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CONTINUING EDUCATION
Developing Effective Drills in
Preparation for a Malignant
Hyperthermia Crisis
SHARON J. HIRSHEY DIRKSEN, PhD; SHARON A. VAN WICKLIN, MSN, RN,
CNOR, CRNFA, CPSN, PLNC; DARLENE LEDRUT MASHMAN, MD;
PAM NEIDERER, BSN, RN; DEBRA ROSE MERRITT, MSN, CRNA
4.7
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Purpose/Goal
To enable the learner to rapidly recognize and treat a malignant
hyperthermia (MH) crisis.
Objectives
1.
2.
3.
4.
5.
Describe the etiology of MH.
Discuss current treatment of MH.
Explain the pathophysiology of MH.
Identify signs and symptoms of MH.
Describe how to use a mock drill to prepare for an MH
crisis.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check with
your state board of nursing for acceptance of this activity for
relicensure.
Conflict of Interest Disclosures
Ms Van Wicklin, Ms Neiderer, and Ms Merritt have no
declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. As
a former employee of the Malignant Hyperthermia Association
of the United States (MHAUS), Dr Hirshey Dirksen has
declared an affiliation that could be perceived as posing
a potential conflict of interest in the publication of this article.
As the recipient of an honorarium from MHAUS for filming
a malignant hyperthermia response plan, Dr Mashman has
declared an affiliation that could be perceived as posing a
potential conflict of interest in the publication of this article.
The behavioral objectives for this program were created by
Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no
declared affiliations that could be perceived as posing potential
conflicts of interest in the publication of this article.
Sponsorship or Commercial Support
Accreditation
No sponsorship or commercial support was received for this
article.
AORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
Disclaimer
Approvals
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
AORN recognizes these activities as continuing education for
registered nurses. This recognition does not imply that AORN
or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2012.12.009
Ó AORN, Inc, 2013
March 2013
Vol 97 No 3 AORN Journal j 329
Developing Effective Drills in
Preparation for a Malignant
Hyperthermia Crisis
SHARON J. HIRSHEY DIRKSEN, PhD; SHARON A. VAN WICKLIN, MSN, RN,
CNOR, CRNFA, CPSN, PLNC; DARLENE LEDRUT MASHMAN, MD;
PAM NEIDERER, BSN, RN; DEBRA ROSE MERRITT, MSN, CRNA
4.7
www.aorn.org/CE
ABSTRACT
A malignant hyperthermia (MH) crisis is a medical emergency. To give the patient
the best possible chance for a successful outcome, a swift, coordinated, multidisciplinary team response is necessary. Malignant hyperthermia occurs infrequently
and, as such, details about its diagnosis, treatment, and management must be
reviewed and reinforced during periodic education sessions. An MH response plan
should be developed to guide a multidisciplinary team during an MH crisis. This
plan should be tailored to the needs of the individual health care organization and
practiced and refined during periodic simulations of MH episodes, such as MH mock
drills. AORN J 97 (March 2013) 330-350. Ó AORN, Inc, 2013. http://dx.doi.org/
10.1016/j.aorn.2012.12.009
Key words: malignant hyperthermia (MH), response plan, mock drill, simulation.
M
alignant hyperthermia (MH) can progress
quickly to a life-threatening situation.
Malignant hyperthermia occurs approximately once in every 3,000 to 50,000 procedures
during which general anesthetics are given, with
a greater incidence in children than adults.1 Despite
the cumulative effect of increased education and
awareness about MH pathophysiology and clinical
manifestations, deaths from MH still occur. Fortunately, early recognition, accurate diagnosis, and
appropriate treatment with dantrolene sodium have
decreased the mortality rate from 80% in the 1970s
to less than 5% as of 2007.2
Wherever general anesthetics or MH-triggering
agents are administered, MH mock drills and education sessions should be implemented to keep the
response team in a state of readiness. This article
provides information about the pathophysiology
and clinical presentation of MH, the development
of an effective MH response plan, and recommendations about how to coordinate, implement, and
evaluate MH mock drills.
CASE STUDY
Mr R, a 25-year-old, healthy, muscular, 175-lb
man, is undergoing routine orthopedic surgery. His
personal and family medical and anesthetic history
does not reveal MH susceptibility. He underwent
surgery at one year of age to correct an inguinal
hernia without surgical or anesthetic complications.
For the orthopedic procedure, the anesthesia professional induces Mr R with midazolam, fentanyl,
http://dx.doi.org/10.1016/j.aorn.2012.12.009
330 j AORN Journal
March 2013 Vol 97 No 3
Ó AORN, Inc, 2013
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS
and propofol, and anesthesia is maintained with
isoflurane. The anesthesia professional uses succinylcholine to facilitate tracheal intubation.
After two hours, the patient’s heart rate slowly
increases from 80 to 100 beats per minute, and the
anesthesia professional gives additional isoflurane.
Mr R’s end-tidal carbon dioxide rises from 40 mm
Hg to 90 mm Hg despite doubling of the amount
of inspired air, and his temperature rises to 39 C
(102.2 F) despite the use of a cooling blanket.
The anesthesiologist suspects MH and calls for
the RN circulator to initiate the facility MH protocol.
The charge RN brings the MH emergency treatment
cart to the OR, and available perioperative personnel
begin to perform their assigned tasks. It takes 15
minutes for the RN circulator and charge RN to
prepare dantrolene sodium and another 10 minutes
for personnel to procure ice. The sticker on the MH
cart that contains the MH Hotline telephone number
is too faded to read, so no one makes the call.
This is an example of an MH crisis for which the
perioperative team was unprepared. This scenario
underscores the importance of understanding the
pathophysiology and clinical presentation of MH
and holding regular education sessions and mock
drills to prepare the team to act quickly and efficiently in the event of a crisis.
www.aornjournal.org
which calcium flows. In the presence of an abnormal
RYR1 gene in MH-susceptible individuals, a triggering agent such as halothane, isoflurane, sevoflurane, desflurane, or enflurane, either alone or in
combination with the depolarizing muscle relaxant
succinylcholine,1,2 initiates uncontrolled calcium
release. This sets off the classic actin-myosin
troponin interaction, shortening of muscle
fibers, and consequent muscle contraction. The
uncontrolled rise in intracellular calcium causes
a sustained state of muscle contraction, leading
to the hypermetabolic MH response.
The MH response spurs a cascade of reactions,
including increased sympathetic activity, increased
production of carbon dioxide and heat from rapid
use of adenosine triphosphate (ATP), increased
oxygen consumption, excess lactate production, and
cellular damage and destruction.4,5 Cell membrane
disruptions lead to potassium, phosphate, magnesium, and myoglobin leakage into the extracellular
fluid, with a resulting rise in serum levels.6 Complications that may occur if MH continues to progress include skeletal muscle damage, hyperthermia,
renal failure, cardiac arrest, and possible death.
The clinical presentation of MH often varies.7 A
classic presentation of MH is identified earliest as
an unexplained increase in end-tidal carbon dioxide
production. Other clinical signs may include unexplained tachycardia or arrhythmia, a mixed respiratory
or metabolic acidosis, muscle rigidity, hyperthermia,
and myoglobinuria.
