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

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Event: #13509

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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

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

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

AORN Journal j 331

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

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

AORN Journal j 333

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

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)

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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

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.

338 j AORN Journal

March 2013 Vol 97 No 3 HIRSHEY DIRKSEN ET AL

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

AORN Journal j 339

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

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

AORN Journal j 341

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.

342 j AORN Journal

March 2013 Vol 97 No 3 HIRSHEY DIRKSEN ET AL

Figure 1. (continued).

AORN Journal j 343

DEVELOPING MALIGNANT HYPERTHERMIA DRILLS www.aornjournal.org

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

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

AORN Journal j 345

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)

346 j AORN Journal

March 2013 Vol 97 No 3 HIRSHEY DIRKSEN ET AL

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

AORN Journal j 347

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

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.

References1. 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 Wash-

ington; 1997-2011. http://www.genetests.org. Updated

January 19, 2010. Accessed November 15, 2012.

2. Rosenberg H, Davis M, James D, Pollock N, Stowell K.

Malignant hyperthermia. Orphanet J Rare Dis. 2007;2:21.

3. Autosomal dominant. Genetics Home Reference. http://

ghr.nlm.nih.gov/glossary¼autosomaldominant. Accessed

November 27, 2012.

4. Noble KA.Malignant hyperthermia: hot stuff! J Perianesth

Nurs. 2007;22(5):341-345.

5. AORN malignant hyperthermia guideline. In: Perioper-

ative Standards and Recommended Practices. Denver,

CO: AORN, Inc; 2012:621-641.

6. Gurunluoglu R, Swanson JA, Haeck PC; ASPS Patient

Safety Committee. Evidence-based patient safety advi-

sory: malignant hyperthermia. Plast Reconstr Surg. 2009;

124(4 Suppl):68S-81S.

7. Larach MG, Gronert GA, Allen GC, Brandom BW,

Lehman EB. Clinical presentation, treatment, and compli-

cations of malignant hyperthermia in North America from

1987 to 2006. Anesth Analg. 2010;110(2):498-507.

8. Davis PJ, Brandom BW. The association of malignant

hyperthermia and unusual disease: when you’re hot

you’re hot or maybe not. Anesth Analg. 2009;109(4):

1001-1003.

9. Hirshey Dirksen SJ, Larach MG, Rosenberg H, et al.

Special article: future directions in malignant hyper-

thermia research and patient care. Anesth Analg. 2011;

113(5):1108-1119.

10. 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. Ac-

cessed November 27, 2012.

11. Burden AR, Carr ZJ, Staman GW, Littman JJ,

Torjman MC. Does every code need a “reader?” im-

provement of rare event management with a cognitive

aid “reader” during a simulated emergency: a pilot

study. Simul Healthc. 2012;7(1):1-9.

12. Goals and plans: turning points for success. In:

St Pierre M, Hofinger G, Buerschaper C. Crisis Man-

agement in Acute Care Settings: Human Factors and

Team Psychology in a High Stakes Environment. Paris,

France: Springer-Verlag; 2008:82-92.

13. Wong CA, Denholm B. Malignant hyperthermia: diag-

nosis, 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.

14. Hommertzheim R, Steinke EE. Malignant hyperthermiadthe perioperative nurse’s role. AORN J. 2006;83(1):

149-164.

15. Brandom BW, Larach MG, Chen MS, Young MC.

Complications associated with the administration of

dantrolene 1987 to 2006: a report from the North

American Malignant Hyperthermia Registry of the

Malignant Hyperthermia Association of the United

States. Anesth Analg. 2011;112(5):1115-1123.

16. Dantrium Intravenous� (dantrolene sodium for injection)

prescribing information [package insert]. Rochester, MN:

JHP Pharmaceuticals, LLC; 2008.

17. Burkman JM, Posner KL, Domino KB. Analysis of the

clinical variables associated with recrudescence after

malignant hyperthermia reactions. Anesthesiology. 2007;

106(5):901-906.

18. Larach MG, Dirksen SJ, Belani KG, et al. Special article:

creation of a guide for the transfer of care of the malig-

nant hyperthermia patient from ambulatory surgery

centers to receiving hospital facilities. Anesth Analg.

2012;114(1):94-100.

19. Arciaga PL, Windokun A, Marbella V, Lewis K.

Simulation training alone does not improve response

to malignant hyperthermia scenario in an ambulatory

surgical center [Abstract A835]. Presented at: Anes-

thesiology 2011: American Society of Anesthesiolo-

gists Annual Meeting; October 17, 2011; Los Angeles,

CA.

20. Position statement number 2.5: malignant hyperthermia

crisis preparedness and treatment. American Association

of Nurse Anesthetists 2010. http://www.aana.com/resour

ces2/professionalpractice/Documents/PPM%20PS%

202.5%20MH%20Preparedness%20and%20Treatment

.pdf. Accessed November 15, 2012.

21. Henrichs BM, Avidan MS, Murray DJ, et al. Performance

of certified registered nurse anesthetists and anesthesiol-

ogists in a simulation-based skills assessment. Anesth

Analg. 2009;108(1):255-262.

22. Galloway S. Simulation techniques to bridge the gap

between novice and competent healthcare professionals.

OJIN. 2009;14(2). http://nursingworld.org/MainMenuCa

tegories/ANAMarketplace/ANAPeriodicals/OJIN/Tableo

fContents/Vol142009/No2May09/Simulation-Technique

s.html. Accessed November 15, 2012.

AORN Journal j 349

March 2013 Vol 97 No 3 HIRSHEY DIRKSEN ET AL

23. Manser T, Harrison TK, Gaba DM, Howard SK. Coor-

dination patterns related to high clinical performance in

a simulated anesthetic crisis. Anesth Analg. 2009;108(5):

1606-1615.

24. Kim J, Neilipovitz D, Cardinal P, Chiu M. A comparison

of global rating scale and checklist scores in the valida-

tion of an evaluation tool to assess performance in the

resuscitation of critically ill patients during simulated

emergencies (abbreviated as “CRM simulator study IB”).

Simul Healthc. 2009;4(1):6-16.

25. Malec JF, Torsher LC, Dunn WF, et al. The Mayo high

performance teamwork scale: reliability and validity for

evaluating key crew resource management skills. Simul

Healthc. 2007;2(1):4-10.

26. Mudumbai SC, Gaba DM, Boulet JR, Howard SK,

Davies MF. External validation of simulation-based

assessments with other performance measures of third-

year anesthesiology residents. Simul Healthc. 2012;7(2):

73-80.

27. Guise JM, Deering SH, Kanki BG, et al. Validation of

a tool to measure and promote clinical teamwork. Simul

Healthc. 2008;3(4):217-223.

28. Ziewacz JE, Arriaga AF, Bader AM, et al. Crisis check-

lists for the operating room: development and pilot testing.

J Am Coll Surg. 2011;213(2):212-217.e210.

29. Martin CL. A practical guide for malignant hyperthermia

management. OR Nurse. 2009;3(3):20-26.

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.

EXAMINATION

CONTINUING EDUCATION PROGRAM

4.7

www.aorn.org/CEDeveloping Effective Drills in

Preparation 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

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

LEARNER EVALUATION

CONTINUING EDUCATION PROGRAM

4.7

www.aorn.org/CEDeveloping Effective Drills in

Preparation 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