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CONTINUING EDUCATION
Developing Effective Drills inPreparation for a MalignantHyperthermia 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 4.7www.aorn.org/CE
Continuing Education Contact Hoursindicates that continuing education contact hours are avail-
able for this activity. Earn the contact hours by reading this
article, reviewing the purpose/goal and objectives, and com-
pleting the online Examination and Learner Evaluation at
http://www.aorn.org/CE. A score of 70% correct on the
examination is required for credit. Participants receive feed-
back on incorrect answers. Each applicant who successfully
completes this program can immediately print a certificate of
completion.
Event: #13509
Session: #0001
Fee: Members $28.20, Nonmembers $56.40
The contact hours for this article expire March 31, 2016.
Purpose/GoalTo enable the learner to rapidly recognize and treat a malignant
hyperthermia (MH) crisis.
Objectives
1. Describe the etiology of MH.
2. Discuss current treatment of MH.
3. Explain the pathophysiology of MH.
4. Identify signs and symptoms of MH.
5. Describe how to use a mock drill to prepare for an MH
crisis.
AccreditationAORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
ApprovalsThis program meets criteria for CNOR and CRNFA recertifi-
cation, as well as other continuing education requirements.
http://dx.doi.org/10.1016/j.aorn.2012.12.009
� AORN, Inc, 2013
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 DisclosuresMs Van Wicklin, Ms Neiderer, and Ms Merritt have no
declared affiliations that could be perceived as posing poten-
tial 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 con-
sultation from Susan Bakewell, MS, RN-BC, director, Peri-
operative 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 SupportNo sponsorship or commercial support was received for this
article.
DisclaimerAORN recognizes these activities as continuing education for
registered nurses. This recognition does not imply that AORN
or the American Nurses Credentialing Center approves or en-
dorses products mentioned in the activity.
March 2013 Vol 97 No 3 � AORN Journal j 329
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M
Developing Effective Drills inPreparation for a MalignantHyperthermia CrisisSHARON 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 4.7www.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, multidis-
ciplinary 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. � AORN, Inc, 2013. http://dx.doi.org/
10.1016/j.aorn.2012.12.009
Key words: malignant hyperthermia (MH), response plan, mock drill, simulation.
alignant hyperthermia (MH) can progress
quickly to a life-threatening situation.
Malignant hyperthermia occurs approxi-
mately 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. Fortu-
nately, 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 ed-
ucation sessions should be implemented to keep the
330 j AORN Journal � March 2013 Vol 97 No 3
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 recommen-
dations 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 pro-
fessional induces Mr R with midazolam, fentanyl,
http://dx.doi.org/10.1016/j.aorn.2012.12.009
� AORN, Inc, 2013
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DEVELOPING MALIGNANT HYPERTHERMIA DRILLS www.aornjournal.org
and propofol, and anesthesia is maintained with
isoflurane. The anesthesia professional uses succi-
nylcholine 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 facilityMH 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 effi-
ciently in the event of a crisis.
PATHOPHYSIOLOGY AND CLINICALPRESENTATION
Malignant hyperthermia is a genetic, autosomal
dominant disorder of the skeletal muscle. An
autosomal dominant gene is the gene that dom-
AORN Resources
n AORN Video Library: Malignant Hyperthermia: Keeping Your
Cool. http://cine-med.com/index.php?nav¼aorn.
n Periop Mastery Program: Malignant Hyperthermia. http://
www.aorn.org/Education/Curriculum/Periop_Mastery_Program/
Malignant_Hyperthermia.aspx.
Web site access verified December 4, 2012.
inates the inherited gene pair
(ie, one from each parent) and
is not on an X or Y chromo-
some (ie, gender-determining
chromosomes).3 The major-
ity of individuals who are
MH susceptible have a defect
in the ryanodine receptor type
1 (RYR1) gene. This gene
encodes an ion channel in the
skeletal muscle cell through
which calcium flows. In the presence of an abnormal
RYR1 gene in MH-susceptible individuals, a trig-
gering agent such as halothane, isoflurane, sevo-
flurane, 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, magne-
sium, and myoglobin leakage into the extracellular
fluid, with a resulting rise in serum levels.6 Com-
plications that may occur if MH continues to prog-
ress 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 unex-
plained tachycardia or arrhythmia, amixed respiratory
or metabolic acidosis, muscle rigidity, hyperthermia,
and myoglobinuria.