Individuals with a family history of MH or with
congenital myopathies, especially those associated
PATHOPHYSIOLOGY AND CLINICAL
PRESENTATION
Malignant hyperthermia is a genetic, autosomal
dominant disorder of the skeletal muscle. An
autosomal dominant gene is the gene that dominates the inherited gene pair
(ie, one from each parent) and
AORN Resources
is not on an X or Y chromosome (ie, gender-determining
n AORN Video Library: Malignant Hyperthermia: Keeping Your
chromosomes).3 The majorCool. http://cine-med.com/index.php?nav¼aorn.
ity of individuals who are
n Periop Mastery Program: Malignant Hyperthermia. http://
MH susceptible have a defect
www.aorn.org/Education/Curriculum/Periop_Mastery_Program/
in the ryanodine receptor type
Malignant_Hyperthermia.aspx.
1 (RYR1) gene. This gene
encodes an ion channel in the
Web site access verified December 4, 2012.
skeletal muscle cell through
AORN Journal j 331
HIRSHEY DIRKSEN ET AL
March 2013 Vol 97 No 3
with a mutation in the RYR1 gene, such as central
core disease or multi-minicore disease, are also
considered at risk for MH.8 Importantly, a history
of previous uneventful general anesthesia does
not rule out the possibility that a patient may be
MH susceptible. The risk for MH is less clear in
patients with other known muscle disorders or
enzyme defects. For these patients, the decision
to use MH-triggering agents must be made on
a case-by-case basis.9
The physiologic manifestations associated with
MH may not present in any particular sequence and
may occur at any point during or within an hour or so
after anesthesia is terminated.1 Physicians, nurses,
and all other team members should be familiar with
the Emergency Therapy for Malignant Hyperthermia
guidelines from the Malignant Hyperthermia Association of the United States (MHAUS),10 which
outline the actions to be taken when caring for
a patient suspected to be experiencing an MH event.
A poster containing the protocol for managing an
MH event can be purchased from MHAUS (http://
mhaus.site-ym.com/store/view_product.asp?id¼
1157088; accessed December 12, 2012).
DEVELOPING AN MH EMERGENCY
RESPONSE PLAN
Chances for a successful outcome after an MH event
increase with rapid, accurate diagnosis and a coordinated, swift, multidisciplinary team response to
deliver the appropriate treatment. This may be
challenging, especially if members of the perioperative team have not received MH crisis management education or have not experienced an
actual MH event in clinical practice.11 When developing an MH response plan for a health care
organization, the multidisciplinary team members
charged with developing the plan should give
careful consideration to the specific health care
environment, assignment of responsibilities, and
any patient transfer issues.
Environment
When planning for a specific health care environment,
it is important to determine the areas in which there is
332 j AORN Journal
a risk for an MH crisis to occur (eg, OR, emergency
department, interventional radiology, labor and delivery, intensive care unit [ICU]). These are areas
where triggering agents are given or are maintained on
standby for emergencies, or areas to which patients
may be taken after they receive triggering agents.
For ambulatory centers (eg, surgery centers, officebased facilities), the MH response plan should include
steps for patient transfer to a nearby hospital that has
critical care capabilities.
When developing a plan, it may be helpful to
consider specific questions:
n
n
n
n
n
n
n
How should the operative or procedure team
call for help from perioperative personnel
available in the area?
How should personnel call for the MH cart if it
is in the perioperative area?
If the crisis is in an area outside of the perioperative area, should there be an MH supply
cart that can be brought from the perioperative
area and added to the emergency cart in those
areas?
How many team members will respond to an
MH crisis?
Will the number of responders vary depending
on whether the MH crisis is in the OR, procedure room, or some another area (eg, postanesthesia care unit [PACU])?
Will the number of available responders vary
depending on the time of day?
For ambulatory centers, is there a plan in place
for stabilizing the patient until he or she can be
transferred safely?
As these questions are answered, it may be helpful
for the multidisciplinary team charged with developing the MH response plan to create a list of
anticipated or existing obstacles, to set priorities
from the list according to urgency, and to plan
actions to address the problems.12
Assignment of Responsibilities
Each MH response plan should include the assignment of specific responsibilities to each
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS
responding team member. Many tasks must be
accomplished simultaneously during a stressful,
high-stakes situation while the patient is decompensating clinically. Performing all of the simultaneous actions required during an MH event is
beyond the capabilities of any single team member.
In most cases, it takes multiple RNs, anesthesia
professionals, allied health care providers (eg,
surgical technologists, ancillary personnel), and
the surgeon to manage the tasks.
AORN and MHAUS have provided suggested
team member task assignments for consideration
during a drill or actual MH event.5,13 Table 1
includes a listing of potential responsibilities to be
carried out during an MH drill or actual MH episode. This list may be useful for assigning roles
and responsibilities for personnel during the development of an organization-specific MH response plan.
Nursing care begins when the patient is scheduled for any procedure involving general anesthesia. First and foremost, the perioperative RN
should be cognizant of risk factors for MH. If the
perioperative RN believes that a patient is MH
susceptible, he or she should notify the surgeon and
anesthesia professional.
During surgery, perioperative RNs and anesthesia professionals must be able to recognize the
clinical manifestations of an MH crisis and initiate
the necessary actions for a coordinated team response. All RNs who may care for patients receiving MH-triggering agents or recovering from
anesthesia should be familiar with the early and late
signs of MH, current treatment protocols, and the
location of MH emergency supplies.
The anesthesia professional is likely to be the
perioperative team member who initially identifies
the impending MH crisis and, based on a rapid
differential diagnosis, determines whether MH is
the likely cause of the symptoms. If MH is suspected, prompt administration of appropriate
treatment is essential (Table 2). The surgeon should
stop the procedure as soon as possible, unless the
procedure is emergent, in which case it should be
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continued with nontriggering anesthetics.14 The
anesthesia professional should discontinue administration of all volatile agents and succinylcholine
immediately and begin treatment for MH.10 He or
she should then hyperventilate the patient with
100% oxygen at flows of 10 L/minute or greater.
Simultaneously, the perioperative RN or anesthesia professional should prepare and administer
dantrolene sodium immediately. Based on the
amount of dantrolene sodium required and the
potential difficulty of preparation, it may take
multiple licensed individuals to reconstitute the
required amounts to accomplish rapid administration during an MH crisis.4
After an MH incident, the perioperative RN
and anesthesia professional should monitor the
stabilized patient, and treatment modalities should
be continued in the OR or PACU until the patient
can be transferred to the ICU for the next 24 to 36
hours. During this time, the critical care RN should
continuously monitor the patient for complications
and signs of recrudescence (ie, recurrence of symptoms after treatment has resolved the condition;
differs from a relapse in the short-term time frame
of the reoccurrence).
Complications that can occur from MH include
metabolic acidosis, bowel ischemia, compartment
syndrome of the limbs resulting from profound
muscle swelling, vital organ dysfunction, acute
renal failure, and disseminated intravascular coagulation.7 In addition, symptoms such as difficulty
swallowing food, muscle weakness, and lightheadedness may be observed in association with
dantrolene sodium administration.15,16 A 20% recrudescence rate has been reported.17 After the
episode, the RN providing discharge instructions
should also provide referrals for patients and family
members to the MHAUS web site (http://www
.mhaus.org) for additional information, when
appropriate.
Transfer Considerations
Each health care organization MH response plan
should include the essential steps for safe transfer
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TABLE 1. Suggested Responsibilities by Role During a Malignant Hyperthermia (MH) Drill or
1-3
Event
Role
Anesthesia professional
Responsibilities
n
n
n
n
n
n
n
n
n
n
n
Surgeon
n
n
n
n
RN circulator
n
n
n
n
n
n
n
n
n
n
n
n
Charge nurse and additional
nurses, as available
n
n
n
334 j AORN Journal
Lead the anesthesia team during treatment.
