Malignant

Hyperthermi
a
January 2015

Objectives
Review background of Malignant
Hyperthermia
Describe diagnostic and treatment
guidelines for Malignant
Hyperthermia
Discuss the current UK HealthCare
protocol for treatment of Malignant
Hyperthermia

Case Report: Drendon Family

First Reported Case

April 14, 1960 21y/o M student at the
University of Melbourne sustained
compound fractures of his right tibia
and fibula
Reported 10 close relatives died
during or after anesthesia

Case Report 2008:Stephanie Kuleba

Brandom, Barbara W. "Ambulatory surgery and malignant hyperthermia." Current Opinion in

Anesthesiology 22.6 (2009): 744-747.

What is Malignant
Hyperthermia (MH)?
Potentially fatal, inherited disorder
usually associated with the
administration of certain general
anesthetics and/or succinylcholine.
The disorder is due to an acceleration
of metabolism in skeletal muscle.

Risk Factors
Family history/blood relative that has been diagnosed with
MH
Patient reports that they personally or a family member has
had problems during anesthesia
History of other muscular orders
Muscular Dystrophy (Duchenne)/Myotonia

History of unexplained fevers that have been evaluated

without diagnosis
History of heat stroke

What provokes Malignant

Hyperthermia?
Dysregulation of
Calcium within
the Cytoplasm
Caused by:
Mutated
Ryanodine
Receptor Gene

Lehmann-Horn, Frank, et al. "Nonanesthetic malignant hyperthermia. Anesthesiology 115.5 (2011): 9115-

Epidemiology
Incidence of MH related to surgical procedures
Adults 1:100,000
Pediatric 1:15,000

There are about 600 reported cases of MH per

year in the US
Median age is 20 years, with range of 2-31
years; seen most often in males
MH hotspots: Wisconsin, Michigan, and
West Virginia, Nebraska

2 Major Categories of MH

Awake Episodes

Heat Stroke and

Exercise Induced
Rhabdomyolysis

Medical Emergency

Classic MH
Triggering Agent

Medical Emergency

Denborough M. Malignant hyperthermia. The Lancet. 1998;352(9134):1131 1136

Trigger vs. Safe

Triggering
Non-Triggering
Anesthetics
Agents

Volatile gaseous
inhalation anesthetics
Isoflurane
Sevoflurane
Desflurane
Halothane
Depolarizing Agents
Succinylcholine

Agents

All others are safe

Propofol
Ketamine
Nitrous Oxide
Non-Depolarizing
muscle relaxants
Vecuronium
Rocuronium

McCarthy EJ. Malignant hyperthermia: pathophysiology, clinical presentation, and treatment. AACN Clin
Issues. 2004; 15:231-7.

Clinical Signs of MH
As Levels of Calcium Increase

EARLY

LATE

Masseter Spasm

Hyperthermia (may exceed

110)
Myoglobinuria

Hypercapnea
(Increased ETCO2)
Unexplained
Tachycardia
Muscle Rigidity
Sudden Hypoxia

Hyperkalemia
Acute Renal Failure
Hemodynamic Instability

Schneiderbanger, et al. "Management of malignant hyperthermia: diagnosis and treatment."

Therapeutics and clinical risk management 10 (2014): 355.

Response for MH Crisis Event in

the OR
Discontinue triggering inhalation agent and deliver 100%
oxygen
Stop procedure
Call for help - Notify
Attending Anesthesiologist
Attending Surgeon
Pharmacy
OR Charge Nurse and Manager
Change charcoal filter on anesthesia machine (this filters
out any residual gases in the machine no longer need to
change machine out)
Any other staff that are available to help (Anesthesia
Technicians)

Response for MH Crisis Event

Outside the OR
CALL OR Main Desk
Chandler: 323-5631
GS: 226-7133
After Hours at GS: Notify HOA (Rapid Response???)

