AORN Malignant Hypothermia Crisis: Team in Action - 1979

Transcript

1. MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 1979
2. 1979 MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION STUDY GUIDE Disclaimer AORN and its logo are registered trademarks of AORN, Inc. AORN does not endorse any commercial company’s products or services. Although all commercial products mentioned in this course are expected to conform to professional medical/nursing standards, inclusion in this course does not constitute a guarantee or endorsement by AORN of the quality or value of such products or of the claims made by the manufacturers. No responsibility is assumed by AORN, Inc, for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise, or from any use or operation of any standards, guidelines, recommended practices, methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the health care sciences in particular, independent verification of diagnoses, medication dosages, and individualized care and treatment should be made. The material contained herein is not intended to be a substitute for the exercise of professional medical or nursing judgment. The content in this publication is provided on an “as is” basis. TO THE FULLEST EXTENT PERMITTED BY LAW, AORN, INC, DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OF THIRD PARTIES’ RIGHTS, AND FITNESS FOR A PARTICULAR PURPOSE. This publication may be photocopied for noncommercial purposes of scientific use or educational advancement. The following credit line must appear on the front page of the photocopied document: Reprinted with permission from the Association of periOperative Registered Nurses, Inc. Copyright 2016 “MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION.” All rights reserved by AORN, Inc. 2170 South Parker Road, Suite 400 Denver, CO 80231-5711 (800) 755-2676 www.aorn.org Video produced by Cine-Med, Inc. 127 Main Street North Woodbury, CT 06798 Tel (203) 263-0006 Fax (203) 263-4839 www.cine-med.com 2
3. PURPOSE..........................................................................................................................................4 OBJECTIVES....................................................................................................................................4 INTRODUCTION: WHAT IS MALIGNANT HYPERTHERMIA?................................................5 MALIGNANT HYPERTHERMIA DISEASE STATE.....................................................................5 Pathophysiology ................................................................................................................................5 Disease Triggers ................................................................................................................................6 Risk Factors ......................................................................................................................................6 Diagnosis ..........................................................................................................................................6 PREPARING FOR MALIGNANT HYPERTHERMIA IN THE OR ..............................................7 Preoperative Patient Assessment ......................................................................................................7 Temperature Monitoring ...................................................................................................................7 Clinical Signs and Symptoms ...........................................................................................................8 MH Supplies and Medications .........................................................................................................9 Preparation for High-Risk Patients ...................................................................................................9 TREATING MALIGNANT HYPERTHERMIA IN THE OR .......................................................10 Preparing and Administering Dantrolene .......................................................................................11 Team Member Roles .......................................................................................................................11 Postoperative Care ..........................................................................................................................12 Patient Education and Follow-up ...................................................................................................13 Patient Care in an Ambulatory Surgery Center ..............................................................................13 CONCLUSIONS AND RESOURCES ...........................................................................................14 Malignant Hyperthermia Association of the United States (MHAUS) ..........................................14 Perioperative Team Training ...........................................................................................................14 Teaching Tips for an MH Crisis Simulated Learning Activity........................................................15 Teaching Resources: Sample Documents........................................................................................18 REFERENCES................................................................................................................................28 POST-TEST.....................................................................................................................................29 POST-TEST ANSWERS.................................................................................................................32 MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION Malignant Hyperthermia Crisis: Team in Action TABLE OF CONTENTS 3
4. MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION PURPOSE The objective of this study guide and the accompanying video is to serve as an interactive learning tool to help prepare members of the perioperative team for what to expect and how to respond when a patient experiences a malignant hyperthermia (MH) crisis. OBJECTIVES Following completion of this training activity, the participant should be able to 1. define MH, 2. recognize signs of MH, 3. specify perioperative team interventions for an MH crisis, 4. discuss drug therapies for MH, and 5. demonstrate the recommended actions to care for a patient who is experiencing an MH crisis. 4
5. MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION INTRODUCTION: WHAT IS MALIGNANT HYPERTHERMIA? Maintaining a normal body temperature through all phases of a surgical procedure is an essential component of patient safety and a critical responsibility for all members of the perioperative team.1 The normal range for a patient’s core body temperature, or normothermia, lies between 36° C and 38° C (96.8° F to 100.4° F).1 Under healthy conditions, this temperature is maintained through precise thermoregulatory mechanisms in the central nervous system, which balance heat production with heat loss.1 In a surgical setting, however, general, epidural, and other regional anesthetic agents as well as environmental factors can influence core body temperature, causing it to fall below or even exceed normal limits. Common temperature ranges are generally categorized as follows1: • Normothermia: 36° C to 38° C (96.8° F to 100.4° F) • Hypothermia: < 36° C (96.8° F) • Hyperthermia: > 38° C (100.4° F) An increase in core body temperature, or hyperthermia, can be classified as being either controlled or uncontrolled by the body. For instance, the onset of fever related to the presence of an infection is one example of controlled hyperthermia.2 Conversely, an increase in core temperature related to high ambient temperatures, exercise, or drug-induced impairment of the body’s thermoregulatory mechanisms would be considered uncontrolled hyperthermia.2 In the early 1960s, a condition known as malignant hyperthermia (MH) was first described.3,4 This form of uncontrolled hyperthermia is a potentially fatal hypermetabolic reaction to which certain individuals are genetically predisposed.5,6 In patients with this rare, autosomal dominant disorder, certain anesthetics, muscle relaxants, or extreme stress in the form of heat or exercise have the ability to trigger an MH crisis.4–6 Although rare, an MH crisis is a life-threatening event that can and does occur in the OR setting.5–7 If MH is not recognized and treated promptly, the patient may suffer severe adverse complications, such as cardiac arrest, organ failure, internal bleeding, brain damage, or even death.5–7 As a result, it is crucial that members of the perioperative team remain up- to-date on the signs and symptoms of MH, recommended patient interventions and drug therapies, and actions recommended to care for a patient experiencing an MH crisis. Teamwork, effective communication, and preparation are essential components in MH crisis training and can be life- saving for those patients who experience MH in the OR. MALIGNANT HYPERTHERMIA DISEASE STATE Overall, the incidence of diagnosed cases of anesthetic- induced MH crisis is approximately one in 15,000 children and one in 50,000 adults.6,8,9 However, as not all anesthetic- exposures may trigger a reaction in patients with MH, the potential susceptibility for an MH crisis has been estimated to be as high as one in every 200 patients.6,8 In the sections that follow, we will discuss the MH disease state in more detail, including: • Pathophysiology • Disease triggers • Risk factors • Diagnosis Pathophysiology Malignant hyperthermia is an autosomal dominant genetic mutation affecting the skeletal muscle.6 In normal skeletal muscle, the movement of calcium from the sarcoplasmic reticulum across the muscle cell membrane and into the myoplasm, or intracellular space, is a tightly regulated process that drives muscle contraction. Two receptors are integral to this process: the ryanodine receptor, which acts as the main calcium release channel, and the dihydropyridine receptor, which aids in initiating and terminating calcium release from the ryanodine receptor.6 Many patients with MH have been shown to have genetic mutations in the ryanodine or dihydropyridine receptors.6 As a result of this, when an MH crisis occurs, the regulation of 5
6. MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 6 calcium influx is disrupted. This leads to an excess of calcium within the myoplasm, causing muscle rigidity, increased heat production, and acidosis, with the potential for irreversible muscle contraction and hypermetabolism.6 A cascade of events follows in which adenosine triphosphate production is reduced, leading to failure of the membrane-bound Na+/K+ pump as well.6 As a result, sodium, chloride, and water begin to flow freely into the muscle cell, driving osmotic cell swelling and causing further injury.6 Overall, disruption of calcium homeostasis has the potential to cause muscle cell necrosis and rhabdomyolysis, or the breakdown of muscle tissue leading to the release of muscle fibers into the bloodstream followed by potential kidney damage.6 Disease Triggers Malignant hyperthermia crises can be triggered by several variables, including5,6: • Inhalation anesthetics (ie, isoflurane, sevoflurane, desflurane, enflurane)5,6 • Depolarizing muscle relaxants (ie, succinylcholine)5,6 • Extreme stress in the form of heat or exercise5,6 • Emotional stress5 • Trauma5 Risk Factors The risk of MH susceptibility (MHS) correlates with a family history of the disorder, or with a history of adverse reactions with a presentation similar to MH during anesthesia.6,9 As an autosomal dominant trait—meaning that MH requires only one affected parent in order for the condition to be inherited by offspring—all first-degree relatives of an individual with MH are considered MH-susceptible (Note that if only one parent has MH, each child has a 50% probability of inheriting the parent’s mutant gene and MH susceptibility).5,9 Individuals with certain congenital myopathies or disorders of the muscle cell membrane may also have a predisposition for MH.5,6 For instance, this may include individuals with Evans myopathy, King-Denborough syndrome, or central core disease6: • Evans myopathy: A genetic muscle disorder with possible muscle wasting6 • King-Denborough syndrome: A muscle disorder characterized by dysmorphic features5,6 • Central core disease: A genetic muscle disorder characterized by hypotonia and proximal muscle weakness6 Diagnosis Genetic testing and muscle biopsy are two types of testing available to test for MH. Currently, the only recognized laboratory test available for diagnosing MHS is known as the In Vitro Contracture Test (IVCT), or the Caffeine-Halothane Contracture Test (CHCT).6,9 With this contracture test, a muscle biopsy is typically taken from the patient’s vastus lateralis or quadriceps femoris muscle.6 The biopsy sample is then immersed separately in caffeine and halothane baths and tested for levels of muscle contractibility. Biopsies from patients who are MHS demonstrate an abnormal response to both caffeine and halothane. Potential outcomes to the test are listed below6: • Malignant hyperthermia susceptible: abnormal response to both caffeine and halothane tests • Malignant hyperthermia equivocal: abnormal response to either caffeine or halothane, but not both • Malignant hyperthermia normal: no abnormal responses are observed In recent years, efforts have been made to develop a genetic test for MHS, with the potential to serve as an alternative to the invasive muscle biopsy required for IVCT/CHCT.6,9 Approximately 50% to 70% of families with MHS have genetic defects in the ryanodine receptor that drives calcium
7. release in skeletal muscle.6,9 However, more than 16 different point mutations in the gene encoding the ryanodine receptor have been noted on chromosome 19; in addition, genetic markers accounting for the remaining 30% to 50% of MHS families remain largely unknown.6,9 As a result, genetic screening is not yet considered equivalent to IVCT/ CHCT for MHS screening.6,9 Genetic testing can be helpful to determine if patients are predisposed to MH or other types of medical conditions. Only a few health care facilities around the country perform the muscle biopsy procedure for MH and patients must travel to a designated testing center for the procedure. It is important a patient consult with a licensed independent practitioner or genetic counselor to determine the type of testing that is best for his or her situation. PREPARING FOR MALIGNANT HYPERTHERMIA IN THE OR In the sections that follow, we will discuss important considerations to help prevent and manage MH reactions in the perioperative setting. This discussion will focus on: • Preoperative patient assessment • Temperature monitoring • Clinical signs and symptoms • MH supplies and medications • Preparation for high-risk patients Preoperative Patient Assessment Prior to the surgical procedure, each patient should be assessed for potential MHS. Information that may indicate risk of an MH reaction may include5: • Previous surgical anesthetic records (ie, history of adverse reactions to anesthetics) • Relevant laboratory results or genetic profiles (ie, IVCT/CHCT results or genetic screens) • Associated inherited metabolic abnormalities (ie, King-Denborough syndrome) • A family history of MH or a family member who experienced a temperature aberration under anesthesia • Planned use of triggering anesthetics (ie, volatile anesthetics or succinylcholine) Temperature Monitoring Temperature elevations may be the first sign of an MH crisis, and it is possible for an elevated temperature to present within 30 minutes of anesthesia induction.10 It is important to note, however, that elevations in core temperature within the first 30 minutes can also be mitigated by the tendency for hypothermic responses in the OR, making it difficult to interpret temperature during this early phase. Based on supporting thermoregulatory and MH studies, the Malignant Hyperthermia Association of the United States (MHAUS) recommends that all patients receiving general anesthesia for longer than 30 minutes should undergo core temperature monitoring.10 Continuous electronic core temperature monitoring may be performed in the esophagus, nasopharynx, tympanic membrane (where the probe is in contact with the membrane), bladder, or pulmonary artery.10 According to the AORN Guideline for Prevention of Unplanned Patient MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 7
8. Hypothermia, the patient’s temperature should be monitored during every phase of the perioperative period.1 Temperature can be measured using either core temperature sites, such as the tympanic membrane, distal esophagus, nasopharynx, or pulmonary artery, or using “near-core” sites, including the mouth, axilla, bladder, rectum, skin, or tympanic membrane (via infrared sensor).1 The method used should be dictated by the clinical requirements of the procedure taking place.1 This may be influenced by factors such as the accessibility or invasiveness of the route, the anesthesia type, or the anesthesia delivery method.1 It is important to note that the hyperthermic process can resolve quickly. As a result, to avoid unintentional hypothermia and cold injuries, cooling efforts should be stopped when the patient’s temperature reaches 38º C (100.4º F).5 Clinical Signs and Symptoms During an MH crisis, a biochemical chain reaction takes place that leads to several characteristic signs and symptoms.5,11 Some clinical signs may be more apparent earlier in the MH cascade, whereas others tend to appear later as the MH crisis progresses. Following is a list of early and late clinical signs that are important indicators of an MH crisis5,11: • Early clinical signs5: • Unexpected, abrupt increase in end-tidal carbon dioxide (ETCO2) • Unexplained tachycardia • Generalized muscle rigidity • Masseter muscle spasm • Hypercarbia • Hypoxia • Metabolic and respiratory acidosis • Tachypnea • Dysrhythmia • Increase in body temperature • Respiratory or ventilatory problems • Difficult intubation • Profuse sweating11 • Cardiac arrythmia11 • Mottling of the skin11 • Unstable arterial pressure11 • Late clinical signs11: • Acute renal failure • Circulatory failure • Dark colored urine due to myoglobinuria • Disseminated intravascular coagulation • Elevated blood creatinine phosphokinase levels • Elevated blood myoglobin levels • Hyperkalemia • Hyperthermia · > 38.8º C (> 101.8º F), or · a rapid temperature increase of > 1º C (> 1.8º F) in 15 minutes • Hypotension • Rhabdomyolysis • Severe cardiac arrhythmias and cardiac arrest Importantly, due to the characteristic decrease in body temperature associated with anesthesia and surgery, temperature increase as a result of MH is not always apparent early in an MH crisis.5 As a result, an increase in body temperature, which may exceed 43.3º C (109.9º F), is often considered a later sign of MH crisis.5 MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 8 ! ! CO2 (mmHg) 45 0 50 37 Normal Increasing Elevated