Recognize and diagnose MH.
Inform the RN circulator to initiate the MH response plan.
Discontinue triggering agents and begin treatment of MH.
Communicate with the MH Hotline consultant.
Communicate with the surgeon about findings, resuscitation, and treatment.
Maintain situational awareness (eg, working diagnosis, intended treatment plan, team
assignments, periodic status updates) and open lines of communication.
Place additional lines or assign a team member to place additional IV or arterial lines as
needed.
Develop a post-acute treatment plan for the patient after the patient is stabilized.
Communicate the transfer-of-care report to the postanesthesia care unit (PACU) RN,
critical care team, and receiving hospital team, and possibly travel with the patient to the
receiving institution, as needed.
Counsel the patient and his or her family members on MH resources available from the
Malignant Hyperthermia Association of the United States (MHAUS), and submit an
Adverse Medical Reaction to Anesthesia (AMRA) report.
Assess the most expeditious surgical plan (eg, close the wound, complete the procedure,
modify the procedure).
Assist with placement of IV, arterial, and central venous lines if asked.
Cool the patient if his or her core temperature is greater than 39 C (102.2 F).
n Lavage open body cavities.
n Apply ice packs.
Order an intensive care unit (ICU) bed for the patient (if not already done).
Initiate the MH protocol.
Call the MH Hotline and put the call on speakerphone if possible.
Call for nursing support/help.
Assign duties to others according to the facility’s response plan.
Begin the documentation and record details of the patient’s treatment, including medication dosages, administration times, and the patient’s response.
Assist the anesthesia professional with placement of additional IV or arterial lines as
needed.
Assist the anesthesia professional with drawing arterial blood gases and other blood work
(eg, arterial blood gas, electrolytes, creatine kinase, coagulation studies).
Help initiate and maintain situational awareness (ie, coordinate with the anesthesia
professional/team leader).
Get any materials that the surgeon needs to irrigate or close the wound, if applicable.
Begin planning the patient’s transfer to a definitive post-acute treatment area when the
patient stabilizes (eg, call for transport, alert PACU/ICU of patient).
Assist with patient transport, as needed; provide the transfer-of-care report to the PACU,
ICU, and receiving institution.
Restock supplies on the MH and emergency carts.
Bring the MH cart, ice, or other supplies (if not already done) and begin to mix and
administer the dantrolene sodium.
Bring the emergency cart to the OR if it is separate from the MH cart.
Prepare and administer additional medications as directed by the anesthesia team leader.
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS
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TABLE 1. (continued ) Suggested Responsibilities by Role During a Malignant Hyperthermia (MH)
1-3
Drill or Event
Role
Responsibilities
n
n
Anesthesia technician
n
n
n
n
n
n
Clinical assistant/runner
n
n
n
n
Front desk personnel
and non-medical personnel
n
n
n
Pharmacist or pharmacy
technician
n
n
n
PACU charge nurse
n
n
n
n
n
n
n
n
Nurse educator or
drill coordinator
n
n
n
n
Monitor the patient’s core temperature and begin activities to cool the patient if his or her
core temperature is greater than 39 C (102.2 F).
Refer the patient to the MHAUS web site (http://www.mhaus.org) after the MH event for
additional information and resources, if applicable.
Respond to a call for help by bringing the MH cart to the site (if not already done).
Set up equipment and medications.
n Bring a tray with crushed ice and zipper bags for ice pack preparation.
n Bring chilled 1-L bags of 0.9% normal saline from the refrigerator to the room.
n Bring a transport monitor and portable oxygen when the patient is ready for transport
and help with transport if needed.
n Bring the arterial line manifold to the site and prepare to set it up.
Assist the anesthesia professional with placing IV, arterial, and central venous lines.
Stand ready for other assignments.
Help set up monitors in the PACU if needed.
Restock anesthesia supplies.
Obtain additional supplies and ice.
Deliver specimens to the laboratory.
Check with the team for additional needs, such as retrieving supplies from areas away
from the MH site.
Obtain an ICU bed if requested.
Restock the ice supply if asked.
Call backup personnel for additional help if asked.
Perform the duties of the runner as needed.
Reconstitute dantrolene sodium.
Prepare additional medications as directed.
Restock medications on the MH cart.
Offer assistance to the OR team.
Ensure continuity of care for the patient who has experienced an MH event.
Ensure that an MH cart with an adequate stock of dantrolene sodium is immediately
available for further treatment.
Continue monitoring the patient for signs and symptoms of MH.
Record and monitor the patient’s temperature and prepare a core temperature probe as
directed.
Prevent recrudescence by administering 1 mg/kg of dantrolene sodium every 4 to 6 hours
or a 0.25 mg/kg/hour infusion.
Ensure that an emergency cart and cooling measures, such as crushed ice and zipper
bags, are readily available.
Confirm that the ICU team is preparing to receive the patient and assist with transporting
the patient to the ICU with a hand-off report.
Schedule the drill with the operative services scheduler, anesthesia professionals, and
surgical team members.
Recruit volunteers for the drill.
Run the drill.
Conduct and set the tone for the debriefing session.
(table continued)
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March 2013 Vol 97 No 3
TABLE 1. (continued ) Suggested Responsibilities by Role During a Malignant Hyperthermia (MH)
1-3
Drill or Event
Role
Responsibilities
n
n
n
n
n
n
Create a summary of the drill and document the strengths and challenges.
Ensure the MH drill site is cleaned of mock materials and the care area is clean.
Ensure all MH supplies and the drill medications are removed, and the MH supplies are
replaced in storage locations.
Ensure that the pharmacist has removed any expired medications or mock drill medications from the MH cart and that it is restocked with MH medications and supplies.
Schedule educational sessions.
Schedule drill programs.
1. AORN malignant hyperthermia guideline. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012:621-641.
2. Hommertzheim R, Steinke EE. Malignant hyperthermiadthe perioperative nurse’s role. AORN J. 2006;83(1):149-164.
3. Wong CA, Denholm B. Malignant hyperthermia: diagnosis, treatment, and prevention. CME Zone. http://www.cmezone.com/ce-bin/owa/pkg_disclaimer
_html.display?ip_company_code¼CMEZ&ip_cookie¼41050135&ip_test_id¼15609&ip_mode¼secure. Published 2011. Accessed November 27, 2012.
of care of the patient. In a hospital, the steps may
include transfer from the OR to the PACU or from
the OR or PACU to the ICU. In an ambulatory facility, the steps should include an efficient transfer
(based on a pre-existing agreement) to a nearby
hospital that has critical care capabilities. The hospital that has agreed to receive an MH patient from
the ambulatory facility also should identify the steps
for transfer from the emergency department to the
ICU or, if the patient will go directly to the ICU, the
hospital must indicate who will respond to care for
the incoming patient.
When the perioperative team members at an
ambulatory center are developing an agreement
with hospitals for transferring an MH patient, they
should consider the following questions:
n
Will the anesthesia professional travel with the
patient?
n Who will communicate with the designated
hospital and the receiving service or physician?
n Who will ensure that the transfer vehicle is
properly equipped to treat MH patients, taking
into account the patient’s condition, the capabilities of the transport services, and the time
required to arrive at the receiving facility?
n Who will make the decision about when and
where to transfer the patient, ensuring that the
336 j AORN Journal
receiving hospital has critical care capability for
treating MH?
n Who will record the patient information to
transfer to the receiving facility?
