Management Of Malignant Hyperthermia, Perioperative Services
10929 Source: Clinical Surgery & Procedures I. PURPOSE: To provide guidelines of early recognition and warning signs for Malignant Hyperthermia (MH). Instructions for suggested standard treatment regimen per physician's orders. II. DEFINITIONS: Malignant Hyperthermia (MH) is a potentially lethal, severe hypermetabolic state triggered in genetically predisposed individuals when exposed to certain inhalation agents and depolarizing muscle relaxants. Early recognition of warning signs: A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. III. Increase in end-tidal carbon dioxide Muscle rigidity, including masseter spasm (the masseter muscle raises and lowers the jaw) Tachycardia or arrhythmias Fever; rapid rise in temp., sustained rise (to as high as 108 F, 42.2 C or more) Tachyphena (spontaneous hyperventilation) Unstable blood pressure Dark blood in surgical field despite adequate inspired oxygen Cyanotic mottling of skin Profuse sweating Discolored urine Central venous desaturation Central venous and arterial hypercarbia Metabolic acidosis Respiratory acidosis Hyperkalemia Myoglobinuria/Myoglobulinemia Elevated CPK (late) Applies to Facilities: Official (Rev: 7) Applies to Departments:
STANDARDS OF PRACTICE: A. B. Performed by:
IV.
STEPS OF PROCEDURE: A. B. Equipment:
Contents of the Malignant Hyperthermia Cart are monitored through the use of the break-away lock system. All locks have a serial number which is documented daily in the Malignant Hyperthermia (MH) log book located on the Malignant Hyperthermia (MH) cart. The integrity of the lock is verified daily and if the lock is broken, the contents are verified and replaced as necessary and a new lock is requested from the pharmacy. The cart contents are checked by pharmacy monthly I. Contents of the MH kit: A.
B.
C. D. E. F. G. H. I.
J. K. L.
M.
Dantrolene sodium for injection (each able to be diluted at the time of use with 60 mL sterile water) - 36 vials b. Sterile water for injection (without a bacteriostatic agent) to reconstitute dantrolene: 100 ml vials x 22 or 1 Liter bag x 2 bags c. Syringes to dilute dantrolene 60 mL - 5 syringes d. Calcium chloride 10% 10 mL - 2 vials or syringes e. Furosemide 40 mg vials - 4 vials f. Amiodarone 150 mg - 3 vials or syringes g. Regular Insulin 100 units/mL - 1 vial (stored in department's medication refrigerator) h. Sodium bicarbonate 8.4% 50 mL - 5 vials or syringes i. Dextrose 50% 50 mL - 2 vials or syringes j. Copy of this procedure, "Management of Malignant Hyperthermia, Perioperative Services" - 1 copy Other supplies that may be needed a. Mini-spike® IV additive pins b. Multi-Ad fluid transfer (to reconstitute dantrolene) c. Angiocaths: 16G, 18G, 20G, 2-inch; 22G, 1-inch; 24G, ¾-inch (for IV access and arterial line) d. NG tubes: (sizes appropriate for the patient population) e. Blood pump f. Irrigation tray with piston syringe for NG irrigation g. Toomy irrigation syringes 60mL for NG irrigation h. Micro drip IV set The anesthesiologist announces the impending MH crisis, and takes charge of the operating room One person will be designated the timekeeper. Stop inhalation anesthetic and do not administer additional succinylcholine if masseter rigidity occurs. If surgery must continue immediately switch to non-triggering anesthetics. Obtain immediate consultation by calling the MH Hotline at 1-800-644-9737 An oropharyngeal or axillary probe is placed if no means to monitor the temperature have been taken. The staff assigned to the room remains in the room; the front desk is notified and the MH cart and stand-by help is requested. Initiate cooling measures. the circulating RN assigns duties as help arrives: 2-4 licensed persons are assigned to Dantrolene Sodium reconstitution; 1 RN is assigned to documentation ; 1 RN is assigned to initiate cooling measures; 1 Anesthesia Technician is assigned to help with establishing arterial lines, drawing labs and other duties as assigned by the anesthesiologist. Other personnel (orderlies, CCE's) are assinged duties as needed. Change anesthesia tubing/tubes and soda lime canisters Hyperventilate with 100% oxygen (flow: 8-10 liters). Continuous monitoring: 1. EKG 2. Vital signs (i.e. blood pressure, pulse rate, body temperature) 3. Oximetry 4. Lab values Administer prescribed medications and solutions. General dosing recommendations are provided. 0. Dantrolene Sodium (Dantrium) IV to treat malignant hyperthermia.
a.