9. MH Supplies and Medications To ensure that a patient experiencing an MH crisis can be properly and efficiently treated, an MH supply cart and dantrolene should be located in a readily accessible location within 5 to 10 minutes from the surgical procedure taking place.5,12 Care should be taken that all perioperative personnel are aware of the location of the MH cart. Supplies that should be present on the MH cart are listed below5: • MH crisis flowchart (attached to the top of the cart) • Dantrolene: There are two preparations of dantrolene currently available on the market, and at least one of these preparations should be immediately available for use in the following recommended amounts: • Dantrolene 20 mg vial · 36 vials · Dantrolene reconstitution kits · 60 mL of sterile water for injection USP (without a bacteriostatic agent) should be available to reconstitute each vial • Dantrolene 250 mg vial · 3 vials · 5 mL of sterile water for injection USP (without a bacteriostatic agent) should be available to reconstitute each vial • Note: Sterile water for irrigation should not be used to reconstitute dantrolene. • MH laboratory tube kit, containing syringes for: • Basal metabolic panel (ie, Chemistry 7) · Sodium · Potassium · Chloride · Bicarbonate or carbon dioxide · Blood urea nitrogen · Creatinine · Glucose • Chemistry 8 (all components of the basal metabolic panel plus calcium) • Myoglobin (ie, serum and urine) • Serum creatinine kinase • Coagulation studies · Platelets · Prothrombin time · Activated partial thromboplastin time · Fibrinogen · D-dimer (ie, fibrin degradation test) • MH Hotline telephone number attached to the top of the cart • MH policy/protocol attached to the top of the cart • Nasogastric tubes and 60 mL irrigation/evacuation syringes for internal lavage • Rectal tubes for internal lavage • Arterial pressure monitoring lines • Arterial blood gas kit • Venous blood gas kit Additional supplies may also include5: • Plastic bags (for ice to place around the patient) • Padding to protect the patient’s ear and nose from frostbite • Indwelling urinary catheter kits • Clipboard The locations of the refrigerators storing cold normal saline irrigation and cold IV saline should also be listed on the MH cart. Preparation for High-Risk Patients For patients with a known or suspected diagnosis of MH or pertinent risk factors during preoperative assessment, additional preparatory measures should be taken prior to the procedure.4,5 First, triggering agents should be avoided, if possible. Additional preventative steps may include preoperatively preparing the anesthesia machine and relevant supplies; obtaining additional blood work; double-checking the contents of the MH cart and ensuring that it is readily accessible; and preoperatively confirming the availability of dantrolene, other emergency medications, necessary equipment, solutions, and supplies for cooling measures.4,5 The health care team should also be informed of the potential risk and given adequate time to ask questions, review team member roles, and establish a plan of action during the time out before the procedure.4,5 MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 9
10. TREATING MALIGNANT HYPERTHERMIA IN THE OR Due to the acute nature of MH, the perioperative team should be prepared to respond immediately in the event of an MH crisis. In this section, we will discuss important considerations for treating MH, such as: • Steps for treating an acute MH event in the OR • Preparing and administering dantrolene • Team member roles • Postoperative care • Patient education and follow-up • Patient care in an ambulatory surgery setting Steps for Treating an Acute MH Event in the OR The following steps should be taken as soon as possible after the anesthesia professional announces that the patient is experiencing an MH crisis and perioperative team members should initiate MHAUS protocols.5,13 • Discontinue triggering agents: The anesthesia professional should immediately discontinue the use of volatile agents and succinylcholine. If surgery must be continued, general anesthesia should be maintained via non-triggering anesthetics (ie, intravenous [IV] sedatives, narcotics, amnestics, and non-depolarizing neuromuscular blockers).13 • Call for help, get dantrolene and the MH cart: Any team member can call for additional help and request that the MH cart containing dantrolene be brought to the OR immediately. Additional personnel may also be needed.13 • Administer dantrolene: The anesthesia professional (or perioperative RN as ordered) should administer IV dantrolene 2.5 mg/kg rapidly through a large-bore IV catheter. Repeat as frequently as needed until a patient response is noted in the form of decreased ETCO2, decreased muscle rigidity, and/or lowered heart rate. Note that doses greater than 10 mg/kg may be needed for individuals with persistent contractures or rigidity.13 • Notify the surgeon to halt the procedure: The anesthesia professional or perioperative RN should immediately announce the MH crisis and notify the surgeon that the procedure should be stopped, if possible.13 • For assistance with patient management: The perioperative RN should call the MHAUS Hotline at (800) 644-9737 or ask another team member to call the MHAUS Hotline..13 • For surgicenters, the perioperative RN should dial 911 or ask another team member for assistance to initiate the communication required to transfer the patient to a higher level of care and to notify the receiving facility.13 In addition to these main steps, subsequent emergency treatment by the anesthesia professional to treat an MH crisis may also include the following considerations13: • Hyperventilate: Hyperventilate with 100% oxygen at flows of 10L/minute to flush volatile anesthetics and lower ETCO2. Activated charcoal filters may also be inserted into the inspiratory and expiratory limbs of the breathing circuit and replaced after each hour of use.13 • Metabolic acidosis: Obtain venous or arterial blood gas to determine the degree of metabolic acidosis. In the event of metabolic acidosis, consider administering sodium bicarbonate (1 mEq/kg–2 mEq/kg dose; maximum dose of 50 mEq).13 • Hyperkalemia: Treat hyperkalemia with the options summarized below13: • Calcium chloride (10 mg/kg; maximum dose 2,000 mg) or calcium gluconate (30 mg/kg; maximum dose 3,000 mg) • Sodium bicarbonate (1 mEq/kg–2 mEq/kg IV; maximum dose 50 mEq) • Glucose/insulin · Pediatric patients: 0.1 units insulin/kg IV and 0.5 g/kg dextrose · Adult patients: 10 units insulin IV and 50 mL 50% glucose • Furosemide (0.5 mg/kg–1 mg/kg once; maximum dose 20 mg) • Dysrhythmias: Treat dysrhythmias with standard medication, but avoid calcium channel blockers as MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 10
11. these may cause hyperkalemia or cardiac arrest when used in combination with dantrolene. Dysrhythmias typically respond to the treatment of acidosis and hyperkalemia.13 Additional emergency actions by the anesthesia professional, surgeon and perioperative RN include considerations for monitoring and treating • Hyperthermia: Check the patient’s core temperature. If core temperature is > 39º C (102.2º F) or rapidly rising, cool the patient by lavaging open body cavities, the stomach, the bladder, or the rectum. Ice can also be applied to the body surface or cold saline can be infused by IV. Stop cooling measures when the patient’s temperature is below 38º C (100.4º F).13 Preparing and Administering Dantrolene According to MHAUS, IV dantrolene should be given at a dose of 2.5 mg/kg rapidly through a large-bore IV, if possible.13 This should be repeated as frequently as needed until the patient begins to demonstrate decreased ETCO2, decreased muscle rigidity, and/or lowered heart rate. Large doses greater than 10 mg/kg may be necessary for individuals with persistent contractures or rigidity who do not respond to the regular dose.13 Currently, there are two preparations of dantrolene available on the market:13 • DANTRIUM®/REVONTO® • Each 20 mg vial should be reconstituted by adding 60 mL of sterile water for injection, USP (without a bacteriostatic agent) • Shake vial until the solution is clear13 • RYANODEX® • Newer preparation of dantrolene • Each 250 mg vial should be reconstituted with 5 mL of sterile water for injection, USP (without a bacteriostatic agent) • Shake to ensure an orange-colored, uniform, opaque suspension13 Note that reconstitution of dantrolene in the 20 mg per vial formulation can be time consuming and may require the assistance of multiple personnel.5 To reconstitute, the appropriate amount of sterile water for injection USP (without a bacteriostatic agent) is added to each vial, as outlined above. The vial must be shaken vigorously until all of the dantrolene is in suspension.13 Team Member Roles Due to the sudden and life-threatening nature of MH events, all members of the perioperative team play an active role in safely and efficiently managing an MH crisis. A summary of the roles and responsibilities of common perioperative team members is outlined below: • Anesthesia professional: The primary focus of the anesthesia professional is the administration of dantrolene and other anesthetic considerations.5 First, the anesthesia professional will announce the MH crisis, stop delivery of the triggering agent (ie, the anesthetic), notify the surgeon to stop the surgery if necessary, and immediately call for the MH cart.5 As the MH cart is being delivered, the anesthesia professional can initiate the switch to a non-triggering agent and call or assign a team member to call the MH Hotline.5 During the MH crisis, the anesthesia professional will administer dantrolene and may need to hyperventilate the patient with 100% oxygen, obtain blood for laboratory tests, consider starting arterial or IV lines, treat hyperkalemia, administer sodium bicarbonate to aid with metabolic acidosis, treat dysrhythmias using beta blockers, monitor renal function and blood glucose, and place a nasogastric tube. • Surgeon: The surgeon must remain focused on the patient at all times; the surgeon’s primary MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 11