These issues must be considered and incorporated
into the facility MH response plan to facilitate
continuity of patient treatment and monitoring
during the MH episode.18,19
EDUCATION SESSIONS
After the response plan is developed, it is critical
for perioperative educators to review task assignments with all members of the perioperative team.
This review usually occurs during planned education sessions, the frequency of which should be
determined by the appropriate personnel (eg, risk
manager, perioperative educator) at the individual
health care organization. The goal is to assemble
an efficient team that has a shared mental image
of the crisis (ie, situational awareness) so that
each team member knows what tasks need to be
accomplished and is prepared to act in the event of
a crisis situation.
AORN recommends that perioperative personnel
and others within the facility who may be involved
in responding to an MH crisis receive education
and complete competency validation activities, as
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS
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TABLE 2. Pathophysiology and Treatment Associated With Each Malignant Hyperthermia Clinical
1-5
Sign
Clinical signs
Rise in end-tidal carbon dioxide (CO2) production:
Excess CO2 production
can cause the CO2
absorbent canister on
the anesthesia machine
to become discolored
and hot to the touch
Metabolic and respiratory
acidosis
Pathophysiology
Increase in myoplasmic
calmodulin-dependent
protein kinase (Ca2þ)
leads to muscle contracture, increased
aerobic and anaerobic
metabolism, excessive
CO2, and lactic acid
production.
As CO2 rises, respiratory
acidosis ensues and
as lactate levels rise,
metabolic acidosis
ensues.
Acute treatment
n
n
n
n
n
n
Post-acute treatment
Discontinue triggering
agent (ie, volatile anesthetic
gas or succinylcholine).
Hyperventilate the patient
with 100% oxygen.
Call for help from any
available perioperative
personnel.
Put an activated charcoal
filter in place, if applicable.
Administer dantrolene
sodium to correct abnormal
myoplasmic calcium
release.
Administer sodium bicarbonate to correct metabolic
acidosis until arterial blood
gas levels are known;
subsequent doses should
be based on analysis of
arterial blood gas levels.
n
n
Monitor end-tidal CO2 with
frequent arterial blood gas
draws.
Complete additional serum
studies, including creatine
kinase, potassium, calcium,
sodium, magnesium,
myoglobin, and clotting
values. Serum and urine
studies will be required until
the results are normal.
Muscle spasm/rigidity: The
Uncontrolled and sustained
masseter muscle of the jaw
increase in myoplasmic
is commonly involved;
Ca2þ leads to muscle
however, trunk or total body contracture and
hypermetabolism.
rigidity may also be seen
n
Continue administration of
dantrolene sodium, which
increases the reuptake of
calcium and prevents the
ongoing release of calcium
from the sarcoplasmic
reticulum, thus reducing
muscle tone and rigidity.
This usually subsides with
time; other muscle relaxants
will not relieve the spasm.
n
Continue administration of
dantrolene sodium and
carefully monitor temperature, skin integrity, urine
output, and blood and urine
studies.
Hyperthermia
n
Start cooling the patient
if his or her core temperature is greater than 39 C
(102.2 F). Actions that
may be helpful in reducing
the patient’s temperature
include
n administering cold IV
fluids;
n placing ice packs on the
patient’s surface areas,
such as the neck,
axillae, and groin;
n
Monitor core body temperature with an esophageal or
rectal probe.
Continue cooling methods
until the patient’s temperature reaches 38 C (100.4
F) and continues to decrease, but do not permit
the patient’s temperature to
drop below 36 C (96.8 F).
Assess the patient’s skin
integrity frequently because
diaphoresis and the use of
Hypermetabolic state leads
to a rise in temperature
from the increased use of
adenosine triphosphate in
combination with the constricting peripheral vasculature, which prevents heat
dissipation.
n
n
(table continued)
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TABLE 2. (continued ) Pathophysiology and Treatment Associated With Each Malignant Hyper1-5
thermia Clinical Sign
Clinical signs
Pathophysiology
Acute treatment
n
n
n
Myoglobinuria
Renal failure
Hypermetabolism leads to
cell membrane damage
and consequently the
intracellular contents (ie,
potassium, magnesium,
phosphate, cellular enzymes [eg, creatinine
kinase], myoglobin) begin
to leak into the bloodstream.
Myoglobin released from
damaged muscle cells
forms casts in the kidneys
that obstruct the renal
tubules.
n
Post-acute treatment
cooling blankets increase
the risk for skin breakdown.
instilling cold irrigation
fluids into the open body
cavities;
performing cold lavage
of the patient’s
stomach, rectum, and
bladder (eg, irrigating
cold saline solution
through a nasogastric or
rectal tube or indwelling
urinary catheter); and
applying a hypothermia
blanket.
Administer diuretics
(eg, furosemide) to reduce fluid overload and
promote excretion of
potassium, sodium,
and myoglobin. A urinary
output of 1 mL/kg/hour
to 2 mL/kg/hour should
be maintained. Notably,
each 20-mg vial of dantrolene sodium also
contains 3 g of mannitol,
an osmotic diuretic.
n
n
n
Tachycardia/tachypnea
Cardiac arrhythmias/arrest/
heart failure
338 j AORN Journal
Hypercarbia, hyperkalemia,
and catecholamine release
stimulate the sympathetic
nervous system.
Increase in serum potassium
(Kþ) (ie, hyperkalemia) and
the inability of the kidneys to
excrete excess potassium
lead to life-threatening
dysrhythmias.
n
n
Administer glucose and
insulin to correct hyperkalemia by facilitating the
uptake of glucose into the
cell and reducing potassium levels regulated by the
sodium-potassium pump
controlled by insulin.
Administer sodium bicarbonate, as well as calcium
chloride or calcium gluconate, to correct hyperkalemia and restore the
n
Monitor urinary output
frequently via an indwelling
urinary catheter and urine
meter. Output should be
maintained at greater than
2 mL/kg/hour to prevent
renal failure.
Observe urine for concentration. Increased or
decreased concentration
may indicate renal failure,
and increased concentration may be a sign of heart
failure.
Observe urine for cola
color, which is an indication
of the presence of
myoglobin, and perform
urine studies to monitor
myoglobin levels.
Check glucose levels hourly
if glucose and insulin are
administered.
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS
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TABLE 2. (continued ) Pathophysiology and Treatment Associated With Each Malignant Hyper1-5
thermia Clinical Sign
Clinical signs
Pathophysiology
Acute treatment
n
Post-acute treatment
balance between potassium and calcium.
Administer antiarrhythmic
agents to treat dysrhythmias not responding to
treatment of acidosis and
hyperkalemia. Implement
the standard advanced
cardiovascular life support
protocoldwith the exception of calcium channel
blockers (eg, diltiazem
[Cardizem]), which may
cause hyperkalemia or
cardiac arrest in the presence of dantrolene.
1. Rosenberg H, Sambuughin N, Dirksen R. Malignant hyperthermia susceptibility. In: Pagon RA, Bird TD, Dolan CR, Stephens K, Adam MP, eds. GeneReviews [Database online]. Seattle, WA: University of Washington; 1997-2011. http://www.genetests.org. Updated January 19, 2010. Accessed
November 15, 2012.
2. AORN malignant hyperthermia guideline. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012:621-641.
3. Gurunluoglu R, Swanson JA, Haeck PC; ASPS Patient Safety Committee. Evidence-based patient safety advisory: malignant hyperthermia. Plast
Reconstr Surg. 2009;124(4 Suppl):68S-81S.