Individuals with a family history of MH or with
congenital myopathies, especially those associated
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March 2013 Vol 97 No 3 HIRSHEY DIRKSEN ET AL
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 Asso-
ciation 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?id¼1157088; accessed December 12, 2012).
DEVELOPING AN MH EMERGENCYRESPONSE PLAN
Chances for a successful outcome after an MH event
increase with rapid, accurate diagnosis and a coor-
dinated, swift, multidisciplinary team response to
deliver the appropriate treatment. This may be
challenging, especially if members of the peri-
operative team have not received MH crisis man-
agement education or have not experienced an
actual MH event in clinical practice.11 When de-
veloping 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
Whenplanning 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 de-
livery, intensive care unit [ICU]). These are areas
where triggering agents are givenor aremaintainedon
standby for emergencies, or areas to which patients
may be taken after they receive triggering agents.
For ambulatory centers (eg, surgery centers, office-
based facilities), theMH 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 How should the operative or procedure team
call for help from perioperative personnel
available in the area?
n How should personnel call for the MH cart if it
is in the perioperative area?
n If the crisis is in an area outside of the peri-
operative 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?
n How many team members will respond to an
MH crisis?
n Will the number of responders vary depending
on whether the MH crisis is in the OR, proce-
dure room, or some another area (eg, post-
anesthesia care unit [PACU])?
n Will the number of available responders vary
depending on the time of day?
n 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 devel-
oping 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 ass-
ignment of specific responsibilities to each
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DEVELOPING MALIGNANT HYPERTHERMIA DRILLS www.aornjournal.org
responding team member. Many tasks must be
accomplished simultaneously during a stressful,
high-stakes situation while the patient is decom-
pensating clinically. Performing all of the simul-
taneous 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 ep-
isode. This list may be useful for assigning roles
and responsibilities for personnel during the de-
velopment of an organization-specific MH re-
sponse plan.
Nursing care begins when the patient is sched-
uled for any procedure involving general anes-
thesia. 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 anes-
thesia professionals must be able to recognize the
clinical manifestations of an MH crisis and initiate
the necessary actions for a coordinated team re-
sponse. All RNs who may care for patients re-
ceiving 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 sus-
pected, 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
continued with nontriggering anesthetics.14 The
anesthesia professional should discontinue admin-
istration 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 anes-
thesia 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 administra-
tion 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 sy-
mptoms 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 coag-
ulation.7 In addition, symptoms such as difficulty
swallowing food, muscle weakness, and light-
headedness may be observed in association with
dantrolene sodium administration.15,16 A 20% re-
crudescence 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 orEvent1-3
Role Responsibilities
Anesthesia professional n Lead the anesthesia team during treatment.n Recognize and diagnose MH.n Inform the RN circulator to initiate the MH response plan.n Discontinue triggering agents and begin treatment of MH.n Communicate with the MH Hotline consultant.n Communicate with the surgeon about findings, resuscitation, and treatment.n Maintain situational awareness (eg, working diagnosis, intended treatment plan, team
assignments, periodic status updates) and open lines of communication.n Place additional lines or assign a team member to place additional IV or arterial lines as
needed.n Develop a post-acute treatment plan for the patient after the patient is stabilized.n 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 thereceiving institution, as needed.
n Counsel the patient and his or her family members on MH resources available from theMalignant Hyperthermia Association of the United States (MHAUS), and submit anAdverse Medical Reaction to Anesthesia (AMRA) report.
Surgeon n Assess the most expeditious surgical plan (eg, close the wound, complete the procedure,modify the procedure).
n Assist with placement of IV, arterial, and central venous lines if asked.n 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.
n Order an intensive care unit (ICU) bed for the patient (if not already done).
RN circulator n Initiate the MH protocol.n Call the MH Hotline and put the call on speakerphone if possible.n Call for nursing support/help.n Assign duties to others according to the facility’s response plan.n Begin the documentation and record details of the patient’s treatment, including medi-
cation dosages, administration times, and the patient’s response.n Assist the anesthesia professional with placement of additional IV or arterial lines as
needed.n Assist the anesthesia professional with drawing arterial blood gases and other blood work
(eg, arterial blood gas, electrolytes, creatine kinase, coagulation studies).n Help initiate and maintain situational awareness (ie, coordinate with the anesthesia
professional/team leader).n Get any materials that the surgeon needs to irrigate or close the wound, if applicable.n 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).n Assist with patient transport, as needed; provide the transfer-of-care report to the PACU,
ICU, and receiving institution.n Restock supplies on the MH and emergency carts.