12. responsibility is to assess the patient’s surgical status, stop surgery when necessary, ensure hemostasis, and identify areas of the patient’s body that can be used for cooling lavage.5 If surgery has not yet started, the surgeon and other scrubbed personnel can aid in restoring normal hemodynamic status.5 In addition, the surgeon is responsible for notifying the family of the patient’s condition. • RN circulator: The RN circulator is responsible for calling for additional help, assisting with dantrolene preparation, delegating tasks, and obtaining any necessary supplies.5 Other responsibilities may include assisting the anesthesia professional, calling for the MH cart and code cart, requesting dantrolene, administering dantrolene or other medications as ordered, communicating with the charge nurse, completing necessary documentation, sending blood samples to the laboratory, inserting an indwelling urinary catheter, applying cooling measures, and obtaining chilled saline and ice for irrigation measures. • Team leader: A team leader should be identified as soon as possible during the MH crisis, and this person should not be the surgeon or the RN circulator.5 Using an MH crisis checklist, the team leader is primarily responsible for observing and supervising as the other members of the team implement response measures and for verifying that actions have been completed. The team leader should also assign team members to necessary tasks, such as collecting relevant supplies and equipment for irrigating body cavities and incision sites with chilled solutions.5 In some cases, the anesthesia professional may act as the team leader during an MH crisis. • Scrub person: The scrub person should maintain the sterile field and provide assistance to the surgeon during the MH crisis.5 He or she may also help other perioperative team members in assembling sterile supplies and providing sterile saline for lavaging body cavities, if necessary.5 • Pharmacist: Pharmacists act as consultants and answer medication-related questions during an MH crisis. They should remain aware of how much dantrolene has been administered in the event that additional medication needs to be obtained or borrowed from other facilities to sufficiently manage the event. • Charge RN: The charge RN can provide support by managing staffing assignments, coordinating postoperative transport and patient transfer, and communicating with other health care professionals who may become involved in the patient’s care. • Assistive personnel: Additional personnel are vital during an MH crisis as many actions are required immediately and simultaneously.5 Although the RN circulator typically calls for additional help, any member of the team can call for additional help via the telephone or the facility’s emergency system. Unlicensed assistive personnel may help by bringing the MH cart, dantrolene, and the emergency cart (ie, code cart) into the OR suite, calling for additional back-up personnel, obtaining ice and other supplies, and transporting blood and other specimens to the laboratory. Additional licensed personnel can help to prepare and administer dantrolene and other medications. Note that it often requires two to three people simultaneously to properly mix the 20 mg per vial dantrolene preparation in order to ensure that the first critical dose is efficiently prepared and administered.5 Postoperative Care During an MH crisis, the patient’s heart rate, core temperature, ETCO2, minute ventilation, electrolytes, creatine kinase, coagulation studies, urine output, urine and serum myoglobin, and blood gases should be monitored.5,13 When the following indicators of stability have been met and the patient is deemed stable, he or she can be transferred to the postanesthesia care unit (PACU) or intensive care unit (ICU) to be monitored for at least 24 hours13: • ETCO2 is declining or normal • Heart rate is stable or decreasing with no signs of ominous dysrhythmias • Hyperthermia is resolving • Generalized muscle rigidity has resolved MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 12
13. Recrudescence of MH—the recurrence of these symptoms or a new onset of MH following a period of remission—can occur at any time within 24 hours following the initial response,5 and there is a chance of MH recurrence within 24 to 48 hours after the initial event.5 As a result, additional doses of dantrolene should be readily available throughout the initial follow-up period. During the patient’s stay in the PACU or ICU, the nurse should monitor the patient’s vital signs and laboratory results as described above.13 In addition, when ordered by the physician, a dantrolene dosage of 1 mg/kg every 4 to 6 hours or 0.25 mg/kg/hour via infusion may be administered.13 Thorough communication should take place among the health care team members to ensure that the patient’s treatments and medications are carefully monitored during the follow-up period.5,13 Patient Education and Follow-up It is important to provide patients in an OR setting with education related to the risk factors and adverse effects of MH. In addition, patients should be encouraged to access outside resources to learn more about MH, such as the MHAUS website discussed in the sections that follow.14 Perioperative RNs may encourage the patient who has experienced an MH crisis or who may be at risk during the postoperative period to wear a medical alert bracelet. The patient may follow-up with a counseling session from an anesthesia professional, during which written information about the event is reviewed and any additional concerns regarding follow-up are discussed. Patients who have experienced MH may be sore for several days after surgery. According to MHAUS, patients and their families should be counseled regarding MH and any further precautions that may be necessary.13 In addition, they should be referred to MHAUS for supplemental information and patient education resources. An Adverse Metabolic Reaction to Anesthesia (AMRA; www.mhreg.org) form can be completed by the anesthesia professional and sent to the patient and his or her primary physician to be included in the patient’s medical records. If the patient was not previously aware of his or her potential susceptibility to MH, the patient should be referred to the nearest biopsy center for testing.13 Patient Care in an Ambulatory Surgery Center If MH is suspected in a patient receiving care at an ambulatory surgery center or physician’s office, perioperative team members should initiate the actions that have been outlined here to stabilize the patient experiencing MH crisis.5 In addition, perioperative team members should call for help by dialing 911, to initiate transfer of the patient to a higher care facility better equipped to treat MH aggressively and provide ample follow-up care. The receiving facility should also be notified at this time. Note that ambulatory surgery centers and office-based surgical locations should have transfer agreements in place with neighboring health care facilities to ensure that efficient care is provided for any patient who may experience an MH crisis.5 Sufficient dantrolene should always be stocked in these settings to ensure that patients can be stabilized before transport.5 If MH occurs outside of a medical facility or in a facility that is not equipped to perform surgical procedures, resources for treating MH may not be available. If this is the case, the emergency medical system must be initiated immediately.5 MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 13