4. Emergency therapy for malignant hyperthermia [poster]. Sherburne, NY: Malignant Hyperthermia Association of the United States; 2011. https://mhaus.si
te-ym.com/store/view_product.asp?id¼1157088. Accessed November 27, 2012.
5. Hommertzheim R, Steinke EE. Malignant hyperthermiadthe perioperative nurse’s role. AORN J. 2006;83(1):149-164.
applicable to their roles, on the actions required to
effectively manage an MH event. Education should
be provided on initial hire or receipt of privileges
and should be ongoing throughout the course
of employment or credentialing by the facility.5
The American Association of Nurse Anesthetists
(AANA) also recommends that certified RN
anesthetists maintain continued competency in
treating MH.20
The content of the education sessions should
include updates on current treatment for MH, early
identification of clinical signs and symptoms, and
review of the response plan. New employees should
be oriented to the MH response plan, as should new
surgeons or anesthesia professionals who have recently been granted privileges at the health care
organization.
Education sessions are a key component of MH
preparedness. In a study using simulation-based
assessment to evaluate the skill levels of anesthesia
professionals in managing several acute conditions,
practitioners’ performance was particularly low
during the MH scenario compared with other
intraoperative emergent scenarios.21 These results
may indicate the need for additional continuing
education with regard to the diagnosis, treatment,
and management of MH.
THE MOCK DRILL
After education sessions have been organized,
the next step is to develop an implementation
and evaluation process. Mock drills for MH
that include using simulation training techniques
provide a powerful means to accomplish this task
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March 2013 Vol 97 No 3
because mock drills permit members of perioperative teams to practice communication,
teamwork, and leadership skills during infrequent
but life-threatening situations. To create efficient
and useful simulation training scenarios, the MH
drill team members should work together to plan
the drill, design the drill, and develop a drill
evaluation tool. After the team is ready, the drill
should be carried out to allow perioperative
team members to practice specific tasks and use
the available tools (eg, the MHAUS Emergency
Therapy for Malignant Hyperthermia poster).
After the drill, a debriefing process can help the
team analyze the process to be better prepared
for future drills or actual MH events.
Simulation Training
Simulation training provides each individual
with an opportunity to participate in a protected
environment that allows for errors to be made and
mechanical techniques to be mastered without
a risk to patients. Compared with traditional education, which primarily includes verbal instruction
and requires the participants to memorize presented material, a well-crafted simulation exercise
promotes enhanced competency by incorporating
kinesthetic learning.22
Mock drills provide the opportunity for perioperative personnel to cultivate the communication
and team skills required to implement emergency
protocols with increased efficiency. The mock drill
process is an important part of MH preparedness,
allowing participants to further develop and practice skills in resource management and decision
making. Simulations can range from use of simple
manikins to high-fidelity simulators that re-create
the OR experience. Simulation experiences can be
accomplished using a variety of methods:
n
role playing (ie, participants act out various roles),
n standardized patients (ie, actors portray patients
using scripted roles),
n partial task trainers (eg, intubation manikins, IV
arms),
340 j AORN Journal
n
complex task trainers (ie, virtual-reality scenarios
that provide the opportunity to practice skills),
n integrated simulators (ie, whole-body manikins
with the capability to respond in real time to
interventions and provide a sense of authenticity), and
n full mission simulation (ie, the learner functions
as a member of a team responding to an emergency situation).22
Coordinating the MH Mock Drill
The MH drill requires institutional preparation that
should be coordinated by an MH drill team. Members required for individual facilities will vary but
at a minimum should include at least one dedicated
anesthesia professional, one perioperative nurse
educator, and a simulator coordinator if a simulation manikin is involved. Involving personnel from
the facility’s quality improvement department,
a perioperative nursing scheduler, and a surgical
services representative is also beneficial. The drill
team coordinates volunteers for the actual drill,
schedules the drill, and prepares the drill site (eg,
the OR). A representative from the drill team
should collaborate with the OR pharmacist about
the possibility of procuring “mock” medications
that can be used to simulate the reality of mixing
and administering required medications during an
MH crisis, opening and using the MH cart and
supplies, and involving OR pharmacists in the drill
where appropriate. The drill team maintains and
updates the response plan, runs the drill, promotes
team dialogue during the debriefing session, and
asks appropriate nonjudgmental questions to help
the team members reflect on their challenges and
strengths. At the conclusion of the drill, the drill
team coordinates the cleanup, examines the MH
cart and initiates restocking, and ensures that the
site is left in a state of MH preparedness.
Designing the MH Mock Drill
When designing an MH mock drill for a health care
organization, the mock drill team should consider
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS
many scenarios. The drill can include specific patient populations (eg, child, adult) or focus on
specific perioperative settings (eg, OR, PACU).
The drill also may be designed to include areas
outside of the perioperative area (eg, obstetrics,
interventional radiology, emergency department,
critical care). Focusing the MH drill toward a
specific population or setting allows team members
to practice their roles, evaluate their system’s
readiness, and then revise the plan for improved
functionality. The drill can be designed to be announced or unannounced. Using the announced
drill method assesses personnel and institutional
readiness in a more controlled way. Unannounced
drills have the surprise factor, which may increase
stress but also provide more “real time” awareness
of the facility’s readiness.
To determine the best time and location for
implementing the MH mock drill, the mock drill
team may consult the head of perioperative services, OR scheduler, perioperative educator, department head and administrative personnel for
anesthesiology, department head and administrative personnel of surgery, and possibly the head
of quality improvement. In an ambulatory setting,
this determination could be made by the nurse
manager, charge RN, or other leader who may have
multiple roles in this type of facility. It is important
to choose a time and date that allows for minimal
disruption of the surgical schedule and maximizes
personnel participation.
The initial MH drill scenario presented to the
perioperative team should be straightforward, such
as a healthy 10-year-old patient presenting for
uncomplicated inguinal hernia repair with no family history of anesthetic complication. As perioperative team members gain experience in MH
mock drills, the drills can be extended to cover
more complex surgical procedures or increased
patient acuity and then extended to personnel from
different specialties and areas. In ambulatory centers, the mock drill should incorporate steps for
transferring the patient to a hospital with critical
care resources and practicing roles during the
www.aornjournal.org
transfer process. It may be possible to extend the
drill to include cooperation from personnel at the
receiving hospital to complete the simulation on
their end. Ideas for clinical scenarios can be procured from case reports in the literature, as well
as from case challenges that are available on the
MHAUS web site.
Scenarios that involve failure to control the syndrome with the first lines of therapy are important to
consider, because this provides the opportunity for
team members to think critically and use multiple
treatment modalities in the MH treatment algorithm.
Also, when writing the scenario, the mock drill team
might find it useful to incorporate “what if” elements
where plans for contingencies must be made. For
example, the team may choose to build into the
overall drill design a scenario in which too few or
too many responders are available or in which the
MH event occurs after hours or during an emergent
procedure.14
Developing an MH Drill Evaluation Tool
The perioperative educator or other perioperative
supervisors should evaluate team performance during an MH drill. To accomplish this, the educator
should design an evaluation tool that incorporates
task assignments and the variety of situations used in
the facility’s mock drills, as well as nontechnical
skills that affect collaboration, communication,
and teamwork.
Developing criteria to evaluate participants’
performance in relation to clinical task assignments as well as skills in collaboration, communication, and effective teamwork is an important
component of the mock drill process. Cognitive
performance and technical proficiency, such as
choosing dantrolene sodium to treat the MH
patient and mixing correctly, are measurable.