Charge nurse and additionalnurses, as available
n Bring the MH cart, ice, or other supplies (if not already done) and begin to mix andadminister the dantrolene sodium.
n Bring the emergency cart to the OR if it is separate from the MH cart.n Prepare and administer additional medications as directed by the anesthesia team leader.
334 j AORN Journal
March 2013 Vol 97 No 3 HIRSHEY DIRKSEN ET AL
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TABLE 1. (continued) Suggested Responsibilities by Role During a Malignant Hyperthermia (MH)Drill or Event1-3
Role Responsibilities
n Monitor the patient’s core temperature and begin activities to cool the patient if his or hercore temperature is greater than 39� C (102.2� F).
n Refer the patient to the MHAUS web site (http://www.mhaus.org) after the MH event foradditional information and resources, if applicable.
Anesthesia technician n Respond to a call for help by bringing the MH cart to the site (if not already done).n 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.
n Assist the anesthesia professional with placing IV, arterial, and central venous lines.n Stand ready for other assignments.n Help set up monitors in the PACU if needed.n Restock anesthesia supplies.
Clinical assistant/runner n Obtain additional supplies and ice.n Deliver specimens to the laboratory.n Check with the team for additional needs, such as retrieving supplies from areas away
from the MH site.n Obtain an ICU bed if requested.
Front desk personneland non-medical personnel
n Restock the ice supply if asked.n Call backup personnel for additional help if asked.n Perform the duties of the runner as needed.
Pharmacist or pharmacytechnician
n Reconstitute dantrolene sodium.n Prepare additional medications as directed.n Restock medications on the MH cart.
PACU charge nurse n Offer assistance to the OR team.n Ensure continuity of care for the patient who has experienced an MH event.n Ensure that an MH cart with an adequate stock of dantrolene sodium is immediately
available for further treatment.n Continue monitoring the patient for signs and symptoms of MH.n Record and monitor the patient’s temperature and prepare a core temperature probe as
directed.n Prevent recrudescence by administering 1 mg/kg of dantrolene sodium every 4 to 6 hours
or a 0.25 mg/kg/hour infusion.n Ensure that an emergency cart and cooling measures, such as crushed ice and zipper
bags, are readily available.n 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.
Nurse educator ordrill coordinator
n Schedule the drill with the operative services scheduler, anesthesia professionals, andsurgical team members.
n Recruit volunteers for the drill.n Run the drill.n Conduct and set the tone for the debriefing session.
(table continued)
AORN Journal j 335
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS www.aornjournal.org
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TABLE 1. (continued) Suggested Responsibilities by Role During a Malignant Hyperthermia (MH)Drill or Event1-3
Role Responsibilities
n Create a summary of the drill and document the strengths and challenges.n Ensure the MH drill site is cleaned of mock materials and the care area is clean.n Ensure all MH supplies and the drill medications are removed, and the MH supplies are
replaced in storage locations.n Ensure that the pharmacist has removed any expired medications or mock drill medi-
cations from the MH cart and that it is restocked with MH medications and supplies.n Schedule educational sessions.n 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.
March 2013 Vol 97 No 3 HIRSHEY DIRKSEN ET AL
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 fa-
cility, the steps should include an efficient transfer
(based on a pre-existing agreement) to a nearby
hospital that has critical care capabilities. The hos-
pital 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 capa-
bilities 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 assign-
ments with all members of the perioperative team.
This review usually occurs during planned educa-
tion 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
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TABLE 2. Pathophysiology and Treatment Associated With Each Malignant Hyperthermia ClinicalSign1-5
Clinical signs Pathophysiology Acute treatment Post-acute treatment
Rise in end-tidal carbon dio-xide (CO2) production:Excess CO2 productioncan cause the CO2
absorbent canister onthe anesthesia machineto become discoloredand hot to the touch
Metabolic and respiratoryacidosis
Increase in myoplasmiccalmodulin-dependentprotein kinase (Ca2þ)leads to muscle con-tracture, increasedaerobic and anaerobicmetabolism, excessiveCO2, and lactic acidproduction.