14. CONCLUSIONS AND RESOURCES To summarize, MH is a serious, life-threatening medical emergency that requires immediate treatment to avoid adverse complications, such as cardiac arrest, organ failure, internal bleeding, brain damage, or even death.5–7 As a result, members of the perioperative team must remain up-to-date on hospital policies and demonstrate the ability to recognize and respond to an MH crisis. Preparation, teamwork, and effective communication are critical components of ensuring a positive outcome in the event of an MH reaction in the OR. Members of the perioperative team are strongly encouraged to seek additional resources from MHAUS, as discussed in the following section. In addition, team members should participate in group training exercises aimed at simulating an MH crisis and drilling team members on the appropriate response. Several resources for those leading team training exercises can be found below. Malignant Hyperthermia Association of the United States (MHAUS) The Malignant Hyperthermia Association of the United States is a non-profit organization aimed at educating health care professionals to rapidly recognize and correctly treat MH crises.14 In addition, MHAUS supports active research in the field and provides educational resources for both health care professionals and patients. The MHAUS website can be accessed at www.MHAUS.org, where you will find14: • health professional resources and information • patient education materials • relevant research findings • resources for consultation during an MH crisis, including the MH Hotline and cell phone applications For health care professionals attempting to manage an active MH crisis, the MHAUS MH Hotline can be reached at (800) 644-9737. The operator may ask for your name, telephone number, facility, and email address to ensure that contact can be reestablished should the call be dropped.14 Perioperative Team Training All members of the surgical team should be aware of the institutional guidelines, policies, procedures, and protocols in place for handling an MH crisis.5 These team members should also be aware of the location of MH carts, emergency carts, supplies, equipment, and medications.5 Simulations and drills should provide ongoing education on how to recognize, treat, and manage an MH crisis in a safe and efficient manner.5 The educator leading MH-preparedness training sessions should consider several factors before initiating each session: • Patient scenarios: Before the scheduled training session, prepare potential patient scenarios that can help to simulate an MH crisis. If possible, use a mannequin to simulate the patient scenario and drill participants on their real-time responses.4 Begin with a brief explanation of the simulation scenario, in which the patient undergoes a routine surgical procedure and experiences an MH crisis. Follow the simulation with a debriefing session to discuss what went well and areas for potential improvement.4 A sample patient scenario previously described by Seifert et al is outlined here5: • John M is a healthy boy, aged 16, who is undergoing a routine appendectomy. During preoperative assessment, John mentions that some members of his family have had “strange reactions” (ie, nonspecific neuromuscular symptoms) to anesthesia in the past. The RN circulator recognizes these factors as high-risk indicators and discusses the assessment with the anesthesia professional. The patient refuses spinal anesthesia and succinylcholine is used. In the time out conducted immediately before the procedure, the anesthesia professional discusses the patient’s family history with the team. Early increases in temperature during the procedure are attributed to the patient’s appendicitis. Following the succinylcholine bolus, the anesthesia professional notes an increase in the patient’s ETCO2. The anesthesia professional announces that an MH crisis is occurring and immediately increases ventilation and begins a propofol infusion. The RN circulator calls for help to initiate the MH protocol and facilitate prompt dantrolene administration. Three doses are administered over the course of 8 hours, and the patient responds with no significant adverse complications.5 • What should be in the MH cart: During the training session, engage participants by asking them to work together to review and update a list of items that should be contained within the MH cart. Use the list provided earlier in this study guide as a quick reference tool to check participants’ answers, and review this complete list with participants following the activity. MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 14
15. • Quick reference guides: Provide participants with relevant checklists, posters, and/or reminder cards that may serve as a quick reference for how to respond in a real-life MH crisis. Beneficial quick reference tools may include a list of contents of the MH cart, flashcards summarizing the role of each team member, directions for reconstituting and administering dantrolene, and the telephone number for the MHAUS MH Hotline. Throughout the training session, encourage participants to be engaged in the activities and aware of the resources available to them. Emphasize that while MH is a rare event, being well prepared to recognize and respond to a patient’s MH reaction can mean the difference between life and death. Teaching Tips for an MH Crisis Simulated Learning Activity As you prepare for an MH crisis simulated learning activity: • Set yourself up to be successful! • Be familiar with the materials and review the DVD and study guide. • Set a date, time, and location for your learning activity. Before the day of the simulated activity 1. Collect your supplies: a. Malignant Hyperthermia Crisis: Team in Action DVD or online access and Study Guide b. DVD player and/or monitor with the ability to stop and start the DVD or online access c. Emergency cart (ie, code cart) and emergency medications d. MH cart including dantrolene sodium. e. Facility-related policy and procedures, documents, checklists for MH crisis, laboratory processes, transfer-of-care processes f. MH crisis checklist for the crisis manager/team leader, procedure list, or instructional chart g. Patient education resources h. Room supplies (mannequin and basic OR supplies for an identified surgery/procedure) i. Supplies to practice mixing dantrolene 2. Reserve a location for the simulated learning activity (a simulation room, an OR, or a procedure room) and set up ahead of time. 3. Prepare the room to simulate a real patient and real MH crisis event. 4. Collect the necessary teaching resources: a. Example: Algorithm b. Example: Briefing checklist c. Example: Debriefing checklist d. Example: Dosing guide for dantrolene sodium 20 mg/vial (Dantrium/Revonto) e. Example: Dosing guide for dantrolene sodium 250 mg/vial (Ryanodex) f. Example: Sample form of worksheet for proposed treatment g. Example: Sequence of Events worksheet h. Example: Simulation Set Up worksheet i. Example: AORN MH Crisis Checklist Day of the simulated activity 1. Assemble your class. 2. Provide introductory remarks to remind the audience this is an interactive learning activity. 3. Start the video. 4. During the video, you will be asked to STOP at six different points. Resources for the instructors that can be used to plan for discussions and activities during these stops are included in this study guide in the sections that follow. The six stops in the video are: a. Stop 1 – Discussion b. Stop 2– Discussion: Immediate Role Responsibilities after an MH Crisis Is Identified c. Stop 3 – Dantrolene: Discussion, Demonstration, and Activity d. Stop 4 – Discussion and Review: Carts and Supplies e. Stop 5 – Activity: MH Crisis Simulation f. Stop 6 – Discussion and Review MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 15
16. Suggestions for the instructor during stops in the video: At Stop 1 - Discussion Discussion 1. Pause the video. 2. You have time now to discuss this scene with the participants. 3. Suggestions for discussion: a. What do you think is happening in this scene? b. What are your observations related to the surgical team and the patient? c. What have you learned about your patient from the video? Resources for the Instructor 1. Briefing checklist. Note: Briefing should occur in the OR before the administration of anesthesia when everyone is in attendance, including the anesthesia professional, surgeon, RN circulator, scrub person, and patient. a. Patient example: Riley Jones is a 14-year-old female who has been in good health up until a few days ago when she started experiencing acute episodic abdominal pain in her lower abdomen. She is scheduled for an exploratory laparotomy. Riley is 110 lb (50 kg) and is 5'3" tall. She has no known allergies. b. Briefing should include: • Team introductions • Goal of surgery • Confirmation that roles and responsibilities are understood • Plan of care • Resources • Opportunity to ask and answer questions At Stop 2 - Discussion: Immediate Role Responsibilities after an MH Crisis Is Identified Discussion 1. Pause the video. 2. You have time now to discuss this scene with the participants. 3. Suggestions for discussion: a. What do you think is happening in this scene? b. What actions should be taken after the anesthesia professional states “This is a malignant hyperthermia crisis!”? c. Encourage participants to identify what each team member’s role would be if this occurred in your operating room or procedure room. Resources for the Instructor 1. Use this time to encourage the participants to identify immediate actions during an MH crisis. If the participants have questions or discussions related to dantrolene, ask them to hold their questions and comments. The dantrolene discussion and activity is at Stop 3. 2. MH Crisis Checklist 3. Encourage the participants to identify the following actions: Any team member • Call for additional help • Bring in MH cart and code cart • Obtain ice and supplies RN Circulator • Call for additional help • Get dantrolene sodium, MH cart, and code cart • Assist the anesthesia professional • Reconstitute and/or administer dantrolene • Communicate with the charge nurse • Delegate tasks that can be delegated • Insert an indwelling urinary catheter using sterile technique • Apply cooling measures • Provide cold, sterile normal saline solution for irrigation to the sterile field • Document Scrub Person • Maintain the sterile field • Assist the surgeon • Help the other perioperative team members assemble sterile supplies Anesthesia Professional • Stop the triggering agent • Hyperventilate with 100% oxygen • Administer dantrolene sodium • Obtain blood for laboratory tests • Call or assign a team member to call the MH Hotline • Consider using an arterial line and/or any additional IV lines • Treat life-threatening hyperkalemia MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 16