Nontechnical skills, such as communication style
and effective teamwork, are more difficult to
assess but are important nonetheless. To illustrate
this, researchers used an observational study to
investigate differences in teamwork patterns
during a simulated MH scenario and found that
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HIRSHEY DIRKSEN ET AL
Figure 1. Malignant hyperthermia mock drill. Reprinted with permission from Mashman D. Malignant hyperthermia: is your team prepared? In: Meeting Syllabus Section VI, Georgia Society of Anesthesiologists Basics at
the Beach Summer Meeting; July 22-24, 2011; St Simons Island, GA.
342 j AORN Journal
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Figure 1. (continued).
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March 2013 Vol 97 No 3
teams that received higher clinical performance
scores were more focused on role coordination
and adaptation relative to the situational requirements.23 Higher scoring teams also prioritized
clinical tasks and communicated more effectively
and more frequently.
When developing the evaluation tool, perioperative educators may find it useful to review available rating scales, checklists, and scoring tools.
Tools used to evaluate teamwork during clinical
event simulations include the Crew Resource
Management Global Rating Scale, the Mayo High
Performance Teamwork Scale, and the Clinical
Teamwork Scale.24-27 Although these tools were
not designed specifically to evaluate team performance during MH event simulations, they may be
useful for developing an MH drill evaluation tool.
In addition, an example tool, although not validated, that is being used in the field and may be
helpful as a template is provided in Figure 1.
After the MH drill evaluation tool is developed,
it can be used to track the team’s performance
and progress. Using the tool to review performance
should help identify areas that need practice in
future mock drills, concepts that need to be reinforced in future education sessions, and areas that
need to be refined in the MH response plan. Procedures should be in place to monitor readiness for
an MH crisis (eg, checking the MH cart for supplies
and medication expiration dates). The mock drill
also may help supervisors evaluate team member
compliance with readiness procedures. The perioperative educator also should periodically evaluate the MH drill evaluation tool for effectiveness
and quality to be sure it is measuring the key
components of the drills that are being performed
at the facility.
Carrying Out the Drill
When the type of drill and clinical scenario are
determined, the MH drill team should organize the
volunteers who will be involved in the scenario.
In the most high-tech intraoperative drill, this
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HIRSHEY DIRKSEN ET AL
may number about eight volunteers, including
an anesthesiologist, an anesthetist or resident or
fellow, a surgeon or surgeon actor, an RN circulator, a scrub person, one or two drill evaluators
from the institution, and an in situ simulator patient with a computer operator or a patient actor.
In ambulatory facilities, individuals in various
ancillary functions (eg, receptionist, billing, environmental services, sterile processing) also may be
involved. The drill team should make and document observations and responses during the drill
using the evaluation tool, or the drill may be
videotaped for subsequent self-evaluation by the
team. The following considerations may be helpful
for developing effective drills at a specific health
care organization.
Preparation of dantrolene sodium. Quick,
efficient preparation of dantrolene sodium is a vital
part of training to handle an MH event. Thus, representatives from the mock drill team should
check with the facility pharmacist about the possibility of retaining expired dantrolene sodium for
use during drills or hands-on education. Another
option is to check with the facility pharmacist
about the possibility of selecting an inexpensive
medication to simulate the dantrolene sodium,
such as an antibiotic that requires dilution for
administration.
Visual aids. Visual aids may be very helpful
training tools for drills. Figure 2, for example,
illustrates a quick and effective method that some
perioperative personnel use to prepare dantrolene
sodium. Although some facilities use bags of sterile water rather than vials to dilute the dantrolene
sodium, MHAUS does not advise using this practice
because of the potential for mistaking a bag of saline
for the intended bag of sterile water, thus putting the
patient at risk for a medication error.
Cognitive aids. The use of cognitive aids,
which provide written instructions for managing
emergency events such as MH, also can be effective for helping health care providers adhere to
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS
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Figure 2. A visual aid may be used to guide the preparation of dantrolene sodium for treatment of malignant
hyperthermia. Box 1 shows the supplies required for mixing: a) 100-mL vial of sterile water (no preservatives);
b) 20-mg vial of dantrolene; c) 60-mL Luer lock syringe; d) dispensing pins 3 2. Box 2 depicts insertion of dispensing pins into vials of sterile water and dantrolene. Box 3 shows how to use a syringe to withdraw 60 mL
of sterile water; there is no need to inject air. Box 4 depicts injection of 60 mL of sterile water into a 20-mg vial
of dantrolene; there is no need to remove air.
and incorporate the necessary protocols during an
MH episode and other life-threatening events.11
The MHAUS Emergency Therapy for Malignant
Hyperthermia guideline10 can be used as a cognitive aid for the management of MH.
Reader. Introducing a “reader” whose responsibility during a critical event is to read the required
actions from a cognitive aid aloud and acknowledge
completion of each action may increase performance. One study, for example, evaluated whether
the use of a reader could improve the performance of critical actions required during emergency
events.11 Before the introduction of the reader,
none of the study participants performed all of
the necessary actions required for managing obstetric cardiac arrest or MH; however, after the
introduction of the reader, all necessary critical
actions were executed.
Checklists. In a study to determine the promise
and usability of emergency management checklists,
the use of checklists resulted in a six-fold reduction
in failure to adhere to critical steps required for
management of eight different scenarios, including
MH.28 The researchers concluded that the use of
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TABLE 3. Suggested Components of Malignant Hyperthermia Emergency Treatment Cart
Medications
n
n
n
n
n
n
n
n
General equipment
n
n
n
n
n
n
n
Monitoring
equipment
n
n
n
Nursing supplies
n
n
n
n
n
n
n
n
n
n
n
n
n
Laboratory testing
supplies
n
n
n
346 j AORN Journal
1,2
Dantrolene sodium, 36 vials
Sterile water for injection USP [United States Pharmacopeia], without bacteriostatic agent, stored in
approximately 28 to 30 100-mL glass vials, not bags, to avoid accidental IV administration
n Reconstitute each vial of dantrolene sodium by adding 60 mL of sterile water, shake until solution is
clear.
n Medication must reach the skeletal muscle, the site of action.