Acute Phase - Starting dose 2.5 mg/kg via rapid IV push. May repeat until there is a control of malignant hyperthermia symtoms. Sometimes more than 10 mg/kg (up to 30 mg/kg) may be necessary. b. Each MH kit contains 36 vials of Dantrolene Sodium. In the event that additional vials are needed (i.e. with a bariatric patient), more vials may be obtained from the following locations: I. Palomar: A. Operating Room (760-739-3470). The MH kit is in the hallway by room #7. B. Pharmacy (x 3092 II. Escondido Surgery Center PACU (760-740-7813). The MH kit is in the PACU. III. Pomerado A. Operating Room (x 4654). The MH kit is in the OR's hallway. 1. The OR is closed, call the house supervisor (x 4496) B. Birth Center (x 4522). The MH kit is in the C-Section Suite. C. Pharmacy (x 4654) c. Post Acute Phase - If clinically warranted 1 mg/kg every 4-8 hours may be considered. Continuous infusion of 0.25 mg/kg/hour for up to 36 hours is a dosing alternative. d. Dantrolene Sodium Preparation i. Dantrolene Sodium must be dissolved in sterile water for injection USP (without bacteriostatic agent). ii. Per MHAUS, Dantrolene Sodium contains mannitol in sufficient quantity; additional mannitol administration is not recommended. iii. Dantrolene Sodium requires vigorous shaking until the solution is clear iv. Do not use glass IV bottles for infusion of Dantrolene Sodium v. Protect from light vi. Use within 6 hours of reconstitution 1. Amiodarone (Corderone) IV if required for arrhythmias. a. Children: . Bolus: Amiodarone 5 mg/kg rapid IV bolus (per PALS guidelines). i. Drip: This is not included in the HM kit. For IV preparation, follow weight-based pediatric continuous infusion dosing chart. Start IV infusion at 5 mcg/kg/min. May increase to 10 mcg/kg/min. b. Adults: . Bolus: Amiodarone 300 mg IV bolus (same as cardiac arrest dose). If VF/pulseless VT recurs, consider administration of a second dose of 150 mg IV. i. Drip: Amiodarone 450mg in 500mL dextrose 5%. This is not included in the HM kit. Obtain additional amiodarone and dextrose bag from a crash cart or pharmacy. Start Infusion at 1 mg/min (according to ACLS recommendations). c. Monitoring: EKG should be monitored during the loading dose for heart rate, PR, QRS, and QT duration. 2. Sodium Bicarbonate 1-2 mEq/kg if blood gas values are not yet available. To correct metabolic acidosis. Blood gas values to determine sodium bicarbonate doses. 3. Glucose and Insulin to correct hyperkalemia. (Obtain insulin vial from departmental med refrigerator.)
a.
N. O.
Children: 0.1 unit/kg of regular insulin and 1 mL/kg of dextrose 50%. Consider hourly glucose checks. Subsequent insulin and dextrose administration may be titrated to potassium level. b. Adults: 0.15 units/kg regular insulin and 1 mL/kg dextrose 50%. Consider hourly glucose checks. Subsequent insulin and dextrose administration may be titrated to potassium level. 4. Calcium Chloride 10mg/kg 5. Lasix (Furosemide) to avoid renal failure from potential rhabdomyolysis. 6. a. Children: furosemide 1 mg/kg every 12 hours. b. Adults: furosemide 50 mg IV push. Administer up to four (4) doses. Additional furosemide may need to be obtained from OR supply or pharmacy. Insert foley if not in place and maintain urine output of at least 2 mL/kg per hour: Use any or all of the following cooling methods to reduce the patient's temperature. Implement protective measures to prevent skin/tissue injury due to thermal source. 0. Administer refrigerated IV Normal Saline (not ringers lactate) 1000 mL/10 min for 30 minutes. 1. Directly lavage peritoneal/thoracic cavity with refrigerated NS irrigation fluid (i.e. if either surgical site is open). 2. Surface cooling with ice in plastic bags to surface areas, especially the neck, axilla and groin areas. Use hypothermia blanket. 3. Lavage of stomach, bladder, rectum, with iced saline (3-6 liters). 4. Discontinue cooling measures when patient's temperature reaches 38 degrees C (100.4 F.) Post-Operative: If an Escondido Surgery Center patient experiences malignat hyperthermia, the patient will be transferred to the Palomar Medical Center ICU or other hospital as appropriate. As soon as the patient is stabilized he or she is moved to the PACU, where a respirator is available. 0. Transport the MH cart with the patient from the OR to the patient's bedside. 1. Monitor EKG, blood pressure, oximetry, and A-line. 2. Follow ETCO2, electrolytes, blood gases, CK, core temperature, urine output and color, coagulation studies 3. Venous blood gases (values may document hypermetabolism better than arterial values). 4. Central venous as needed. 5. The patient will later be transferred to an intensive care unit for a minimum of 36 hours. 6. Dantrolene is administered for at least 36 hours. 7. Follow vital signs and labs as above (see C & D). 8. Monitor coagulation status, watching for DIC. Register the patient with the North American MH Registry forms are available by contacting: 0. MHAUS 11 East State St., P.O. Box 1069, Sherburne, NY 13460-1069 1. 1-800-986-7910 2. Refer for testing at nearest center. Malignant Hyperthermia Association of United States (MHAUS) 0. 24-hour HOT LINE 1-800-644-9737 Non-emergency or patient referral call 1-800-986-4287.