State you have an suspected MH patient and need anesthesia

and MH cart STAT and state event location
NOTIFY PHARMACY
Chandler: 218-1306
GS: 226-7038

If anesthesia provider present, call OR main desk and request

MH Cart and additional assistance STAT

What to do in an MH Crisis?
Call Anesthesia Stat and call pharmacy
Obtain closest MH cart
Primary nurse will assign tasks according to the MH RN Crisis
Cards
Carts are stocked with the initial supplies you will need to get
started
Carts also contain needed lab slips
Nurse &/or Pharm-D may assist anesthesia with recording
times & medication dosages

MH Carts
Carts are set up the same in all areas
There are RN Crisis Cards located on the
carts
These cards are distributed by the circulating
nurse to assisting staff as they are available
Each RN Crisis Card is in a zip-loc bag with the
initial supplies needed to get started and other
supplies possibly needed will be in Cart
drawers

MH CART LOCATIONS
Chandler:
PAV A Center Core
HA Center Core
3rd floor OB Operating Room
Hallway

Good Sam:
2nd floor b/t ORs 1 & 2
5th floor in supply/instrument
room

CAS:
4th floor anesthesia workroom

RN Crisis Cards

Primary Nurse

GET HELP
CALL PHARMACY ________
ABGs & LABS STAT call ________
ASSIGN ROOM RECORDER
ASSIGN TRAFFIC MONITOR @ OR
DOOR
CALL BIO-MED- PAGER ___________
NAME TAGS FOR STAFF
ASSIGN MANAGEMENT CRISIS BOARD
RECORDER

Contents of Bag
Lab tubes (adult/peds)
ABG syringes x 2
Peds butterfly vacutainer
Lab slips (Blood Gas forms &
Flow sheet, Lab 1 forms, Ua
form)
IV Start Kit

DANTROLENE RN
Central Pharmacy ________
Administer Dantrolene as Follows: 2.5 mg/kg
1. First Dose RYANODEX Each 250mg vial of Ryanodex should
be reconstituted with 5ml of sterile water for injection and the vial
shaken until clear
2. SUBSEQUENT DOSES REVONTO Each 20mg vial should be
reconstituted by adding 60ml of sterile water for injection and vial
shaken until the solution is clear
3. Administer IV dantrolene 2.5mg/kg rapidly through large bore IV
and repeat as frequently as needed until the patient responds
with a decreased ETCO2, decreased muscle rigidity, and/or
lowered heart rate

Contents of Bag/Box
18 g blunt needles x2
60 ml syringes x2
MiniSpikes
IV tubing x2
Stickers for Dantrolene: mix time/date
(good for 6 hours after mixed)
Dantrolene Dosage Chart(yellow)

MEDICATION RN
CRASH CART TO ROOM
ASSIST IN STARTING LARGE BORE IV
GET NCT/PCT GLUCOSE FINGER STICK
REFERENCE DANTROLENE DOSING CHART
ASSIST ANESTHESIA WITH MEDICATION
NEEDS
Pharm-D/ or RN TRACK MEDICATIONS ON MED
TRACKING SHEET

(Return Med Tracking sheet to Nurse responsible for patient record

when complete)

Contents of Bag
16 & 18g Angio x2
each
IV Start Kit x2
Alcohol pads
Calculator

COOLING RN
SEND FOR ICE
SEND FOR COLD FLUIDS
FOLEY CATH PLACED: UA STAT_________
ICE TO AXILLARIES/GROIN/HEAD
LAVAGE BLADDER, etc
RECTAL TUBE PLACED
ORAL GASTRIC TUBE PLACED

Contents of Bag/Box
Toomey syringe
Red rubber catheter 10g
& 22g
Blue top UA collection
cup
Bag decanters
Sterile bowl(stored in

ROOM RECORDER x2
DRUGS & MEDICATIONS
GIVEN, TIME & AMOUNTS
STAFF IN/OUT OF ROOM
VITAL STATISTICS
RECORDED
CRISIS MANAGEMENT
BOARD
(kept in top drawer)

PT WEIGHT - kg & lbs

PT NAME
PT AGE
PT ALLERGIES
LAB TIMES OUT
PHONE MONITOR
NAME TAGS

Contents of
Bag/Box
Memo pad & pen
Dry erase sheet
with marker
Color-coded name
tags

Dantrolene
Dantrolene is the only medication that can
be used to treat MH
It is a direct acting skeletal muscle
relaxant
2 brand names of dantrolene utilized at UK
Ryanodex initial dose
Revonto subsequent doses

