December 17, 2019

Is your staff ready to manage malignant hyperthermia?

By: OR Manager

Malignant hyperthermia (MH) is a rare but life-threatening surgical complication that seems to turn the effects of general anesthesia upside down. Instead of relaxing, muscles become rigid, releasing large amounts of acid and potassium into the blood. Instead of a normal slowing of breathing, respirations quicken, and end-tidal CO2 rises. Other signs include tachycardia and a spike in body temperature that can reach over 110°F. Without rapid treatment, MH can lead to cardiac arrest and death.

Fortunately, MH crisis is rare, occurring in only one in about 100,000 adult procedures and one in about 30,000 pediatric procedures, according to the Malignant Hyperthermia Association of the United States (MHAUS, However, when MH does strike, it requires rapid response by highly trained staff.

So how do you keep your staff’s skills sharp enough to treat this potentially catastrophic condition, which many healthcare professionals have never seen? OR Manager spoke with nurse leaders at three US healthcare facilities who have found that drills are a good way to raise awareness and build confidence in the ability to manage a MH crisis.

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Developing an SBT drill

Julie Blakeley, BSN, RN, CNOR

An online competency alone just won’t cut it, says Julie Blakeley, BSN, RN, CNOR, perioperative coordinator and educator, perioperative services, CHRISTUS Trinity Mother Frances Health System, Tyler, Texas.

“Staff need to participate in realistic drills to become competent and comfortable in responding to a MH crisis,” Blakely says. “Real-life simulation-based training [SBT] makes the information more meaningful for staff than reviewing it on a PowerPoint presentation or listening to a lecture or in-service.”

Blakeley and a multidisciplinary team developed a MH drill inspired by SBT that is used by other high reliability organizations. These organizations include airlines, which also must respond efficiently to low-volume, unpredictable, high-risk safety issues.

“MH crisis is also a low-volume, high-risk event,” says Blakeley. “It is unpredictable and rare but can happen in any area that uses a triggering anesthetic agent.”

The MH SBT uses equipment and often computer software to create a realistic scenario to which participants respond. Equipment includes a pediatric mannequin with a functioning IV. The mannequin is covered with a forced-air warming blanket and draped for surgery. It is intubated and connected to an anesthesia circuit. The back table and Mayo stand are draped as well.

Blakeley and her team developed the SBT scenario based on a pediatric patient to provide simultaneous practice and build confidence with managing this population, which has a higher incidence of MH crisis than adults.

The team also decided to incorporate the use of task cards into SBT. The “badge buddy” task cards are key to role recognition during a MH crisis response. The task cards are:

• individualized for the roles that RNs, OR assistants, and surgical technologists play in a MH crisis response

• modified to address different treatment areas, such as the OR, labor and delivery, and the cardiac catheterization lab

• imprinted with the MHAUS hotline number and other key phone numbers to call for STAT ABGs (arterial blood gas) and other labs

• developed on a Word document, so they can be easily modified when needed, such as when a key telephone number changes or the location of supplies is moved.

SBT is scheduled as one of the system’s yearly drills for multiple disciplines, including the anesthesia and OR staff. It is strongly encouraged for all staff working in areas of the CHRISTUS Trinity Mother Frances Health System where triggering agents are administered. This includes the ICU, postanesthesia care unit (PACU), emergency department, labor and delivery, cardiac catherization lab, bronchoscopy lab, and all outpatient surgical facilities.


Implementing an SBT drill

Before the SBT drill, staff complete a seven-question questionnaire about MH to determine their baseline level of knowledge. “The questionnaire is anonymous, so staff are comfortable with it, even if they don’t know all the answers,” says Blakeley. “They don’t feel embarrassed or like they will be called out about a wrong answer.”

The MH drill is led by anesthesia providers, as in real life. Staff are presented with a scenario that includes the patient, age, diagnosis, family history, and the kind of anesthesia administered. Anesthesia providers tell staff their assessment of the patient, such as changes in vital signs and their interpretation of the reasons for them. Three minutes into the drill, the anesthesia provider determines that a MH crisis is occurring. At that point, the clock is started to time how quickly staff retrieve the MH cart and respond to orders from the anesthesia provider.