As CO2 rises, respiratoryacidosis ensues andas lactate levels rise,metabolic acidosisensues.
n Discontinue triggeringagent (ie, volatile anestheticgas or succinylcholine).
n Hyperventilate the patientwith 100% oxygen.
n Call for help from anyavailable perioperativepersonnel.
n Put an activated charcoalfilter in place, if applicable.
n Administer dantrolenesodium to correct abnormalmyoplasmic calciumrelease.
n Administer sodium bicar-bonate to correct metabolicacidosis until arterial bloodgas levels are known;subsequent doses shouldbe based on analysis ofarterial blood gas levels.
n Monitor end-tidal CO2 withfrequent arterial blood gasdraws.
n Complete additional serumstudies, including creatinekinase, potassium, calcium,sodium, magnesium,myoglobin, and clottingvalues. Serum and urinestudies will be required untilthe results are normal.
Muscle spasm/rigidity: Themasseter muscle of the jawis commonly involved;however, trunk or total bodyrigidity may also be seen
Uncontrolled and sustainedincrease in myoplasmicCa2þ leads to musclecontracture andhypermetabolism.
n Continue administration ofdantrolene sodium, whichincreases the reuptake ofcalcium and prevents theongoing release of calciumfrom the sarcoplasmicreticulum, thus reducingmuscle tone and rigidity.This usually subsides withtime; other muscle relaxantswill not relieve the spasm.
n Continue administration ofdantrolene sodium andcarefully monitor tempera-ture, skin integrity, urineoutput, and blood and urinestudies.
Hyperthermia Hypermetabolic state leadsto a rise in temperaturefrom the increased use ofadenosine triphosphate incombination with the con-stricting peripheral vascula-ture, which prevents heatdissipation.
n Start cooling the patientif his or her core tempera-ture is greater than 39� C(102.2� F). Actions thatmay be helpful in reducingthe patient’s temperatureincluden 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 temper-ature with an esophageal orrectal probe.
n Continue cooling methodsuntil the patient’s tempera-ture reaches 38� C (100.4�
F) and continues to de-crease, but do not permitthe patient’s temperature todrop below 36� C (96.8� F).
n Assess the patient’s skinintegrity frequently becausediaphoresis and the use of
(table continued)
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TABLE 2. (continued) Pathophysiology and Treatment Associated With Each Malignant Hyper-thermia Clinical Sign1-5
Clinical signs Pathophysiology Acute treatment Post-acute treatment
n instilling cold irrigationfluids into the open bodycavities;
n performing cold lavageof the patient’sstomach, rectum, andbladder (eg, irrigatingcold saline solutionthrough a nasogastric orrectal tube or indwellingurinary catheter); and
n applying a hypothermiablanket.
cooling blankets increasethe risk for skin breakdown.
Myoglobinuria
Renal failure
Hypermetabolism leads tocell membrane damageand consequently theintracellular contents (ie,potassium, magnesium,phosphate, cellular en-zymes [eg, creatininekinase], myoglobin) beginto leak into the bloodstream.
Myoglobin released fromdamaged muscle cellsforms casts in the kidneysthat obstruct the renaltubules.
n Administer diuretics(eg, furosemide) to re-duce fluid overload andpromote excretion ofpotassium, sodium,and myoglobin. A urinaryoutput of 1 mL/kg/hourto 2 mL/kg/hour shouldbe maintained. Notably,each 20-mg vial of dan-trolene sodium alsocontains 3 g of mannitol,an osmotic diuretic.
n Monitor urinary outputfrequently via an indwellingurinary catheter and urinemeter. Output should bemaintained at greater than2 mL/kg/hour to preventrenal failure.
n Observe urine for concen-tration. Increased ordecreased concentrationmay indicate renal failure,and increased concentra-tion may be a sign of heartfailure.
n Observe urine for colacolor, which is an indicationof the presence ofmyoglobin, and performurine studies to monitormyoglobin levels.
Tachycardia/tachypnea
Cardiac arrhythmias/arrest/heart failure
Hypercarbia, hyperkalemia,and catecholamine releasestimulate the sympatheticnervous system.