Dantrolene Preparation
Both types of dantrolene are reconstituted with sterile
water for injection (without a bacteriostatic agent)
Shake vial until solution is clear
Protect the contents of the vial from direct light
Each vial is good for 6 hours after reconstituted
Send additional mixed vials with patient if discharged
to another area)

Dantrolene Dosage
2.5mg/kg is the initial dose for Pediatrics & Adults
If suspected MH patient coming to the OR notify
pharmacy
Reference the dantrolene dosage chart located in
the MH cart
May do drug calculations prior to patient coming
to OR (know your patients weight in kg)

Dantrolene Dosage
Administration of dantrolene
Patient needs a large bore IV
Ryanodex 2.5mg/kg given rapid IV push over one
minute
Revonto 2.5mg/kg given rapid IV push

Continue dantrolene as long as symptoms

persist
Patient could be treated with dantrolene for up
24-48 hours after surgery

Dantrolene - Ryanodex
Give one 250mg vial for
the first dose following
2.5mg/kg dosing
Mix 5ml of sterile water for
injection
Give rapid IV push over 1
minute
One vial is located in the
dantrolene drawer of the
MH cart
Packaging will state FIRST

Dantrolene - Revonto
Revonto will be given for
subsequent doses
Mix with 60ml of sterile
water for injection
Give rapid IV push
9 vials are located in the
dantrolene drawer of the
MH cart along with vials of
sterile water

Additional MH Medications on Cart

Sodium Bicarbonate
Dextrose
Calcium Chloride
Lidocaine
Insulin and additional Dantrolene will
be brought to the room when
pharmacy responds to event

Cooling the Patient

Use measures for surface cooling
Ice packs to groin, axilla, head
Cooling blanket

Lavage stomach, bladder and rectum

with iced solution
Iced lavage to peritoneal cavity, if open
May cool by use of heart/lung machine
Cease cooling efforts when patient
temperature down to 100.4 F (38 C)

Post Acute Phase

Give Dantrolene 1mg/kg every 4-6 hours for 24-48
hours
Monitor for reappearance of symptoms rate is 25%
Follow electrolytes, blood gases, CK, core temperature,
urine output and color, coagulation studies
Monitor for signs of myoglobinuria and rhabdomyolysis
and institute therapy to prevent renal failure

Post Op
For patients with a known history of
MH that have an uneventful
anesthetic course
continue to monitor vital signs for
one to two hours
Patients that experienced a mild
increase in jaw tension during a
procedure should be observed for
at least 12 hours post op

After the Crisis

Medications & supply charging
Place a patient sticker on top of the Supply Charging and
Restocking Form (found in the resource binder on the MH
cart)
Mark the quantity used on the form for charging and
return to OR materials

Cleaning & restocking the cart and refrigerator

The OR Anesthesia Techs are responsible for cleaning the
cart, restocking the supplies on cart and in refrigerator
and returning the cart to its home- you will need to
contact them and make sure this is being done

When do we start using

the cart?
The MH cart will go live Monday,
February 9, 2015.
Look for it in the sterile corridor when
you work on or after that date so that
you are familiar with where it is.
Remember that endoscopy (down the
hall from us) will be sharing this cart
with us, so if they have a MH crisis
they will be coming to get the cart.

? COMMENTS/QUESTIONS
?
Please contact Courtney
Howard with any
questions.

References
Brandom, Barbara W. "Ambulatory surgery and malignant
hyperthermia." Current
Opinion in Anesthesiology 22.6 (2009):
744-747.
Denborough M. Malignant hyperthermia. The Lancet.
1998;352(9134):1131 1136
Lehmann-Horn, Frank, et al. "Nonanesthetic malignant
hyperthermia.
Anesthesiology 115.5 (2011): 9115-917
McCarthy EJ. Malignant hyperthermia: pathophysiology, clinical
presentation, and treatment. AACN Clin Issues. 2004; 15:231-7.

Schneiderbanger, et al. "Management of malignant

hyperthermia: diagnosis and treatment." Therapeutics and
clinical risk management 10
(2014): 355.