Best Practices for MH Crisis Response

Readiness for the rare-but-serious sudden-onset condition requires preparation and repeated drilling.

A provider can go their entire career without encountering a malignant hyperthermia (MH) event. But if one does occur on your watch, a few minutes can make the difference between a lifesaving or catastrophic outcome.

Because MH is so rare, staff’s lack of real-world experience with the condition makes preparation essential — and a challenge. If you aren’t already, take these two critical steps now to set them up for success: Conduct drills and training sessions to familiarize them with MH, and have all the tools needed for MH emergency response easily accessible at all times.

Drill your staff regularly

The best way to test your staff’s current level of rapid readiness for a sudden MH crisis is a mock drill. “The first thing I advise any site that uses triggering agents is to check when their last mock drill or educational event was. They should be held at least once a year,” says Stacey Watt, MD, MBA, MHPE, FASA, president of the board of directors of the Malignant Hyperthermia Association of the United States (MHAUS).

Dr. Watt says surprise mock drills often produce the best results. “You get to see how they will respond,” she says. “You might think your team is ready, but it really shows when it’s not a planned drill.” She believes more vigilance about MH response is needed at many surgical facilities, and leaders should drill with the same regular cadence they use for fires or active shooter events. “With an MH event, if you don’t have an appropriate, timely response, deaths can occur,” says Dr. Watt. “And if you don’t experience an MH event, you can get rusty.”

Prepare your MH cart

Perhaps the most critical factor in MH response preparation is to ensure your facility’s MH cart is stocked, maintained and quickly accessible. While this sounds simple, the infrequency with which this cart is used can create surprising roadblocks when time is of the essence.

“A fully stocked and prepared MH cart is crucial,” says Carlos A. Ibarra Moreno, MD, PhD, DESAIC, an anesthesiologist at Toronto General Hospital.

The core product in the cart is dantrolene, the direct-acting skeletal muscle relaxant used to treat MH. Facilities that administer triggering anesthesia agents are required to have it on hand. MHAUS recommends having 36 vials on hand. State and federal agencies may have their own requirements. Regardless, facilities must be mindful of the shelf life and expiration dates of the medication. One tip is once replaced, use the expired vials to practice mixing during drills.

An additional challenge, and one that should be fully covered in mock drills, is that dantrolene isn’t ready to administer, but rather must be prepared by providers on the spot during an MH event. The medication must be carefully dissolved in sterile water, which should also be included in sufficient quantities in the MH cart.

Dr. Ibarra Moreno says other items that should be in the cart that can help your teams respond quickly to an MH event include activated charcoal filters for the anesthesia circuit, any ancillary equipment needed to run additional IV lines, a central venous line or an arterial line and a set of 60 cc syringes for mixing the dantrolene. (Check out MHAUS’ comprehensive list of what should be on your MH cart.)

The location of your MH cart is also key. The best location will vary by facility, but what’s important is that everyone knows where it is, and that it’s quickly and easily accessible to everyone in the OR. Dr. Watt suggests placing your MH cart next to your code cart.

Your MH cart should be checked weekly to ensure supplies are full and that nothing on it has been borrowed for other purposes and then not replaced, she says.

Deeper quarterly inspections of your MH cart should include checking for missing or expired medications, as well as the basic functionality of the cart. For example, is it mobile with properly working wheels? Is it easily pushed by one person and accessible from multiple rooms? Do any of the drawers stick? “I’ve seen carts that had no wheels, and one that was chained to a wall,” says Dr. Watt. “In a crisis, those kinds of things can cost precious seconds.”

Practices to save lives

LIFESAVER The core product in the MH cart is dantrolene, which is crucial to administer quickly.

A well-stocked MH cart does little good without strong, well-understood protocols in place.

The key to successfully managing an MH crisis is early recognition. “The anesthesia provider should be the team leader,” says Dr. Ibarra Moreno. “That person tells the surgeon ‘Houston, we have a problem,’ and the next step is to call for help because this is a team effort. It requires the people already in the OR and additional people who may be floating and able to help.”

Your staff’s promptness in administering dantrolene is a key predictor of survival for patients who experience MH. “If we need seven vials of dantrolene to mix and have seven pairs of hands, it can be done quickly. If there is only one person, it takes longer,” he says.

Your staff should be cross-trained in multiple roles within their scope of practice so they can jump in wherever they’re needed during an MH emergency. “In an MH event, the more hands, the better the outcome,” says Dr. Watt. This includes calling for additional staff who are not involved with the patient’s scheduled procedure to assist.

“I’ve never seen teams pull together more than during an MH crisis,” says Dr. Watt. “On the MHAUS crisis hotline [800-644-9737] you can hear the difference in tone between the teams that have really practiced this and those that haven’t. And I’m sure that’s reflected in the outcomes.”

Due to the infrequency of MH events, training needs to be as memorable as possible for staff. “Because it is an almost-never event, it’s important to enforce that ‘sticky’ factor,” says Dr. Watt.

She advises facilities to provide information to staff in advance, perform drills and administer post-training quizzes. “Then, wait half a year and revisit the information,” she says.

She also recommends conducting a second, preferably unscheduled drill if a post-training quiz shows a decline in correct answers. “I believe unscheduled drills are the most effective way to reinforce the learning,” she says. “It improves recall and the ability to react. It saves lives and is better for the team and their comfort. They will be so thankful for the training if they’re faced with a crisis.”

Dr. Watt has seen the results of effective training firsthand. She recalls one case in which a pediatric patient was in an evolving MH crisis.

“They saw the patient seemed tight, and the anesthesiologist realized quickly that the paralytic wasn’t the problem,” she says. “Their CO2 and their temperature was rising. So they caught it very early.”

The team then immediately called for help and responded quickly and efficiently. MHAUS recommends administering dantrolene within five minutes, but in this case, they did it within two minutes.

“I was incredibly proud of the team and how well choreographed they were throughout the event. They were proud as well,” says Dr. Watt. “More importantly, the patient did great because the response by the team was so quick.”

Diligence is key

Proactive planning is key to readiness. By running regular, realistic drills and stocking your MH cart, you can ensure a high-confidence response if an MH event occurs. When seconds matter, the only thing more powerful than the right medication is a team that knows exactly what to do. OSM