Increase in serum potassium(Kþ) (ie, hyperkalemia) andthe inability of the kidneys toexcrete excess potassiumlead to life-threateningdysrhythmias.
n Administer glucose andinsulin to correct hyper-kalemia by facilitating theuptake of glucose into thecell and reducing potas-sium levels regulated by thesodium-potassium pumpcontrolled by insulin.
n Administer sodium bicar-bonate, as well as calciumchloride or calcium gluco-nate, to correct hyper-kalemia and restore the
n Check glucose levels hourlyif glucose and insulin areadministered.
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TABLE 2. (continued) Pathophysiology and Treatment Associated With Each Malignant Hyper-thermia Clinical Sign1-5
Clinical signs Pathophysiology Acute treatment Post-acute treatment
balance between potas-sium and calcium.
n Administer antiarrhythmicagents to treat dysrhyth-mias not responding totreatment of acidosis andhyperkalemia. Implementthe standard advancedcardiovascular life supportprotocoldwith the excep-tion of calcium channelblockers (eg, diltiazem[Cardizem]), which maycause hyperkalemia orcardiac arrest in the pres-ence of dantrolene.
1. Rosenberg H, Sambuughin N, Dirksen R. Malignant hyperthermia susceptibility. In: Pagon RA, Bird TD, Dolan CR, Stephens K, Adam MP, eds. Gen-eReviews [Database online]. Seattle, WA: University of Washington; 1997-2011. http://www.genetests.org. Updated January 19, 2010. AccessedNovember 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. PlastReconstr 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.site-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.
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS www.aornjournal.org
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 re-
cently 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 HIRSHEY DIRKSEN ET AL
because mock drills permit members of peri-
operative 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 edu-
cation, which primarily includes verbal instruction
and requires the participants to memorize pre-
sented material, a well-crafted simulation exercise
promotes enhanced competency by incorporating
kinesthetic learning.22
Mock drills provide the opportunity for peri-
operative 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 prac-
tice 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 authen-
ticity), and
n full mission simulation (ie, the learner functions
as a member of a team responding to an emer-
gency situation).22
Coordinating the MH Mock Drill
The MH drill requires institutional preparation that
should be coordinated by an MH drill team. Mem-
bers 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 simula-
tion 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
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DEVELOPING MALIGNANT HYPERTHERMIA DRILLS www.aornjournal.org
many scenarios. The drill can include specific pa-
tient 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 an-
nounced 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 ser-
vices, OR scheduler, perioperative educator, de-
partment head and administrative personnel for
anesthesiology, department head and administra-
tive 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 fam-
ily history of anesthetic complication. As peri-
operative 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 cen-
ters, the mock drill should incorporate steps for
transferring the patient to a hospital with critical
care resources and practicing roles during the
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 pro-
cured 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 syn-
drome 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 du-
ring 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 assign-
ments as well as skills in collaboration, commu-
nication, 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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Figure 1. Malignant hyperthermia mock drill. Reprinted with permission from Mashman D. Malignant hyper-thermia: is your team prepared? In: Meeting Syllabus Section VI, Georgia Society of Anesthesiologists Basics atthe Beach Summer Meeting; July 22-24, 2011; St Simons Island, GA.
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Figure 1. (continued).
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March 2013 Vol 97 No 3 HIRSHEY DIRKSEN ET AL
teams that received higher clinical performance
scores were more focused on role coordination
and adaptation relative to the situational require-
ments.23 Higher scoring teams also prioritized
clinical tasks and communicated more effectively
and more frequently.
When developing the evaluation tool, perioper-
ative educators may find it useful to review avail-
able 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 perfor-
mance during MH event simulations, they may be
useful for developing an MH drill evaluation tool.
In addition, an example tool, although not vali-
dated, 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 rein-
forced in future education sessions, and areas that
need to be refined in the MH response plan. Pro-
cedures 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 peri-
operative educator also should periodically eval-
uate 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
344 j AORN Journal
may number about eight volunteers, including
an anesthesiologist, an anesthetist or resident or
fellow, a surgeon or surgeon actor, an RN circu-
lator, a scrub person, one or two drill evaluators
from the institution, and an in situ simulator pa-
tient with a computer operator or a patient actor.
