The mock codes at Mercy Hospital in Portland, Maine, were simply good practice until the end-tidal CO2 of a relatively healthy 54-year-old man undergoing routine shoulder surgery began to rise. Minutes later, he was in the midst of a fulminant malignant hyperthermia episode. The surgical team assembled bedside in seconds, established extra IV access, started mixing dantrolene and ultimately rescued the patient.
Later, the surgical nurses told Theresa Clifford, MSN, RN, CPAN, that the entire scene played out as they had rehearsed. "A nurse even retrieved the MH cart before anyone called for it because she recognized what was happening," says the hospital's nurse manager of perioperative services and the nurse liaison for special projects of the American Society of PeriAnesthesia Nurses. "The entire team knew exactly what to do and when to do it. That helped save a life that day."
Ready for action
Can you guarantee your staff won't face an MH emergency on your watch? No. But you can ensure they're prepared if an event strikes.
- Practice response protocols. "Drill, drill, drill," says anesthesiologist Andrew Herlich, DMD, MD, FAAP, professor and vice chair for faculty development at the University of Pittsburgh School of Medicine, who volunteers his services to the Malignant Hyperthermia Association of the United States (see "Answering the Calls for Help").
Don't run through the motions. Make your practice runs as realistic as possible. As Ms. Clifford's experience shows, staff who know exactly what to do are able to respond quickly and save lives.
Conduct mandatory annual MH drills for the entire surgical team, including anesthesia providers. Use expired dantrolene so staff feels what it's like to reconstitute the rescue agent with bucket-brigade-like precision. Clearly communicate your expectations, even if requests or responsibilities might seem obvious.
Ms. Clifford's surgery center has a limited supply of ice, but it sits on a hospital campus. "We had arranged with the dietary office years ago to make sure they responded in a timely manner if we called for ice," she explains. When the shoulder surgery patient became stricken, a food-service employee arrived quickly, but with only 2 small bags of ice, enough to spread on a sprained ankle. "Now, whoever makes the call for ice clearly states where it's needed, and that it's for a patient-life event," says Ms. Clifford.
Answering the Calls for Help
What must it be like to be on the receiving end of a call to the emergency hotline of the Malignant Hyperthermia Association of the United States?
"I'll tell you exactly what it's like," says anesthesiologist Andrew Herlich, DMD, MD, FAAP, professor and vice chair for faculty development at the University of Pittsburgh School of Medicine, who volunteers his services to MHAUS. "The very first case I got called about involved a 3-year-old. Two hours into the case the surgical team realized something was wrong. "The kid ultimately died," recalls Dr. Herlich, traces of the memories and emotions of the day still evident in his voice. "I needed help for post-traumatic stress disorder, and wasn't even actively involved in the case.
"Was that a typical outcome? No," he says. "But you can imagine the emotional burden surgical teams feel during MH events when trying to save the young, healthy lives they're responsible for."
— Daniel Cook
- Recognize warning signs. A panel of 13 MH experts published a guide in the January 2012 issue of Anesthesia and Analgesia that included key warning signs of an event and tips for transporting patients from surgery centers to hospitals for timely follow-up care and improved outcomes. The guide tells you to look for elevated ETCO2, muscle rigidity, hyperthermia, acidemia/acidosis and myoglobinuria during exposure to triggering agents — sevoflurane, desflurane, isoflurane, halothane, enflurane, methoxyflurane and succinylcholine.
Be aware that the telltale muscle rigidity might not occur where you'd expect. "The very first case of MH I ever experienced occurred when I was working with an oral surgery resident who was on his anesthesia rotation," says Dr. Herlich. "He recognized the attack because the patient's forearm muscle tightened, not the masseter muscle, which is the one that usually does."
Trust your instincts, and don't discount MH as a possibility when early warning signs manifest. "Denial — this can't be happening to us — is the worst way to react," says Dr. Herlich. "By the time you get to rescuing, it's too late."
- Call for help. Gather every available member of your clinical team to the patient's bedside, and call 911 and the MHAUS hotline (800-644-9737). The expert volunteers who staff the hotline are available 24/7 to help you manage emergencies or answer questions before or after anesthesia induction. You can also call with general questions or for guidance when deciding whether to operate on a high-MH-risk patient.
- Start treatment. Discontinue the administration of volatile anesthetic agents and succinylcholine, change the anesthesia breathing circuit, hyperventilate the patient with 100% O2, apply bags of ice to initiate surface cooling and begin mixing and administering the rescue agent dantrolene.
You must have 36 vials of IV dantrolene 2.5mg/kg on hand if you use triggering agents or succinylcholine, enough to deliver the maximum 10mg/kg dose to a 70kg patient. Reconstituting dantrolene vials with sterile preservative-free water is a labor-intensive process that demands help from as many members of your clinical staff as possible.
- Transfer for follow-up care. The experts published in Anesthesia and Analgesia say MH-stricken patients should be transferred to an acute care hospital when, if possible, they're deemed stable: ETCO2 is declining or normal, heart rate is declining or stable with no signs of abnormal beats, the administration of dantrolene has begun, core body temperature is declining and generalized muscle rigidity, if present, is resolving.
"Appropriate arrangements must be in place to transfer patients to a medical center that has an ICU," says Randall Klotz, CRNA, MEd, MSN, an anesthetist who practices at Miami Valley Hospital and Far Hills Surgical Center in Germantown, Ohio. "This would include a mobile intensive care unit transfer team or, at a minimum, an ACLS-qualified transport team."
Too risky for ASCs?
Mortality associated with MH events is much higher in outpatient settings than in acute care hospitals, according to Ms. Clifford. "The misconception is that patients seeking surgery in outpatient settings are basically healthy, but MH can occur at any time," she says.
Even patients who've had previous surgeries without experiencing MH might be at risk, notes Ms. Clifford, adding that it can take up to 6 exposures to anesthesia to have an event.
"ASCs can provide a safe anesthetic," says Mr. Klotz, who cares for patients in both surgery centers and hospitals. "The real issue surrounds the safe transport of stricken patients to a hospital for definitive care."
So can high-risk patients be safely operated on in outpatient facilities? "Absolutely," says Ms. Clifford. "Knowing that they have the propensity for an event is half the battle. There are better anesthetic techniques now that don't require use of triggering agents."
When sedating high-risk patients, MHAUS recommends you flush anesthesia circuits with pure oxygen for 20 minutes and monitor them longer than normal in PACU.
Pre-anesthesia assessments are a good screening tool that help identify at-risk patients, but you'll never know for sure. Always expect the unexpected, and practice emergency responses often enough so your surgical staff feels as if they've already seen their life-saving response in action.