17. • give calcium chloride 10 mg/kg or calcium gluconate 30 mg/kg • give regular insulin 10 units IV in 50 mL of 50% glucose (adult dose) • 0.1 units regular insulin/kg IV and 0.5 g/kg dextrose (pediatric dose) • give furosemide 0.5 mg/kg–1 mg/kg • Give Na+ bicarbonate if metabolic acidosis is present (1 mEq/kg–2 mEq/kg) • Treat dysrhythmias using beta blockers (no calcium channel blockers) • Monitor renal function • Monitor blood glucose • Place nasogastric tube At Stop 3 - Dantrolene: Discussion, Demonstration, and Activity Discussion 1. Pause the video. 2. Review dantrolene. 3. Review recommended dosing guidelines for dantrolene. 4. Suggestions for discussion: • What strength of dantrolene is available at your facility? • Ask participants to identify the locations where dantrolene is stored. • Identify supplies required to mix dantrolene. Activity 1. Practice skills related to medication administration per facility policies. 2. Practice medication calculations. 3. Ask participants to determine the loading dose 2.5 mg/kg for dantrolene for patients in milligrams/kilogram. 4. What is loading dose for this patient (weighs 50 lb, weighs 110 lb, weighs 150 lb)? 5. What resources (eg, preprinted dosing guidelines) are available at your facility? 6. Practice mixing dantrolene. Resources for the Instructor 1. Vials of expired dantrolene 2. Supplies for practice (eg, sterile water for injection, syringes, package inserts, dosing guidelines or predetermined weight-based calculations for a variety of patient weights, sharps, and trash receptacles) 3. Quick reference: DANTRIUM®/REVONTO® (20 mg vial) • Each vial should be reconstituted by adding 60 mL of sterile water for injection, USP (without a bacteriostatic agent). • Shake the vial until the solution is clear. RYANODEX® (250 mg vial) • Each vial should be reconstituted with 5 mL of sterile water for injection, USP (without a bacteriostatic agent). • Shake the vial to ensure an orange-colored uniform, opaque suspension. IMPORTANT CONSIDERATIONS • If administering large doses (> 10 mg/kg) without symptom resolution, consider alternative diagnoses. • Dosing guideline charts are available for both concentrations of dantrolene from the industry representatives. • As warranted by the clinical severity of the patient, monitor the patient’s heart rate, core temperature, ETCO2, minute ventilation, blood gases, K+, creatine kinase (CK), and urine myoglobin and coagulation studies. KEY INDICATORS OF STABILITY • ETCO2 is declining or normal • Heart rate is stable or decreasing with no signs of ominous dysrhythmias • Hyperthermia is resolving • If it was present, generalized muscular rigidity has resolved • Triggering agents: • Inhalational (volatile) anesthetics • Succinylcholine At Stop 4 - Discussion and Review: Carts and Supplies Discussion 1. Pause the video. 2. Review the content of the facility carts (eg, MH cart, code cart). 3. Identify the location of supplies, equipment, medications (eg, ice machines and supplies for ice packs, cold IV and irrigation solutions cabinets, MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 17
18. cooling blankets) 4. Discuss the process and supplies needed for sending diagnostic laboratory tests (eg, arterial or venous blood gases, serum myoglobin, urinalysis) Resources for the Instructor 1. MH cart 2. Code cart 3. MH crisis checklist 4. Supplies and location of ice At Stop 5 – Activity: MH Crisis Simulation Activity 1. Pause the video. 2. Simulate an MH crisis: a. Assign team roles. b. A minimum of five participants is necessary and should include the RN circulator, scrub person, anesthesia provider, surgeon, and the crisis manager/team leader. c. If there are more than five participants, assign additional roles. d. The assigned anesthesia provider states, “This is a malignant hyperthermia crisis.” e. The participants should simulate the activities to effectively respond to an MH crisis in the OR or procedure room. f. As part of this simulation, the crisis manager/team leader should verbally verify actions using the MH crisis checklist. Resources for the Instructor 1. Print out an additional MH crisis checklist. 2. Observe the participants actions. 3. Write notes of your observations of the participants. At Stop 6 – Discussion and Review Discussion 1. Pause the video. 2. Debrief the participants’ activities. 3. Identify the facility processes to follow for patient transfers, patient education, management of resources, and documentation. Resources for the Instructor 1. Debrief checklist 2. Review team roles 3. Review patient education Teaching Resources: Sample Documents The following resources can be used as supplements during MH Crisis Training: • AORN MH Crisis Checklist (page 19) • MH Simulation Set-Up (page 20) • MH Simulation Sequence of Events (page 21) • MH Simulation Algorithm (page 22) • MH Simulation Debrief (page 23) • MH Simulation Resources: Visual Aid to Guide Dantrolene Sodium Preparation (page 24) • MH Simulation Resources: MH Worksheet (page 27) MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 18
19. MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 19                                                                                                                                                                                                                                                         Yes Yes A c one e som Did b ill w o Wh sk: A Ă Đ Ɛ ƌ Ğ ď ŵ Ğ ŵ ŵ Ă Ğ ƚ Ğ ǀ ŝ ƚ Ă ƌ Ğ Ɖ Ž ŝ ƌ Ğ W r e g a n a m                                                                                                                                                                                                                                                         rmia e rth e nt Hyp Maligna AORN lp he or f ll ca o t one e som n assig or lp he ional addit or f ll ca no, f I lp? he or f ll ca _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ n ssig A r? e manag isis cr he t be Ɛ ŝ Ś ƚ Ğ ƚ Ğ ů Ɖ ŵ Ž Đ ͟ ͕ Ž Ŷ ͞ Ĩ / ͍ Ğ ů ď ŝ Ɛ Ɛ Ž Ɖ Ɛ Ă Ŷ Ž Ž Ɛ Ɛ Ă Ğ ƌ Ƶ Ě Ğ Đ Ž ƌ Ɖ Ğ Ś ƚ ƚ ů Ă Ś Ž ƚ Ě Ğ ŝ Ĩ ŝ ƚ Ž Ŷ Ŷ Ž succinylcholin and s nt age ile olat v e inu discont u yo Did r: ide prov sia he st ane e o s low f at n e yg ox 100% h it w ing ilat nt rve pe hy u yo re A r: ide prov sia he st ane e ƚ Ɛ ŝ Ś ƚ Ğ ƚ Ğ ů Ɖ ŵ Ž Đ Ž ƚ Ŷ Ž Ɛ ƌ Ğ Ɖ Ă Ŷ Ő ŝ Ɛ Ɛ Ă ͟ ͕ Ž Ŷ ͞ Ĩ / ͍ ŵ Ž Ž ƌ Ğ Ś ƚ Ŷ ŝ ƚ ƌ Ă Đ Ă ŝ ŵ ƌ Ğ Ś ƚ ƌ Ğ Ɖ LJ Ś ƚ Ŷ ͘ Ŭ Ɛ Ă ƚ Ɛ ŝ Ś ƚ Ğ ƚ Ğ ů Ɖ ŵ Ž Đ Ž ƚ Ŷ Ž Ɛ ƌ Ğ Ɖ Ă Ŷ Ő ŝ Ɛ Ɛ Ă ͟ ͕ Ž Ŷ ͞ Ĩ / ͍ ŵ Ž Ž ƌ Ğ Ś ƚ Ŷ ͘ Ŭ Ɛ Ă ƚ Ɛ ŝ Ś ƚ Ğ ƚ Ğ ů Ɖ ŵ Ž Đ Ž ƚ Ŷ Ž Ɛ ƌ Ğ Ɖ Ă Ŷ Ő ŝ Ɛ Ɛ Ă ͟ ͕ Ž Ŷ ͞ Ĩ / ͍ ŵ Ž Ž ƌ Ğ Ś ƚ Ŷ ŝ ƚ ͘ Ŭ Ɛ Ă ƚ Ɛ ŝ Ś ƚ Ğ ƚ Ğ ů Ɖ ŵ Ž Đ Ž ƚ Ŷ Ž Ɛ ƌ Ğ Ɖ Ă Ŷ Ő ŝ Ɛ Ɛ Ă ͟ ͕ Ž Ŷ ͞ Ĩ / ͍ ϭ ϭ ϵ ů ů Ă Đ Ğ Ŷ Ž Ğ ŵ Ž Ɛ Ě ŝ Ě ͗ LJ ů Ɛ ŝ Ś ƚ Ğ ƚ Ğ ů Ɖ ŵ Ž Đ Ž ƚ Ŷ Ž Ɛ ƌ Ğ Ɖ Ă Ŷ Ő ŝ Ɛ Ɛ Ă ͟ Ž Ŷ ͞ Ĩ / ͍ ϳ ϯ ϳ ϵ ϰ ϰ ϲ Ϳ Ϭ Ϭ ϴ ; Ğ Ŷ ŝ ů ƚ Ž , , D Ğ Ś ƚ ů ů Ă Đ Ŷ Ő ŝ ů Ă ŵ Ă Ɛ ŝ Ɛ ŝ Ś d ͞ ͕ Ɛ Ğ Đ Ŷ Ƶ Ž Ŷ Ŷ Ă ƌ Ğ Ě ŝ ǀ Ž ƌ Ɖ Ă ŝ Ɛ Ğ Ś ƚ Ɛ Ğ Ŷ Ă Ŷ Ă Ŷ Ğ Ś ǁ ƚ Ɛ ŝ ů Ŭ Đ Ğ Ś Đ Ɛ ŝ Ś ƚ Ğ Ɛ Ƶ Ŷ Ă a h c a e n e h w k r a m k c e h c a e c a l p d n a n o i t c a h c a e y f i r e v y l l a b r e V : r e d a e l m a e t / r e s e th y f i r ve d n a k s a y l l a b r e : V r ge a n a m s i s i Cr s n ctio a te a i d e m m i 2 a r) 2 e rd o y n a n i d e t e l comp e b n ca s n o i (Act                                                                                                                                                                                                                                                         t lis Check is Cris . ͘ Ŭ Ɛ Ă ƚ ? e n ? e t inu /m L 10 of ͘ Ŭ Ɛ Ă ƚ ͘ Ŭ Ɛ Ă ƚ Ɛ . ible poss if , V I ore -b arge Ŷ Ő ŝ Ɛ Ɛ Ă ͟ ͕ Ž Ŷ ͞ Ĩ / ͘ Ϳ Ğ ů ŝ Ĩ Ž ƌ Ɖ Ŷ Ž ŝ ƚ Ă ů Ƶ Ő Ă Ž Đ ͕ Ŷ ŝ ď Ž ů Ő Ž LJ ŵ Ğ Ŷ ŝ ƌ Ƶ ͘ Ŭ Ɛ Ă ƚ Ɛ ŝ Ś ƚ Ğ ƚ Ğ ů Ɖ ŵ Ž Đ Ž ƚ Ŷ Ž Ɛ ƌ Ğ Ɖ Ă Ŷ Ő ŝ Ɛ Ɛ Ă ͟ ͕ Ž Ő Ŷ ŝ Ŷ Ğ ƚ Ă Ğ ƌ Ś ƚ Ͳ Ğ Ĩ ŝ ů ƌ Ž Ĩ Ϳ Ő ŵ Ϭ Ϭ Ϭ ͕ ϯ Ğ Ɛ Ž Ě ŵ Ƶ ŵ ŝ dž Ă ŵ ; ) t an t r impo t no ation rising rapidly Ϳ Ŷ ŝ Ŭ Ɛ Ɛ ͛ ƚ Ŷ Ğ ŝ ƚ Ă Ɖ Ğ Ś ƚ ƚ Đ Ğ ƚ Ž ƌ Ɖ ; LJ ů ů r e at w d s pack ice e ter e h Ɛ ŝ Ɛ ŝ ƌ Đ Ğ Ś ƚ ƌ Ž Ĩ Ɛ Ŷ Ž ŝ ƚ Đ Ƶ ƌ ƚ Ɛ Ŷ / ͟ Ɛ ŝ Ɛ ŝ ƌ Đ Ă ŝ ŵ ƌ Ğ Ś ƚ ƌ Ğ Ɖ LJ Ś ƚ Ŷ Ă . d e t e l p m o c n e e b s a h n o i t c a 1 ted. e l p com e r a e t comple o t rson pe a n assig d, ne assig is one no f ov                                                                                                                                                                                                                                                         Yes es Y Yes Yes Yes Yes Yes N Y /A N Ž Ğ Ő ƌ Ƶ Ɛ Ğ Ś ƚ Ɛ Ă t he t h it w y rif e V he t h it w y rif e V Ŷ Ă Ŷ Ő ŝ ů Ă ŵ Ğ Ś ƚ Ɛ / ŝ Ğ Ŷ Ğ ů Ž ƌ ƚ Ŷ Ă Ě Ɛ / ƌ Ă Đ Ğ Ě Ž Đ Ğ Ś ƚ Ɛ / Ŷ Ž ƌ Ğ ƚ Ŷ Ğ Đ ŝ Ő ƌ Ƶ ^ Đ Ğ Ŷ Ž Ğ ŵ Ž Ɛ Ě