Staff must then locate real supplies on the cart and mix the dantrolene, a laborious process. (Expired dantrolene is used for drills.) To get a realistic feel for administering the drug, they give the bolus dose IV push into the mannequin’s functioning IV.

“Staff have the opportunity to find and handle emergency resources and to calculate the amount of dantrolene needed for individual patients in a safe environment,” says Blakeley. “They also open all the drawers and review where the supplies are located.”

MH is rare, and Blakeley is not aware of any incidents occurring at any of the facilities of CHRISTUS Trinity Mother Frances Health System. However, Blakeley says the staff benefit from the first-hand experience of anesthesia providers and RN staff who have seen MH crisis in other organizations. As a part of the learning process, these staff share their experiences.


Debriefings yield improvements

After the drill, staff complete the same predrill questionnaire to evaluate learning. They also participate in a debriefing session in which they can ask questions and share what they have learned. Challenges and stumbling blocks are discussed, along with possible solutions and new ideas to streamline MH crisis response.

For example, the task cards indicate the drawer number for a specific supply stocked on the MH cart. However, during the initial drill, staff discovered that the cart drawers were labeled with the supplies but not with the numbers referred to on the task cards. Blakely and the team were concerned that this relatively minor oversight might slow response time, so they labeled the drawers to match the task cards. Without the real-life style of the drill, this issue may not have been realized until an actual event took place, says Blakely.

As a result of the debriefing, they have increased the number of mini-dispensing spikes to streamline the complex dantrolene mixing process and moved syringes into the same drawer with dantrolene for quicker access, Blakely notes.


Bringing expertise to the table

Blakeley stresses the importance of bringing together a multidisciplinary team when developing SBT and a MH crisis drill. She worked with the clinical education department, surgical services leadership, anesthesia department, and unit-based, nonsurgical educators.

“Multidisciplinary input is better than having one specialty speak for another,” she says. “Everyone’s experience is crucial to bring to the planning table, and you get better buy-in in the end.”

For example, OR senior leadership supported the idea of performing the drills in a real OR suite. “SBT in the OR is more realistic than it is in a training room,” Blakeley says. “It improves familiarity by giving staff the opportunity to find the supplies in the real places they are kept.”

Results of the SBT drill, including the use of task cards, have been positive. SBT drills have helped to increase staff knowledge, confidence, and skill, Blakeley says. Before and after the initial SBT drill, staff rated their knowledge and skills in handling a MH crisis. They used a Likert scale of 1 to 5. Before the SBT drill, 84% of staff gave themselves a rating of equal to or less than 3. That rose dramatically to 100% giving themselves a rating of equal to or greater than 3. A full 70% gave themselves a rating of equal to or greater than 4.

Blakeley says staff like being active learners and getting hands-on experience during the SBT drills.

“It shakes up the in-service when you have to respond, get your hands on the right equipment, and use it properly when someone is timing you,” she says. “You can’t get more real than that.”


Effective process improvement tool

Casey Orth-Nebitt, BSN, RN, CNOR

OR leaders at Buena Vista Regional Medical Center in Storm Lake, Iowa, have also found that hands-on MH crisis response drills are an effective learning and process improvement tool.

“What we learned by drilling was profound,” says Casey Orth-Nebitt, BSN, RN, CNOR, director of surgery. “Drills may find holes in your system and will spark discussion about how to address them.”

Drilling helped the response team fine-tune the best number of responders for a MH crisis. They found the ideal number of staff for their response team (in addition to regular OR staff) is five: two to perform cooling, two to mix dantrolene, and one to chart. “Having enough people who are trained to respond to a MH crisis is critical, but having too many people respond can be problematic and create confusion,” says Orth-Nebitt.

In addition, anesthesia providers recommended an activated charcoal filter to clear the anesthesia lines quickly in addition to stocking multiple Sofnolime filters in the MH cart. “This issue may not have come up without the drill,” says Orth-Nebitt. “We also found that the emergency room has a device that can be used for patient cooling that the OR team wouldn’t have known about without the drill.”

Drills have also boosted confidence with handling dantrolene. “Nurses get their hands on the drug, are able to mix it, and get more comfortable with the procedure mechanically,” says Orth-Nebitt.