a.
P. Q. R.
S.
T. U.
II.
Appendix A - Dantrolene Dosing Chart
Dantrolene Dosing Chart
Based on recommended loading dose of 2.5 mg per kg Chart calculated using 20mg vials of Dantrolene reconstituted with 60mLs of Sterile water (without a bacteriostatic agent) Patient’s weight Number of Milligram dosage mL’s of Patient’s weight in Kilograms needed reconstituted in Pounds 20 mg vials of Dantrolene to Dantrolene to Open administer 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 3 4 4 5 5 6 7 7 8 9 9 10 10 11 12 12 13 14 14 15 15 16 17 17 18 19 19 50 mg 62.5 mg 75 mg 87.5 mg 100 mg 112.5 mg 125 mg 137.5 mg 150 mg 162.5 mg 175 mg 187.5 mg 200 mg 212.5 mg 225 mg 237.5 mg 250 mg 262.5 mg 275 mg 287.5 mg 300 mg 312.5 mg 325 mg 337.5 mg 350 mg 362.5 mg 375 mg 150 mL 187.5 mL 225 mL 262.5 mL 300 mL 337.5 mL 375 mL 412.5 mL 450 mL 487.5 mL 525 mL 562.5 mL 600 mL 637.5 mL 675 mL 712.5 mL 750 mL 787.5 mL 825 mL 862.5 mL 900 mL 937.5 mL 975 mL 1012.5 mL 1050 mL 1087.5 mL 1125 mL 44 55 66 77 88 99 110 121 132 143 154 165 176 187 198 209 220 231 242 253 264 275 286 297 308 319 330
V.
PUBLICATION HISTORY: Revision Number Effective Date 01/23/2012 Document Owner at Publication Michelle Fennell, Nurse Education Specialist, Periop Michelle Fennell, Nurse Education Specialist, Periop Michelle Fennell, Nurse Education Specialist, Periop Version Notes adding a title 22 recommendation need to revise the statement in "J" to reflect 2011 AORN standards Revise procedure to change storage of insulin vial from MH cart to department's medication refrigerator. Storage requirements as per manufacturer and American Diabetes Association. Additional change to the water used to reconstitute Dantrolene. (The revision was from 2008 and was never signed) Document is being revised to include 2010 AORN standards. Approved P&T 122-10. Change Clacuim Chloride to 10mg/kg per recommendations from Bill Turner Director of Parmacy @ Pomerado. Add verbage regarding process for documenting break away locks and restocking of contents. Update to October 2004 MHAUS guidelines and recommendations. General dosing guidelines were also added. Also added comments about transferring the patient if MH event was at ESC. Reviewed, minor changes. Combined with PMC/POM The previous revision date is: 2/22/02.
Virginia L. Ogren, RN BSN, CNOR, Clinical Educator/Supervisor Glenell Rutkoff, RN, Nurse Manager
Authorized Signer(s): VI. REFERENCES: Reference Type Source Documents
( 01/23/2012 ) Paul Patchen, Director Cardiovascular Services
Title
Notes
Assessment of Patients JCAHO CAMH Standard Assesment of Patients JCAHO CAMH Standard Care of Patients JCAHO CAMH Standard Medical Staff
Paper copies of this document may not be current and should not be relied on for official purposes. The current version is in Lucidoc at .
