crisis no longer feels like an unfamiliar and scary situation. Staff know responding to a real-life emergency will be stressful, but they have confidence knowing they've practiced response protocols that could someday help them save a patient's life. OSM

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