ŝ                                                                                                                                                                                                                                                          Yes Yes Yes Yes N/A Đ Ğ Ŷ Ž Ğ ŵ Ž Ɛ Ě ŝ  he t h it w y rif e V he t h it w y rif e Ĩ Ğ Ś ƚ Ğ ǀ Ă , t rson pe a st o t d e dicat de rson pe he t is o Wh . ask t his t ro dant he t of ion rat nt e conc at Wh ŝ Ŭ Ŷ ŝ ƚ Ś Ő ŝ Ğ ǁ Ɛ ͛ ƚ Ŷ Ğ ŝ ƚ Ă Ɖ Ğ Ś ƚ Ɛ ŝ ƚ Ă Ś t V                                                                                                                                                                                                                                                         2 Ĩ / ͍ ϳ ϯ ϳ ϵ Ͳ ϰ ϰ ϲ Ϳ Ϭ Ϭ ϴ ; Ğ Ŷ ŝ ů ƚ Ž , , D Ğ Ś ƚ ů ů Ă Đ da V I r e inist dm A r: ide prov sia he st ane e ing at re t u yo re A r: ide prov sia he st ane e Ɛ Ğ ƚ LJ LJƚ ů Ž ƌ ƚ Đ Ğ ů Ğ ; ͍ ƚ Ŷ Ğ Ɛ Ŷ Ğ Ğ ď Ɛ ď Ă ů Ő Ŷ ŝ ǁ Ž ů ů Ž Ĩ . ask t his t e t comple o t _ _ _ _ _ _ _ _ _ _ _ _ ? ne role dant ing mix art t d? re e ist admin ing be is ne ole Ϳ Ő Ŭ ; ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͍ Ɛ ŵ Ă ƌ Ő Ž ů r e v and nue onti C                                                                                                                                                                                                                                                         /via g m 20 vi / g m 0 25 Ɛ ŝ Ś ƚ Ğ ƚ Ğ ů Ɖ ŵ Ž Đ Ž ƚ Ŷ Ž Ɛ ƌ Ğ Ɖ Ă Ŷ Ő ŝ Ɛ Ɛ Ă ͕ Ž Ŷ la h hroug t rapidly /kg mg 5 2. ne role ant ias? hm t hy yt arr g Ƶ ͬ ŵ Ƶ ƌ Ğ Ɛ ͕ Ϳ <  ; Ğ Ɛ Ă Ŷ ŝ Ŭ Ğ Ŷ ŝ ƚ Ă Ğ ƌ Đ ŵ Ƶ ƌ Ğ Ɛ ͕ Ɛ f I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ y f fy i if r ons ti ac e s the . r de or ny n a i 2 , 1 al al                                                                                                                                                                                                                                                         Yes Yes Yes Yes A N/ t rson pe a Ğ Ś ƚ Ś ƚ ŝ ǁ LJ Ĩ ŝ ƌ Ğ s a rk pe hy f I ŵ Ƶ ŝ Đ ů Ă  ͻ m ale k r pe hy ŵ Ƶ ŝ Ě Ž ^ ͻ ͬ Ğ Ɛ Ž Đ Ƶ ů ' ͻ dia e P o lt du A o ŵ Ğ Ɛ Ž ƌ Ƶ & ͻ ucos gl is at Wh Ă Ɖ Ğ Ś ƚ Ɛ ŝ ƚ Ă Ś t                                                                                                                                                                                                                                                         Yes N Yes Yes N Yes N A N/ N A N/ N/A A N/ Yes N/A . ask t his t e t comple o t Ŷ ͞ Ĩ / ͍ ƚ Ŷ Ğ Ɛ Ŷ Ğ Ğ ď Ϳ ů Ă ŝ ƌ Ğ ƚ ƌ Ă ƌ Ž Ɛ Ƶ Ž Ŷ Ğ ǀ ; Ɛ Ğ Ɛ Ă Ő Ě Ž Ž ů ď Ğ ǀ Ă , ͗ ƌ Ğ Ě ŝ ǀ Ž ƌ Ɖ Ă ŝ Ɛ Ğ Ś ƚ Ɛ Ğ Ŷ Ă Ğ K ( mia ale + h: it w at re t , nt se pre is s) change G C E h it w ss le or 9 5. > Ő Ŭ ͬ Ő ŵ Ϭ ϯ Ğ ƚ Ă Ŷ Ž Đ Ƶ ů Ő ŵ Ƶ ŝ Đ ů Ă Đ ƌ Ž Ϳ Ő ŵ Ϭ Ϭ Ϭ ͕ Ϯ Ğ Ɛ Ž Ě ŵ Ƶ ŵ ŝ dž Ă ŵ ; Ő Ŭ ͬ Ő ŵ Ϭ ϭ Ğ Ě ŝ ƌ Ž ů Ś Đ mia Ϳ Ƌ  ŵ Ϭ ϱ Ğ Ɛ Ž Ě ŵ Ƶ ŵ ŝ dž Ă ŵ ; s / Ő Ŭ ͬ Ƌ  ŵ Ϯ Ͳ ϭ Ğ ƚ Ă Ŷ Ž ď ƌ Ă Đ ŝ ď Ŷ ŝ ů Ƶ Ɛ Ŷ ŝ ͬ mulation for in % ( e s o xtr de g /k g 5 . d 0 an V I g k ulin/ ins r ula g e r s it un 1 0. : nts ie t pa ic r t e s o luc g 50% mL 0 d 5 an V ulin I ins r ula g e r s it un 10 : nts ie t pa Ϳ Ő ŵ Ϭ Ϯ Ğ Ɛ Ž Ě ŵ Ƶ ŵ ŝ dž Ă ŵ ; Ğ Đ Ŷ Ž Ő Ŭ ͬ Ő ŵ ϭ Ͳ ϱ ͘ Ϭ Ğ Ě ŝ ŵ _ _ _ _ _ : ime t xt ne at d min e R s. ck che ucose gl Hourly _ _ _ _ _ l? e v le se ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͺ ͍ Ğ ƌ Ƶ ƚ Ă ƌ Ğ Ɖ ŵ Ğ ƚ LJ Ě Ž ď Ğ ƌ Ž Đ Ɛ ͛ ƚ Ŷ Ğ ŝ ƚ is ure rat e mp e t if ss le r F) o 102° ( 39° C han t r e at gre is ure rat e mp e t e cor if nt saline V I use nf I V I d chille st que e R ice st que e R Ă Ŷ ƌ Ğ ƚ dž Ğ Ɛ Ŭ Đ Ă Ɖ Ğ Đ ŝ LJ ů Ɖ Ɖ  cold h it w e lavag ric ast ie it v ca y bod n ope e avag L F) 100° ( 38° C han t ss le o t d ase e cr de has ure rat e mp e t f ͘ Ŭ Ɛ Ă ƚ Ɛ ŝ Ś ƚ Ğ ƚ Ğ ů Ɖ ŵ Ž Đ Ž ƚ Ŷ Ž Ɛ ƌ Ğ Ɖ Ă Ŷ Ő ŝ Ɛ Ɛ Ă ͟ Ž Ŷ ͞ Ĩ / ͍ Ğ Đ Ă ů Ɖ Ŷ ŝ ƌ Ğ ƚ Ğ Ś ƚ ed? r o it n mo g n ei b s er rs amet r e r tu a r e p tem e t ca y r a n i r u th i w t u tp u o ed t n a r r a w f g i n i r o t i n o m s u o en v l a r t n ce r o / d n a l a i er t r y f fy i if r e v and nue onti C ons ti ac e s the . r de or ny n a i 2 , 1 sal Nasog a e                                                                                                                                                                                                                                                         s Yes Yes N Yes Yes /A Yes N N N/A Yes es Y Yes N/A N/A N/A N/A /A N N /A N Yes Ă Ɖ Ğ Ś ƚ Ɛ ŝ ƚ Ă Ś t n ie he t ool if cooling TOP ƚ Ă Đ LJ ƌ Ă Ŷ ŝ ƌ Ƶ Ă Ɛ / a p e es h t e r A C pat S                                                                                                                                                                                                                                                         N/A A Yes Yes N / Yes N A Yes N N /A N N/A A N/ N/ C I d lle ca o Wh . t lis k c he c is is r c m o o r ating r Ope 1. o s e /r g r o . s lab ne ad ari . w w //w : ps htt y H nt na alig M . is is r a c ing ag an M 2. 015. 26, 2 r be o t Oc                                                                                                                                                                                                                                                         Yes Yes Yes Yes Yes Yes 2 CO n i b o gl yo e m n i r ͺ ͺ ͺ ͺ ͍ ƚ Ƶ Ɖ ƚ Ƶ Ž Ğ Ŷ ŝ ƌ Ƶ Ɛ ŝ ƚ Ă Ś t ƌ Ő Ž ƚ Ğ Ɛ Ğ ƌ Ƶ ŝ Ě ͕ Ž Ŷ Ĩ / ͻ _ _ _ _ ? re ca e iv rat ope post or f U C A /P U C H for r nte e C int o J A : s ab L ne iad r A 2013 2 r be o t d Oc e s s e c c A /. s ad nlo w o /d s e urc o d S nite U he t iation of c o s s A mia r he t r pe y K+ ET u                                                                                                                                                                                                                                                         N N A N/A A N N A N/ N/ N/A A N/ N/ n o i t a l i t en e v t u n i es i d u t s n o i t a l gu a Ƶ Ž Ś ͬ Ő Ŭ ͬ > ŵ ϭ Ŷ Ă Ś ƚ ƌ Ğ ƚ Ă Ğ ƌ Ő ƚ ŝ Ɛ / ͺ ͺ ͺ ͺ ͺ ͺ ƚ Ƶ Ɖ ƚ Ƶ Ž Ğ Ŷ ŝ ƌ Ƶ ƌ Ƶ Ž Ś ͬ Ő Ŭ ͬ > ŵ ϭ Ŷ Ă Ś ƚ ƌ Ğ ƚ Ă Ğ ƌ n assig d, lle ca has one no f I _ _ _ _ _ _ _ _ _ _ uly d J e is v e R . ation v o nn I ms e t s Sy alth e H 015. 26, 2 a althc e /h g r o . us mha . w w //w p: htt . s ate t CK m co                                                                                                                                                                                                                                                         Ɛ Ğ z zĞ ප ͍ ƌ Ƶ ͘ ƚ . ask t his t e t comple o t rson pe a n . 1) 3. 07241 ( 2013 y d e s s e c c A . is is r -a-c ing ag /man ls na io s fes o r are-p                                                                                                                                                                                                                                                        
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27. MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 27 Malignant Hyperthermia Perioperative Simulation Scenarios Resources Example: Sample form Participant MH Worksheet for Proposed Correct Treatment MH Worksheet MH Hotline: 1-800-644-9737 Patient _____________________Last 4______ Weight____ Date _____ Time_____ Staff Present: Anesthesia_________________Surgeon__________________Primary RN__________________Other __________________________ Immediate Actions † Stop Triggering Agent † Notify Anesthesiologist on call † Hyperventilate † Call Code 99 or Rapid Response Team † Call MHAUS Hotline 1-800-644-9737 Interventions † Give dantrolene as indicated Apply cooling measures (groin, axilla, head, under patient) discontinue when the patient’s temperature is 38°C, 99 F † Place Foley with temperature probe † Give cool IV Fluids (switch to Normal Saline) † Insert monitoring lines when able † Aline † Central Line † Have 2 large bore IVs patent and eventually a central line † Treat Hyperkalemia – Calcium chloride 10mg/kg or calcium gluconate 10-50 mg/Kg – Regular insulin 10 units IV in 50 mL of 50% glucose – Give Na+ bicarb if metabolic acidosis is present (1-2 mEq/kg) † Treat Dysrhythmias – Amiodarone or lidocaine – Beta blockers (metoprolol, esmolol) – Do not use calcium channel blockers (can cause cardiac arrest in the presence of dantrolene) † Monitor renal function: IV fluids, furosemide, mannitol † Obtain lab tests – ABG: watch for acidosis, increase PaCO2 – Electrolyte panel: increase K+, Ca++, MG++, decrease Na+ – CBC: decreased platelets – Coagulation studies: prolonged PTT, PT Watch for DIC (disseminated intravascular coagulation) – Serum studies: increase CPK and myoglobin, creatinine, glucose, lactate Vital Signs Time ETCO2 Temp Pulse Rhythm BP RR SPO2 O2 Time Medication Route Amount Given Time Amount Dose Time Amount Dose 20 mg 1 20 mg(220 mg) 11 20 mg(40 mg) 2 20 mg(240 mg) 12 20 mg(60 mg) 3 20 mg(260 mg) 13 20 mg(80 mg) 4 20 mg(280mg) 14 20 mg(100 mg) 5 20 mg(300 mg) 15 20 mg(120 mg) 6 20 mg(320 mg) 16 20 mg(140 mg) 7 20 mg(340 mg) 17 20 mg(160 mg) 8 20 mg(360 mg) 18 20 mg(180 mg) 9 20 mg(380 mg) 19 20 mg(200 mg) 10 20 mg(400 mg) 20 Medications (give Dantrolene as soon as possible) Dantrolene Given PH PCO2 PO2 HCO3- BE Hct O2Sat Na+ K+ Ca++ Glucose CK Myoglobin Labs Reprinted with permission from AORN SImulation Scenario: Malignant Hyperthermia. Copyright © 2014, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.