Sodium bicarbonate 8.4%, 50 mL 5
Furosemide 40 mg/ampoules 4; 3-mL syringes (with 21 Ga 1½” needles if not using a needleless
system) for drawing up furosemide
Dextrose 50%, 50-mL vials 2
Calcium chloride 10%, 10-mL vials 2
Regular insulin 100 units/mL 1; insulin syringes (with 29 Ga ½” needle if not using a needleless
system)
Lidocaine (2%) for injection, 100 mg/5 mL or 100 mg/10 mL in preloaded syringes 3
n Amiodarone is also acceptable
n Do not give lidocaine or procainamide if wide-QRS complex arrhythmia is present because of the
potential for hyperkalemia; using lidocaine or procainamide may result in asystole
Syringes 60 mL Luer lock 6 to dilute dantrolene sodium
IV dispensing pins 12 to reconstitute dantrolene sodium
Clean, commercially available, charcoal filters, if used at the facility
IV catheters for arterial and venous access
Nasogastric tubes and Toomey or catheter tip irrigation syringes 60 mL 2 with adapter (if required)
for nasogastric irrigation
IV administration tubing
Alcohol preps for wiping IV ports and tops of vials
Esophageal or other core temperature probes (nasopharyngeal, tympanic membrane, rectal, bladder,
pulmonary artery catheter)
Central venous pressure tray
Transducer kits for arterial and central venous cannulation
MH treatment algorithm
> 3,000 mL refrigerated cold saline solution for IV cooling
Large sterile adhesive incise drape to cover the wound, if necessary
Urine meter 1 for accurate measurement of urine output
Irrigation tray with piston syringe, 60 mL, for irrigation
Large clear plastic bags for ice 4
Small plastic bags for ice 4
Bucket for ice
Test strips for urine analysis
5-in-1 connectors, Y connectors
Catheter plugs
3-way indwelling urinary catheter with 5-mL and 30-mL bulbs (for urinary and rectal irrigation); if stored,
stock 30-mL and 5-mL syringes to fill the bulbs
Supportive documentation and other materials to manage the crisis (eg, cognitive aids, worksheets)
Syringes or kits for blood gas analysis 6
Supplies for drawing and labeling blood samples
Blood specimen tubes 2 per test
n Creatine kinase, myoglobin, electrolytes, chemistries (eg, lactate dehydrogenase, thyroid)
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS
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TABLE 3. (continued ) Suggested Components of Malignant Hyperthermia Emergency Treatment
1,2
Cart
Prothrombin time/partial thromboplastin time, fibrinogen, d-dimer, lactate
Complete blood count, platelets
n Blood gas syringe (lactic acid level)
n
If no immediate laboratory analysis is available, keep samples on ice for later analysis; store
some foam cups to be filled with ice and used to transport arterial blood gas samples
n
Blood cultures to rule out bacteremia
Urine collection container for myoglobin level
Laboratory and arterial blood gas requisition forms, if using paper documentation
Specimen transport bags
Pens and blank physician’s order forms to document orders
n
n
n
n
n
n
1. Wong CA, Denholm B. Malignant hyperthermia: diagnosis, treatment, and prevention. CME Zone. http://www.cmezone.com/ce-bin/owa/pkg_disclaimer
_html.display?ip_company_code¼CMEZ&ip_cookie¼41050135&ip_test_id¼15609&ip_mode¼secure. Published 2011. Accessed November 27, 2012.
2. Stocking the MH Cart. Malignant Hyperthermia Association of the United States. http://www.mhaus.org/mhaus-faqs-healthcare-professionals/stockingmh-cart/. Accessed November 15, 2012.
Adapted from Wong CA, Denholm B. Malignant hyperthermia: diagnosis, treatment, and prevention with permission from CMEZone.com.
checklists can improve safety and management of
emergencies in the OR.
Rotation of personnel responsibilities for
the MH cart. In a properly stocked MH cart,
medications and equipment should be ready and
immediately accessible to all anesthesia delivery
sites. Rotating personnel responsibilities for checking the MH cart each month for outdated supplies
and medications helps to familiarize multiple team
members with the MH cart contents. Table 3
contains a suggested list of MH cart contents.
Use of an emergency whiteboard. Whiteboards are particularly useful for designating team
member assignments for emergency situations,
including MH. These assignments may change on
a daily basis and may include duties for ancillary
personnel, such as ensuring that there is an adequate
ice supply or functioning as a runner when items
are needed from outside the room where the MH
crisis is occurring. There must be a process in
place to verify that these assignments are made
on a daily basis, because the assignments may vary
depending on the number of personnel working
each day.
Documentation of patient weight in
kilograms. Dantrolene sodium is administered
in doses of 2.5 mg/kg. Standardizing documentation
of patient weight in kilograms eliminates the
necessity of doing a conversion in the middle of
a crisis situation, which helps prevent miscalculations. In addition, facilities may want to keep a
dosage conversion chart on the MH cart.
Other. An MH mock drill kit and procedural
manual from MHAUS facilitates MH training and
preparedness efforts. In addition, the MH Hotline
may be available to participate in training calls.
An MH app, which functions much like an interactive MH algorithm, also may be used to facilitate
management of an MH event during a mock drill or
actual MH episode. Table 4 provides a list of these
and other educational tools that are available for
use in developing MH drills.
After the Drill
After the mock drill, a debriefing sessiondone of
the most beneficial components of the mock drill
processdshould be held so that all team members
can analyze the process together and better prepare
for future MH events.5,29 Typically, a member of
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TABLE 4. Educational Tools Available for the Development of Malignant Hyperthermia (MH) Drills
n
n
n
n
n
n
MH mock drill kit*
MH procedural manuals for hospitals, ambulatory surgery centers, and office settings*
Emergency Therapy for Malignant Hyperthermia poster for the OR*
MH Hotline call for use during a mock drill*
MH application (available from iTunes) developed by the Malignant Hyperthermia Association of the United States (MHAUS)
and European MH Group
MH dantrolene dosage conversion chart*
* Available from MHAUS (http://www.mhaus.org)
the MH drill team will serve as facilitator of this
session. The debriefing should begin with one or
a series of nonjudgmental, open-ended questions,
such as “Overall, how do you think the drill went?”
The purpose of this session is to use verbal discussion and reflection to reveal what has been
learned from the experience, clarify areas of misunderstanding, address knowledge gaps, and assist
the learners in transferring and applying what has
been learned into clinical practice.22 Novel solutions to identified challenges should be welcomed
during this session.
During the debriefing session, or in a separate
session conducted afterward, the MH drill evaluation tool may be used to guide the discussion about
performance and to recap solutions to challenges. A
second debriefing session may work well for some
health care teams, allowing participants to receive
a critique of their performance after they have had
a chance for self-evaluation.
FINE-TUNING THE RESPONSE PLAN
After the debriefing session has been conducted and
solutions to challenging areas developed, it is important for the MH drill team to conduct a formal
education session to review the team’s performance
and summarize challenges, successes, and resultant
changes to the MH response plan. After this is
accomplished, another drill should be conducted to
assess the updated response plan. This process
should continue until the organization response
plan evolves to a point at which the team performs
348 j AORN Journal
all tasks smoothly during a mock drill no matter
what drill design is used.
Along with prominent nursing associations
such as AORN and AANA, MHAUS strongly
recommends that MH practice drills be conducted
at periodic intervals so that all team members
remain familiar with MH protocols. At a minimum, MHAUS recommends that drills be conducted on an annual basis. In a facility with
a high frequency of turnover in personnel, drills
may need to be performed more often.
CONCLUSION
In the case presented at the beginning of this
article, a number of problems that are associated
with the diagnosis and treatment of MH could be
addressed in the debriefing session:
n
identifying initial tachycardia as the first sign
of MH,
n taking too much time to prepare the dantrolene
sodium,
n taking too much time to retrieve ice, and
n difficulty reading the MH Hotline number on
the sticker and not making the call.
An evaluation tool can be designed to help identify
these types of problems. Conducting mock drills on
a regular basis can help eliminate these types
of problems.
Perioperative team members face the daily challenge of being prepared and competent to respond to
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS
the myriad emergency events that may occur in the
perioperative environment. Preparation for such
medical emergencies, especially high-impact, lowfrequency events such as MH, must include not only
didactic educational sessions but also regular mock
drills and simulation exercises to allow for improvement of cognitive, mechanical, and teamwork skills.
Only then can we expect the best possible outcomes for
our patients.
Acknowledgment: The authors thank Henry
Rosenberg, MD, director, Department of Medical
Education and Clinical Research, Saint Barnabas
Medical Center, Livingston, NJ, and President,
Malignant Hyperthermia Association of the United
States, Sherburne, NY, for his review and helpful
comments during preparation of this manuscript.