“The most important intervention in a MH crisis is to get dantrolene started right away. We saved our expired dantrolene for staff to practice mixing because that procedure can be problematic and time-consuming,” she explains.

The use of rapid injector devices made it easiest to mix and only took about 30 seconds. These devices draw directly from a preservative-free 1000 mL bag of sterile water for IV injection. They then seamlessly inject the water directly into the dantrolene vial.

“We found that the dantrolene powder reconstitutes nicely using this technique and requires minimal rolling and shaking to ensure the powder is dissolved,” Orth-Nebitt notes. “For this reason, we have replaced all of our 50 mL bottles of sterile water with 1000 mL bags.”


Easy access to resources

Orth-Nebitt stresses that the number one rule for rapid MH crisis response is to ensure everyone knows where the MH cart is and to make it intuitive and user-friendly.

Defining team members’ roles is also critical. The response team uses role cards, which are kept on the MH cart, to define the role of each team member. The role cards provide pertinent information for each role, such as the MHAUS hotline number and necessary labs to draw.

There is a designated dantrolene nurse who has a role card that includes a quick-reference dose chart for dantrolene. In addition, a laminated dosing chart with a broad range of weights is located on top of the MH cart for rapid reference.

An ongoing challenge for the MH response team is ensuring accurate documentation during a MH crisis. “Because the OR staff do not use code navigator software for code responses, we thought documentation using that software would be a great job for the house supervisor,“ says Orth-Nebitt. “After drills, the supervisors were excited that they had a new skill, and they feel confident assisting in this type of emergency. However, the software lacks some important features, such as the specific lab order set needed in a MH crisis. We are working with our electronic medical record provider to see if some features specific to MH can be added.”


The element of surprise

To keep staff on their toes, OR leaders at Premier Health’s Miami Valley Hospital, Dayton, Ohio, have planted the element of surprise into their MH crisis drills.

Natasha Luster, MSN, RN, CNOR

“We used to tell staff when they were going to participate in a MH crisis drill,” says Natasha Luster, MSN, RN, CNOR, nurse manager, surgical services. “We now announce it overhead unexpectedly because that’s how it is going to happen in real life. Its helps ensure staff stay current with the information at all times and don’t just review it before a planned drill.”

Luster partnered with her hospital’s anesthesia department to create a program of yearly MH training and drills. Training includes MH crisis education for new OR staff during orientation, as well as yearly in-services and an online computer module for all surgical services staff.

Drills include use of a monitored mannequin and mock scenarios. Participants include anesthesia providers and all surgical services and PACU staff. The real-life response team includes at least one anesthesia provider who leads the team and two highly trained OR nurses.

“In our drills, we ensure staff can demonstrate that they can hit all the necessary response elements and follow the protocols for MH crisis,” says Luster. These include calling for help (including the MHAUS hotline), grabbing the MH code cart, designating tasks, mixing the dantrolene properly, and securing fluids, ice, and other supplies. The scenario is then taken to the next step, into a full cardiac arrest, and the staff is run through a full ACLS (Algorithms for Advanced Cardiac Life Support) protocol.

A debriefing after each drill gives staff time to discuss what went well and what needed work. Debriefing also gives them a chance to ask about anything that might need more clarification. “We want to ensure staff are confident in their skills when asked, ‘How comfortable are you if a MH crisis were to really happen?’” says Luster.

The training and drill program also include education of the entire hospital staff in identification of a MH crisis and training superusers of the MH crisis protocol in other departments of the hospital, such as the ICU.


Practice to ensure adequate preparation

Walking OR staff through MH crisis scenarios has increased the likelihood that they will be able to manage it successfully. The approaches used at these three facilities offer a roadmap for OR leaders who may want to implement MH practice drills in their organizations. Until such training takes place, it’s impossible to identify all the possible “what ifs” that can crop up in an emergency, and anything that can be done to save a life is worth the time and trouble it takes to enable staff to respond appropriately. ✥

Catherine Spader, RN, is a medical writer, editor, and award-winning fiction author based in Littleton, Colorado.


Blakeley J. Know your role: Using task cards and simulation-based training for malignant hyperthermia drills. Poster. 2019 AORN Global Surgical Conference & Expo.

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