28. REFERENCES 1. Guideline for prevention of unplanned patient hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016:531-554. 2. Lenhardt R, Grady M, Kurz A. Hyperthermia during anaesthesia and intensive care unit stay. Best Pract Res Clin Anaesthesiol. 2008;22(4):669- 694. 3. Denborough MA, Forster JF, Lovell RR, Maplestone PA, Villiers JD. Anaesthetic deaths in a family. Br J Anaesth. 1962;34:395-396. 4. Cain CL, Riess ML, Gettrust L, Novalija J. Malignant hyperthermia crisis: optimizing patient outcomes through simulation and interdisciplinary collaboration. AORN J. 2014;99(2):301-308; quiz 309-311. doi:10.1016/j.aorn.2013.06.012. 5. Seifert PC, Wahr JA, Pace M, Cochrane AB, Bagnola AJ. Crisis management of malignant hyperthermia in the OR. AORN J. 2014;100(2):189-202. doi:10.1016/j.aorn.2014.06.014. 6. Kozack JK, MacIntyre DL. Malignant Hyperthermia. Phys Ther. 2001;81(3):945-951. 7. Mullen L, Byrd D. Using simulation training to improve perioperative patient safety. AORN J. 2013;97(4):419-427. doi:10.1016/j.aorn.2013.02.001. 8. Sessler DI. Malignant hyperthermia. Acta Anaesthesiol Scand Suppl. 1996;109:25-30. 9. MH-Susceptibility and Operating Room Personnel: Defining the Risks. Malignant Hyperthermia Association of the United States. http://www.mhaus.org/healthcare- professionals/mhaus-recommendations/malignant- hyperthermia-susceptible-operating-room- personnel. Accessed August 2, 2015. 10. Temperature Monitoring during Surgical Procedures. Malignant Hyperthermia Association of the United States. http://www.mhaus.org/healthcare- professionals/mhaus- recommendations/temperature-monitoring. Accessed August 2, 2015. 11. Malignant Hyperthermia Crisis Preparedness and Treatment. Park Ridge, IL: American Association of Nurse Anesthetists; 2015. 12. MH Hotline – Professional Advisory Council Meeting. May 2011. Malignant Hyperthermia Association of the United States. http://www.mhaus.org/blog/post/2113/an- overview-of-the-first-ever-mh-hotline- professional-advisory-council-meeting. Accessed January 15, 2016. 13. Managing an MH Crisis. Malignant Hyperthermia Association of the United States. http://www.mhaus.org/healthcare- professionals/managing-a-crisis. Accessed August 2, 2015. 14. Official MHAUS Home Page. Malignant Hyperthermia Association of the United States. http://www.mhaus.org/. Accessed July 30, 2015. MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 28
29. MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 29 1. Which term characterizes a patient with a core body temperature that is greater than 38º C (100.4º F)? a. Normothermia b. Hypothermia c. Hyperthermia d. None of the answers is correct. 2. Which of the following best describes malignant hyperthermia? a. A controlled form of hyperthermia b. The onset of fever caused by the presence of an infection c. A form of cancer that can cause life-threatening hyperthermia d. An autosomal dominant genetic disorder that can cause hyperthermia in response to certain triggers 3. Which of the following statements about MH is FALSE? a. MH is an autosomal dominant disorder. b. MH can cause adverse complications, but is not life-threatening. c. MH can be caused by certain anesthetics, muscle relaxants, or extreme stress in the form of heat or exercise. d. MH is a hypermetabolic reaction affecting the transport of calcium in skeletal muscle. 4. The incidence of MH diagnosed in adults is a. one in 200. b. one in 15,000. c. one in 50,000. d. not known. 5. The estimated number of patients that may be susceptible to MH crisis is a. one in 200. b. one in 15,000. c. one in 50,000. d. not known. 6. Which receptor acts as the main calcium release channel transporting calcium from the sarcoplasmic reticulum across the muscle cell membrane and into the myoplasm? a. Ryanodine receptor b. Dihydropyridine receptor c. Na+/K+ pump d. None of the answers is correct. 7. Genetic mutations in which receptor account for MHS in 50% to 70% of all families? a. Ryanodine receptor b. Dihydropyridine receptor c. Na+/K+ pump d. None of the answers is correct. 8. Which of the following is NOT a triggering agent for an MH crisis? a. Inhalation anesthetics (ie, isoflurane, sevoflurane, desflurane, enflurane) b. Depolarizing muscle relaxants (ie, succinylcholine) c. Extreme stress from heat, exercise, emotional stress, or trauma d. All of these can be triggering agents. 9. If one parent has MH, what is the probability that his or her child will inherit the parent’s mutant gene and MH susceptibility? a. 10% b. 25% c. 50% d. 100% 10. What is the best laboratory test available for diagnosing patients with MH? a. In Vitro Contracture Test (IVCT) b. Caffeine-Halothane Contracture Test (CHCT) c. Genetic testing d. Both a and b are correct. POST-TEST MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION Multiple choice. Please choose the word or phrase that best completes the following statements.
30. 11. The genetic mutation driving MH remains unknown in approximately what percentage of MHS families? a. 10% to 20% b. 30% to 50% c. 60% to 80% d. 90% to 100% 12. Which of the following responses during patient assessment does NOT need to be reported to the anesthesia professional prior to the OR procedure? a. I have had a strange reaction to anesthetics in the past. b. I have King-Denborough syndrome. c. My sister had a strange temperature increase the last time she was under anesthesia, but I’ve never had any problems with anesthesia. d. All of these responses should be reported. 13. To avoid unintentional hypothermia and cold injuries, cooling efforts should be stopped when the patient’s temperature reaches a. 37º C (98.6º F). b. 38º C (100.4º F). c. 39º C (102.2º F). d. 40º C (104º F). 14. Of the following clinical signs of an MH crisis, which is considered an EARLY sign? a. Abrupt increase in ETCO2 b. Acute renal failure c. Elevated blood myoglobin level d. Hyperkalemia 15. Of the following clinical signs of an MH crisis, which is considered a LATE sign? a. Muscle rigidity b. Hyperthermia c. Tachycardia d. Hypoxia 16. How many vials of dantrolene (20 mg per vial formulation) should be stocked at all times on the MH cart? a. 12 b. 24 c. 36 d. 48 17. What is the name of the dantrolene preparation currently available on the market? a. DANTRIUM® b. REVONTO® c. RYANODEX® d. All of the answers are correct. 18. The first main steps suggested by MHAUS when treating an acute MH event include calling for help, bringing the dantrolene and MH cart into the procedure room, administering dantrolene 2.5 mg/Kg IV, and a. notifying the surgeon to halt the procedure and discontinuing volatile agents and succinylcholine. b. cooling the patient if core temperature is >39°C or less if rapidly rising. c. obtaining a venous or arterial blood gas. d. treating for hyperkalemia. 19. Which perioperative team member is primarily responsible for notifying the team that the patient is experiencing an MH crisis? a. Surgeon b. Anesthesia professional c. RN circulator d. Scrub person 20. Which perioperative team member is primarily responsible for calling for additional help, assisting with dantrolene preparation, and obtaining necessary supplies? a. Surgeon b. Anesthesia professional c. RN circulator d. Scrub person 21. Which perioperative team member is primarily responsible for stopping surgery, when necessary? a. Surgeon b. Anesthesia professional c. RN circulator d. Scrub person MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 30
31. 22. Which of the following is a TRUE statement? a. A physician office where a patient’s care includes receiving general anesthesia with isoflurane is exempt from stocking dantrolene. b. As long as an ambulatory surgery center has a pharmacy agreement in place with neighboring facilities to obtain dantrolene, there is no need to stock dantrolene on-site for MH-susceptible patients. c. Every facility where MH triggering anesthetics are administered should stock the recommended amount of dantrolene, medications, and supplies to treat an MH crisis. d. Each vial of RYANODEX® and DANTRIUM® require reconstitution with 60 mL of sterile water for injection. 23. To avoid recrudescence, how long should a patient be monitored in the PACU or ICU following an MH crisis? a. At least 8 hours b. At least 12 hours c. At least 24 hours d. At least 72 hours 24. Recrudescence of MH refers to a. the recurrence of MH symptoms. b. a new onset of MH following a period of remission. c. Both answers are correct. d. Neither answer is correct. MALIGNANT HYPERTHERMIA CRISIS: TEAM IN ACTION 31