11.
12.
13.
14.
15.
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January 19, 2010. Accessed November 15, 2012.
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CO: AORN, Inc; 2012:621-641.
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124(4 Suppl):68S-81S.
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management. OR Nurse. 2009;3(3):20-26.
Sharon J. Hirshey Dirksen, PhD, was a scientific officer, Malignant Hyperthermia Association of the United States (MHAUS), Sherburne,
NY, at the time this article was written. As
a former employee of MHAUS, Dr Dirksen has
declared an affiliation that could be perceived
as posing a potential conflict of interest in the
publication of this article.
350 j AORN Journal
HIRSHEY DIRKSEN ET AL
Sharon A. Van Wicklin, MSN, RN, CNOR,
CRNFA, CPSN, PLNC, is a perioperative
nursing specialist, AORN, Inc, Denver, CO. Ms
Van Wicklin has no declared affiliation that
could be perceived as posing a potential conflict
of interest in the publication of this article.
Darlene LeDrut Mashman, MD, is an assistant
professor of anesthesiology, Emory University
School of Medicine, Children’s Healthcare of
Atlanta, Egleston Hospital, Atlanta, GA. As the
recipient of an honorarium from MHAUS for
filming a malignant hyperthermia response plan,
Dr Mashman has declared an affiliation that
could be perceived as posing a potential conflict
of interest in the publication of this article.
Pam Neiderer, BSN, RN, is the director of
surgical services, Memorial Hospital and the
Surgical Center of York, York, PA. Ms Neiderer
has no declared affiliation that could be perceived as posing a potential conflict of interest in
the publication of this article.
Debra Rose Merritt, MSN, CRNA, is a staff
nurse anesthetist, Cone Health System, The
Women’s Hospital of Greensboro, Greensboro,
NC. Ms Merritt has no declared affiliation that
could be perceived as posing a potential conflict
of interest in the publication of this article.
EXAMINATION
4.7
CONTINUING EDUCATION PROGRAM
Developing Effective Drills in
Preparation for a Malignant
Hyperthermia Crisis
www.aorn.org/CE
PURPOSE/GOAL
To enable the learner to rapidly recognize and treat a malignant hyperthermia (MH)
crisis.
OBJECTIVES
1.
2.
3.
4.
5.
Describe the etiology of MH.
Discuss current treatment of MH.
Explain the pathophysiology of MH.
Identify signs and symptoms of MH.
Describe how to use a mock drill to prepare for an MH crisis.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1.
2.
Malignant hyperthermia (MH)
1. can progress quickly to a life-threatening
situation.
2. occurs during procedures in which general
anesthetics are administered.
3. occurs more frequently in children than
adults.
4. occurs primarily in patients with cancer.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 3
d. 1, 2, 3, and 4
The MH response spurs a cascade of reactions,
including
1. cellular damage and destruction.
2. excess lactate production.
3. increased oxygen consumption.
Ó AORN, Inc, 2013
increased production of carbon dioxide and
heat.
5. increased sympathetic activity.
6. rise in serum levels of potassium, phosphate,
magnesium, and myoglobin.
a. 1, 3, and 5
b. 2, 4, and 6
c. 2, 3, 5, and 6
d. 1, 2, 3, 4, 5, and 6
4.
3.
Complications that may result if MH continues to
progress include
1. skeletal muscle damage.
2. hyperthermia.
3. ketoacidosis.
4. renal failure.
5. cardiac arrest.
6. death.
a. 1, 3, and 5
b. 2, 4, and 6
c. 1, 2, 4, 5, and 6
d. 1, 2, 3, 4, 5, and 6
March 2013
Vol 97 No 3 AORN Journal j 351
CE EXAMINATION
March 2013 Vol 97 No 3
4.
The earliest sign of a classic presentation of MH is
a. unexplained increase in end-tidal carbon
dioxide production.
b. muscle rigidity.
c. hyperthermia.
d. unexplained tachycardia or arrhythmia.
2.
5.
A history of previous uneventful general anesthesia rules out the possibility that a patient may
be MH susceptible.
a. true
b. false
6.
6.
As soon as an MH episode is suspected
1. the surgeon should stop the procedure as
soon as possible.
2. the anesthesia professional should discontinue administration of all volatile agents
and succinylcholine immediately.
3. the anesthesia professional should hypoventilate the patient with 50% oxygen at
flows of 3 L/minute.
4. the perioperative RN or anesthesia professional should prepare and administer dantrolene sodium immediately.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
7.
A mock drill conducted to enhance MH preparedness can be accomplished with
1. actors portraying patients using scripted
roles.
352 j AORN Journal
3.
4.
5.
complex task trainers with virtual-reality
scenarios.
full mission simulation.
integrated whole-body manikin simulators.
partial task trainers such as intubation
manikins and IV arms.
role-playing.
a. 1, 3, and 5
b. 2, 4, and 6
c. 2, 3, 5, and 6
d. 1, 2, 3, 4, 5, and 6
8.
It is important to choose a time and date that
allows for disruption of the surgical schedule to
maximize the reality of the drill.
a. true
b. false
9.
Dantrolene sodium is administered in doses of
a. 2.5 mg/kg.
b. 3 mg/kg.
c. 3.5 mg/kg.
d. 4 mg/kg.
10.
The purpose of the MH drill debriefing is to
1. address knowledge gaps.
2. assist the learners in applying what has been
learned into clinical practice.
3. clarify areas of misunderstanding.
4. identify novel solutions to challenges experienced during the drill.
5. use discussion and reflection to reveal what
was learned from the experience.
a. 4 and 5
b. 1, 2, and 3
c. 1, 2, 3, and 4
d. 1, 2, 3, 4, and 5
LEARNER EVALUATION
4.7
CONTINUING EDUCATION PROGRAM
Developing Effective Drills in
Preparation for a Malignant
Hyperthermia Crisis
T
his evaluation is used to determine the extent to
which this continuing education program met
your learning needs. Rate the items as described
below.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Describe the etiology of malignant hyperthermia
(MH). Low 1. 2. 3. 4. 5. High
2. Discuss current treatment of MH.
Low 1. 2. 3. 4. 5. High
3. Explain the pathophysiology of MH.
Low 1. 2. 3. 4. 5. High
4. Identify signs and symptoms of MH.
Low 1. 2. 3. 4. 5. High
5. Describe how to use a mock drill to prepare for an
MH crisis. Low 1. 2. 3. 4. 5. High
CONTENT
6. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
7. To what extent were your individual objectives met?
Low 1. 2. 3. 4. 5. High
8. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
Ó AORN, Inc, 2013
www.aorn.org/CE
9. Will you change your practice as a result of reading
this article? (If yes, answer question #9A. If no,
answer question #9B.)
9A. How will you change your practice? (Select all that
apply)
1. I will provide education to my team regarding
why change is needed.
2. I will work with management to change/
implement a policy and procedure.
3. I will plan an informational meeting with
physicians to seek their input and acceptance
of the need for change.
4. I will implement change and evaluate the
effect of the change at regular intervals until
the change is incorporated as best practice.
5. Other: ________________________________
9B. If you will not change your practice as a result of
reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make
a change.
4. Other: _______________________________
10. Our accrediting body requires that we verify
the time you needed to complete the 4.7 continuing education contact hour (282-minute)
program: _________________________________
March 2013
Vol 97 No 3 AORN Journal j 353