In ambulatory facilities, individuals in various
ancillary functions (eg, receptionist, billing, envi-
ronmental services, sterile processing) also may be
involved. The drill team should make and docu-
ment 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, re-
presentatives from the mock drill team should
check with the facility pharmacist about the pos-
sibility 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 ster-
ile 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 ef-
fective for helping health care providers adhere to
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Figure 2. A visual aid may be used to guide the preparation of dantrolene sodium for treatment of malignanthyperthermia. 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 dis-pensing pins into vials of sterile water and dantrolene. Box 3 shows how to use a syringe to withdraw 60 mLof sterile water; there is no need to inject air. Box 4 depicts injection of 60 mL of sterile water into a 20-mg vialof dantrolene; there is no need to remove air.
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS www.aornjournal.org
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 cog-
nitive aid for the management of MH.
Reader. Introducing a “reader” whose responsi-
bility during a critical event is to read the required
actions from a cognitive aid aloud and acknowledge
completion of each action may increase perfor-
mance. One study, for example, evaluated whether
the use of a reader could improve the perform-
ance 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 ob-
stetric 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 Cart1,2
Medications n Dantrolene sodium, 36 vialsn 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 administrationn 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.
n Sodium bicarbonate 8.4%, 50 mL � 5n Furosemide 40 mg/ampoules � 4; 3-mL syringes (with 21 Ga 1½” needles if not using a needleless
system) for drawing up furosemiden Dextrose 50%, 50-mL vials � 2n Calcium chloride 10%, 10-mL vials � 2n Regular insulin 100 units/mL � 1; insulin syringes (with 29 Ga ½” needle if not using a needleless
system)n Lidocaine (2%) for injection, 100 mg/5 mL or 100 mg/10 mL in preloaded syringes � 3
n Amiodarone is also acceptablen 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
General equipment n Syringes 60 mL Luer lock � 6 to dilute dantrolene sodiumn IV dispensing pins � 12 to reconstitute dantrolene sodiumn Clean, commercially available, charcoal filters, if used at the facilityn IV catheters for arterial and venous accessn Nasogastric tubes and Toomey or catheter tip irrigation syringes 60 mL � 2 with adapter (if required)
for nasogastric irrigationn IV administration tubingn Alcohol preps for wiping IV ports and tops of vials
Monitoringequipment
n Esophageal or other core temperature probes (nasopharyngeal, tympanic membrane, rectal, bladder,pulmonary artery catheter)
n Central venous pressure trayn Transducer kits for arterial and central venous cannulation
Nursing supplies n MH treatment algorithmn > 3,000 mL refrigerated cold saline solution for IV coolingn Large sterile adhesive incise drape to cover the wound, if necessaryn Urine meter � 1 for accurate measurement of urine outputn Irrigation tray with piston syringe, 60 mL, for irrigationn Large clear plastic bags for ice � 4n Small plastic bags for ice � 4n Bucket for icen Test strips for urine analysisn 5-in-1 connectors, Y connectorsn Catheter plugsn 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 bulbsn Supportive documentation and other materials to manage the crisis (eg, cognitive aids, worksheets)
Laboratory testingsupplies
n Syringes or kits for blood gas analysis � 6n Supplies for drawing and labeling blood samplesn Blood specimen tubes � 2 per test
n Creatine kinase, myoglobin, electrolytes, chemistries (eg, lactate dehydrogenase, thyroid)
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TABLE 3. (continued) Suggested Components of Malignant Hyperthermia Emergency TreatmentCart1,2
n Prothrombin time/partial thromboplastin time, fibrinogen, d-dimer, lactaten Complete blood count, plateletsn Blood gas syringe (lactic acid level)
n If no immediate laboratory analysis is available, keep samples on ice for later analysis; storesome foam cups to be filled with ice and used to transport arterial blood gas samples
n Blood cultures to rule out bacteremian Urine collection container for myoglobin leveln Laboratory and arterial blood gas requisition forms, if using paper documentationn Specimen transport bagsn Pens and blank physician’s order forms to document orders
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/stocking-mh-cart/. Accessed November 15, 2012.
Adapted from Wong CA, Denholm B. Malignant hyperthermia: diagnosis, treatment, and prevention with permission from CMEZone.com.
