Malignant Hyperthermia: Mock Code

ABC’s of managing MH Pre-operative: Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained fever or death); Aware of clinical signs Body temperature Capnographic monitoring Dantrolene (MHAUS, 2009)

Intraoperative Primary Survey/Clinical Signs: Awareness: suspecting MH crisis? Airway: severe masseter spasm Breathing: difficult to ventilate/intubate Body rigidity after succinylcholine Body temperature high (late sign) Capnography: elevation of end CO2 Drugs: triggering agents Exposure/Examine: skin color, perfusion,temperature, urine color, extremities, muscle tone (MHAUS, 2009)

Emergency Treatment Ask for Help/Ask for MH cart Breathing: hyperventilate with 100% oxygen Cooling: blanket; fluids-15cc/kg IV 3 times; irrigate wound, stomach, & stomach; Call MH Hotline: 1-800-644-9737 Dantrolene: 2.5 mg/kg IV and until signs are controlled Check Electrolytes-**potassium (MHAUS, 2009)

Secondary steps Acidosis? Monitor blood gases. Bicarbonate? 1-2 mEq/kg guided by pH Circulation/monitoring: arterial line, venous catheter, labs, blood gases, CBC, Coagulation tests, CK, myoglobin levels Dysrhythmias: treat Diuresis: output > 1 ml/kg/hr Electrolytes: treat Follow up: Arterial and venous blood gases; Body temperature (core); end-tidal CO2; CK, Coagulation tests; Diuresis; Electrolytes (MHAUS,2009)

Post-Operative Post-Crisis Problems: Alkalinize urine & diurese, monitor for ARF (acute myoglobinuric renal failre) Beware hypothermic, hyperkalemic, hypervolemic overshoot Creatine Kinase levels (CK)- severity of rhabdomylosis (watch for renal failure) Compartment Sundrome Elevated liver functions 12-36 hours post MH Follow CNS function Good communication to medical specialists (MHAUS,2009)

Post-Acute Phase Aware of recrudescence signs Ask relatives about Anesthesia problems /neuromuscular disorders Biopsy: send to center for evaluation Contact MHAUS for information/referral Dantrolene 1 mg/kg IV q 4-6 hrs and continued for 24-48 hours Document: submit forms to the national/international North American MH Registry: www.mhreg.org (MHAUS, 2009)

Mock Code Scenario 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 Stops inhalation agents and uses non-triggering agents (Anesthesia Duty) Hyperventilate with 100% oxygen at high flows: at least 10 L/min (Anesthesia Duty) Circulator: notifies control desk and a MH code is called by the person in charge. Ask for additional help from PACU if needed Anesthesia tech or assigned team member will take a replacement anesthesia machine into operating room (Corporate Surgical Committee, 2010)

Operating Room If replacement not available, the soda line and circuit are changed immediately and the system is flushed with oxygen before proceeding. (Anesthesia Duty) Anesthesia MD in charge of crisis intervention (Corporate Surgical Committee, 2010)

Roles are assigned Anesthesia Staff: Change anesthesia machine Monitor vital signs Administer Dantrolene and other meds to treat symtoms Assist with cooling by providing large quantities of iced saline lavage Place additional monitoring lines e.g. arterial line (Corporate Surgical Committee, 2010)

Surgeon, Scrub, & Circulator Assist in cooling the patient by providing iced saline lavage direct to peritoneal or thoracic cavity if open Stop surgical procedure as soon as possible Scrub secures the incision site (i.e. applies dressings or covers wound to protect it from disruption) (Corporate Surgical Committee, 2010)

Second Circulator Assists preparing Dantrolene for administration Each vial should be reconstituted with 60 ml of sterile water (bacteriostatic agent) Records medication and progress of interventions (Corporate Surgical Committee, 2010)

Third Circulator Assists in surface cooling of the patient as directed Obtains additional supplies as directed (Corporate Surgical Committee, 2010)

Scrub tech/Clinical Tech/RN Immediately available to run specimens to the lab Immediately available to assist as directed (Corporate Surgical Committee, 2010)

Surgery Desk Nurse Assigns staff to the operating room where the MH crisis is (may include help from PACU) Notifies PACU personnel and Nursing Operations Manager (Corporate Surgical Committee, 2010)

MH suspected in PACU Primary care nurse to notify the control desk and a MH Code is to be called by the person in charge. Additional help may be asked from the operating room/pre-op staff Hyperventilate with 100% oxygen at high gas flows: at least 10 L/min Charge Nurse (Team Leader) will immediately assign a staff member to get the MH cart Anesthesia MD is in charge (Corporate Surgical Committee, 2010)

Anesthesia Staff Will administer Dantrolene and medications used to treat symptoms Assist in cooling patient by providing large quantities of cold saline lavage Place additional monitoring lines. E.g. arterial line (Corporate Surgical Committee, 2010)

Second RN Assists preparing Dantrolene for administration Records medications and progress of intervention (Corporate Surgical Committee, 2010)

Third RN Assists in surface cooling of the patient as directed Obtains additional supplies as directed (Corporate Surgical Committee, 2010)

Debriefing of Mock Code Using the report of the timing of the events as a guide Each participant discusses what went right and what could be improved. Notes are taken and used to guide future drills (Corporate Surgical Committee, 2010)

Clinical Tech/RN Immediately available to run specimens to the lab Immediately available to assist as directed (Corporate Surgical Committee, 2010)

PACU Desk/ Charge Nurse Assigns staff to the patient where the MH crisis is (may include help from OR) Submits MH form to the national/international North American MH Registry of MHAUS (Corporate Surgical Committee, 2010)

References Corporate Surgical Committee. (2010). Malignant hyperthermia crisis intervention. Orlando Health. The Malignant Hyperthermia Association of the United States[MHAUS]. (2009). Guide to malignant hyperthermia. Retrieved from http://www. mhaus.org