Malignant Hyperthermia:

Mock Code

ABC’s of managing MHO Pre-operative:

O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained fever or death); Aware of clinical signs

O Body temperatureO Capnographic monitoringO Dantrolene

(MHAUS, 2009)

IntraoperativeO Primary Survey/Clinical Signs:

O Awareness: suspecting MH crisis?O Airway: severe masseter spasmO Breathing: difficult to ventilate/intubateO Body rigidity after succinylcholineO Body temperature high (late sign)O Capnography: elevation of end CO2O Drugs: triggering agentsO Exposure/Examine: skin color,

perfusion,temperature, urine color, extremities, muscle tone

(MHAUS, 2009)

Emergency TreatmentO Ask for Help/Ask for MH cartO Breathing: hyperventilate with 100%

oxygenO Cooling: blanket; fluids-15cc/kg IV 3 times;

irrigate wound, stomach, & stomach; Call MH Hotline: 1-800-644-9737

O Dantrolene: 2.5 mg/kg IV and until signs are controlled

O Check Electrolytes-**potassium

(MHAUS, 2009)

Secondary stepsO Acidosis? Monitor blood gases.O Bicarbonate? 1-2 mEq/kg guided by pHO Circulation/monitoring: arterial line, venous

catheter, labs, blood gases, CBC, Coagulation tests, CK, myoglobin levels

O Dysrhythmias: treatO Diuresis: output > 1 ml/kg/hrO Electrolytes: treatO Follow up: Arterial and venous blood gases;

Body temperature (core); end-tidal CO2; CK, Coagulation tests; Diuresis; Electrolytes

(MHAUS,2009)

Post-OperativeO Post-Crisis Problems:

O Alkalinize urine & diurese, monitor for ARF (acute myoglobinuric renal failre)

O Beware hypothermic, hyperkalemic, hypervolemic overshoot

O Creatine Kinase levels (CK)- severity of rhabdomylosis (watch for renal failure)

O Compartment SundromeO Elevated liver functions 12-36 hours post

MHO Follow CNS functionO Good communication to medical

specialists(MHAUS,2009)

Post-Acute PhaseO Aware of recrudescence signsO Ask relatives about Anesthesia

problems /neuromuscular disordersO Biopsy: send to center for evaluationO Contact MHAUS for

information/referralO Dantrolene 1 mg/kg IV q 4-6 hrs and

continued for 24-48 hoursO Document: submit forms to the

national/international North American MH Registry: www.mhreg.org

(MHAUS, 2009)

Mock Code ScenarioO A 40-year-old, 90 kg woman is

undergoing liposuction under general anesthesia. She is intubated and receiving desflurane anesthesia. When she is turned from prone to supine, the patient feels stiff. No temperature probe is in place and she feels warm. Her heart rate is now 160 bpm and her ETCO2 is 82 despite minute ventilation of 12 L/min: Pt has Malignant Hyperthermia

(MHAUS, 2009)

Operating Room: When MH is suspected

O Stops inhalation agents and uses non-triggering agents (Anesthesia Duty)

O Hyperventilate with 100% oxygen at high flows: at least 10 L/min (Anesthesia Duty)

O Circulator: notifies control desk and a MH code is called by the person in charge. Ask for additional help from PACU if needed

O Anesthesia tech or assigned team member will take a replacement anesthesia machine into operating room

(Corporate Surgical Committee, 2010)

Operating RoomO If replacement not available, the

soda line and circuit are changed immediately and the system is flushed with oxygen before proceeding. (Anesthesia Duty)

O Anesthesia MD in charge of crisis intervention

(Corporate Surgical Committee, 2010)

Roles are assignedO Anesthesia Staff:

O Change anesthesia machineO Monitor vital signsO Administer Dantrolene and other

meds to treat symtomsO Assist with cooling by providing large

quantities of iced saline lavageO Place additional monitoring lines e.g.

arterial line

(Corporate Surgical Committee, 2010)

Surgeon, Scrub, & Circulator

O Assist in cooling the patient by providing iced saline lavage direct to peritoneal or thoracic cavity if open

O Stop surgical procedure as soon as possible

O Scrub secures the incision site (i.e. applies dressings or covers wound to protect it from disruption)

(Corporate Surgical Committee, 2010)

Second CirculatorO Assists preparing Dantrolene for

administrationO Each vial should be reconstituted

with 60 ml of sterile water (bacteriostatic agent)

O Records medication and progress of interventions

(Corporate Surgical Committee, 2010)

Third CirculatorO Assists in surface cooling of the

patient as directedO Obtains additional supplies as

directed

(Corporate Surgical Committee, 2010)

Scrub tech/Clinical Tech/RN

O Immediately available to run specimens to the lab

O Immediately available to assist as directed

(Corporate Surgical Committee, 2010)

Surgery Desk NurseO Assigns staff to the operating room

where the MH crisis is (may include help from PACU)

O Notifies PACU personnel and Nursing Operations Manager

(Corporate Surgical Committee, 2010)

MH suspected in PACUO Primary care nurse to notify the control desk

and a MH Code is to be called by the person in charge.

O Additional help may be asked from the operating room/pre-op staff

O Hyperventilate with 100% oxygen at high gas flows: at least 10 L/min

O Charge Nurse (Team Leader) will immediately assign a staff member to get the MH cart

O Anesthesia MD is in charge

(Corporate Surgical Committee, 2010)

Anesthesia StaffO Will administer Dantrolene and

medications used to treat symptomsO Assist in cooling patient by providing

large quantities of cold saline lavageO Place additional monitoring lines.

E.g. arterial line

(Corporate Surgical Committee, 2010)

Second RNO Assists preparing Dantrolene for

administrationO Records medications and progress of

intervention

(Corporate Surgical Committee, 2010)

Third RNO Assists in surface cooling of the

patient as directed O Obtains additional supplies as

directed

(Corporate Surgical Committee, 2010)

Debriefing of Mock Code

O Using the report of the timing of the events as a guide

O Each participant discusses what went right and what could be improved.

O Notes are taken and used to guide future drills

(Corporate Surgical Committee, 2010)

Clinical Tech/RNO Immediately available to run

specimens to the labO Immediately available to assist as

directed

(Corporate Surgical Committee, 2010)

PACU Desk/ Charge Nurse

O Assigns staff to the patient where the MH crisis is (may include help from OR)

O Submits MH form to the national/international North American MH Registry of MHAUS

(Corporate Surgical Committee, 2010)

ReferencesO Corporate Surgical Committee.

(2010). Malignant hyperthermia crisis intervention. Orlando Health.

O The Malignant Hyperthermia Association of the United States[MHAUS]. (2009). Guide to malignant hyperthermia. Retrieved from http://www. mhaus.org