DEVELOPING MALIGNANT HYPERTHERMIA DRILLS www.aornjournal.org
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 check-
ing 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. White-
boards 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 miscalcu-
lations. 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 inter-
active 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 MH mock drill kit*n MH procedural manuals for hospitals, ambulatory surgery centers, and office settings*n Emergency Therapy for Malignant Hyperthermia poster for the OR*n MH Hotline call for use during a mock drill*n MH application (available from iTunes) developed by the Malignant Hyperthermia Association of the United States (MHAUS)
and European MH Groupn MH dantrolene dosage conversion chart*
* Available from MHAUS (http://www.mhaus.org)
March 2013 Vol 97 No 3 HIRSHEY DIRKSEN ET AL
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 dis-
cussion and reflection to reveal what has been
learned from the experience, clarify areas of mis-
understanding, address knowledge gaps, and assist
the learners in transferring and applying what has
been learned into clinical practice.22 Novel solu-
tions to identified challenges should be welcomed
during this session.
During the debriefing session, or in a separate
session conducted afterward, the MH drill evalua-
tion 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 im-
portant 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 min-
imum, MHAUS recommends that drills be con-
ducted 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 chal-
lenge of being prepared and competent to respond to
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DEVELOPING MALIGNANT HYPERTHERMIA DRILLS www.aornjournal.org
the myriad emergency events that may occur in the
perioperative environment. Preparation for such
medical emergencies, especially high-impact, low-
frequency events such as MH, must include not only
didactic educational sessions but also regular mock
drills and simulation exercises to allow for impro-
vement of cognitive,mechanical, and teamwork skills.
Only thencanweexpect thebest 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.
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11. Burden AR, Carr ZJ, Staman GW, Littman JJ,
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15. Brandom BW, Larach MG, Chen MS, Young MC.
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March 2013 Vol 97 No 3 HIRSHEY DIRKSEN ET AL
23. Manser T, Harrison TK, Gaba DM, Howard SK. Coor-
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3
Sharon J. Hirshey Dirksen, PhD, was a scien-
tific officer, Malignant Hyperthermia Associa-
tion 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.
50 j AORN Journal
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 per-
ceived 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.
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EXAMINATION
CONTINUING EDUCATION PROGRAM4.7
www.aorn.org/CEDeveloping Effective Drills inPreparation for a MalignantHyperthermia Crisis
PURPOSE/GOAL
�
To enable the learner to rapidly recognize and treat a malignant hyperthermia (MH)
crisis.
OBJECTIVES
1. Describe the etiology of MH.
2. Discuss current treatment of MH.
3. Explain the pathophysiology of MH.
4. Identify signs and symptoms of MH.
5. Describe how to use a mock drill to prepare for an MH crisis.
The Examination and Learner Evaluation are printed here for your conven-
ience. To receive continuing education credit, you must complete the Exami-
nation and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1. 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
AORN, Inc, 2013
c. 1, 2, and 3 d. 1, 2, 3, and 4
2. The MH response spurs a cascade of reactions,
including
1. cellular damage and destruction.
2. excess lactate production.
3. increased oxygen consumption.
4. 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
March 2013 Vo
c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
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
l 97 No 3 � AORN Journal j 351
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March 2013 Vol 97 No 3 CE EXAMINATION
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.
5. A history of previous uneventful general anes-
thesia rules out the possibility that a patient may
be MH susceptible.
a. true b. false
352 j AORN Journal
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 dis-
continue administration of all volatile agents
and succinylcholine immediately.
3. the anesthesia professional should hypo-
ventilate the patient with 50% oxygen at
flows of 3 L/minute.
4. the perioperative RN or anesthesia profes-
sional should prepare and administer dan-
trolene 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 pre-
paredness can be accomplished with
1. actors portraying patients using scripted
roles.
2. complex task trainers with virtual-reality
scenarios.
3. full mission simulation.
4. integrated whole-body manikin simulators.
5. partial task trainers such as intubation
manikins and IV arms.
6. 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 expe-
rienced 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
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LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM4.7
www.aorn.org/CEDeveloping Effective Drills inPreparation for a MalignantHyperthermia Crisis
This 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
� AORN, Inc, 2013
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 con-
tinuing education contact hour (282-minute)
program: _________________________________
March 2013 Vol 97 No 3 � AORN Journal j 353