malignant hyperthermia: mock code. abc’s of managing mh o pre-operative: o ask about personal and...

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Malignant Hyperthermia: Mock Code

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Page 1: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Malignant Hyperthermia:

Mock Code

Page 2: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

ABC’s of managing MHO Pre-operative:

O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained fever or death); Aware of clinical signs

O Body temperatureO Capnographic monitoringO Dantrolene

(MHAUS, 2009)

Page 3: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

IntraoperativeO Primary Survey/Clinical Signs:

O Awareness: suspecting MH crisis?O Airway: severe masseter spasmO Breathing: difficult to ventilate/intubateO Body rigidity after succinylcholineO Body temperature high (late sign)O Capnography: elevation of end CO2O Drugs: triggering agentsO Exposure/Examine: skin color,

perfusion,temperature, urine color, extremities, muscle tone

(MHAUS, 2009)

Page 4: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Emergency TreatmentO Ask for Help/Ask for MH cartO Breathing: hyperventilate with 100%

oxygenO Cooling: blanket; fluids-15cc/kg IV 3 times;

irrigate wound, stomach, & stomach; Call MH Hotline: 1-800-644-9737

O Dantrolene: 2.5 mg/kg IV and until signs are controlled

O Check Electrolytes-**potassium

(MHAUS, 2009)

Page 5: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Secondary stepsO Acidosis? Monitor blood gases.O Bicarbonate? 1-2 mEq/kg guided by pHO Circulation/monitoring: arterial line, venous

catheter, labs, blood gases, CBC, Coagulation tests, CK, myoglobin levels

O Dysrhythmias: treatO Diuresis: output > 1 ml/kg/hrO Electrolytes: treatO Follow up: Arterial and venous blood gases;

Body temperature (core); end-tidal CO2; CK, Coagulation tests; Diuresis; Electrolytes

(MHAUS,2009)

Page 6: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Post-OperativeO Post-Crisis Problems:

O Alkalinize urine & diurese, monitor for ARF (acute myoglobinuric renal failre)

O Beware hypothermic, hyperkalemic, hypervolemic overshoot

O Creatine Kinase levels (CK)- severity of rhabdomylosis (watch for renal failure)

O Compartment SundromeO Elevated liver functions 12-36 hours post

MHO Follow CNS functionO Good communication to medical

specialists(MHAUS,2009)

Page 7: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Post-Acute PhaseO Aware of recrudescence signsO Ask relatives about Anesthesia

problems /neuromuscular disordersO Biopsy: send to center for evaluationO Contact MHAUS for

information/referralO Dantrolene 1 mg/kg IV q 4-6 hrs and

continued for 24-48 hoursO Document: submit forms to the

national/international North American MH Registry: www.mhreg.org

(MHAUS, 2009)

Page 8: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Mock Code ScenarioO A 40-year-old, 90 kg woman is

undergoing liposuction under general anesthesia. She is intubated and receiving desflurane anesthesia. When she is turned from prone to supine, the patient feels stiff. No temperature probe is in place and she feels warm. Her heart rate is now 160 bpm and her ETCO2 is 82 despite minute ventilation of 12 L/min: Pt has Malignant Hyperthermia

(MHAUS, 2009)

Page 9: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Operating Room: When MH is suspected

O Stops inhalation agents and uses non-triggering agents (Anesthesia Duty)

O Hyperventilate with 100% oxygen at high flows: at least 10 L/min (Anesthesia Duty)

O Circulator: notifies control desk and a MH code is called by the person in charge. Ask for additional help from PACU if needed

O Anesthesia tech or assigned team member will take a replacement anesthesia machine into operating room

(Corporate Surgical Committee, 2010)

Page 10: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Operating RoomO If replacement not available, the

soda line and circuit are changed immediately and the system is flushed with oxygen before proceeding. (Anesthesia Duty)

O Anesthesia MD in charge of crisis intervention

(Corporate Surgical Committee, 2010)

Page 11: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Roles are assignedO Anesthesia Staff:

O Change anesthesia machineO Monitor vital signsO Administer Dantrolene and other

meds to treat symtomsO Assist with cooling by providing large

quantities of iced saline lavageO Place additional monitoring lines e.g.

arterial line

(Corporate Surgical Committee, 2010)

Page 12: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Surgeon, Scrub, & Circulator

O Assist in cooling the patient by providing iced saline lavage direct to peritoneal or thoracic cavity if open

O Stop surgical procedure as soon as possible

O Scrub secures the incision site (i.e. applies dressings or covers wound to protect it from disruption)

(Corporate Surgical Committee, 2010)

Page 13: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Second CirculatorO Assists preparing Dantrolene for

administrationO Each vial should be reconstituted

with 60 ml of sterile water (bacteriostatic agent)

O Records medication and progress of interventions

(Corporate Surgical Committee, 2010)

Page 14: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Third CirculatorO Assists in surface cooling of the

patient as directedO Obtains additional supplies as

directed

(Corporate Surgical Committee, 2010)

Page 15: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Scrub tech/Clinical Tech/RN

O Immediately available to run specimens to the lab

O Immediately available to assist as directed

(Corporate Surgical Committee, 2010)

Page 16: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Surgery Desk NurseO Assigns staff to the operating room

where the MH crisis is (may include help from PACU)

O Notifies PACU personnel and Nursing Operations Manager

(Corporate Surgical Committee, 2010)

Page 17: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

MH suspected in PACUO Primary care nurse to notify the control desk

and a MH Code is to be called by the person in charge.

O Additional help may be asked from the operating room/pre-op staff

O Hyperventilate with 100% oxygen at high gas flows: at least 10 L/min

O Charge Nurse (Team Leader) will immediately assign a staff member to get the MH cart

O Anesthesia MD is in charge

(Corporate Surgical Committee, 2010)

Page 18: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Anesthesia StaffO Will administer Dantrolene and

medications used to treat symptomsO Assist in cooling patient by providing

large quantities of cold saline lavageO Place additional monitoring lines.

E.g. arterial line

(Corporate Surgical Committee, 2010)

Page 19: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Second RNO Assists preparing Dantrolene for

administrationO Records medications and progress of

intervention

(Corporate Surgical Committee, 2010)

Page 20: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Third RNO Assists in surface cooling of the

patient as directed O Obtains additional supplies as

directed

(Corporate Surgical Committee, 2010)

Page 21: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Debriefing of Mock Code

O Using the report of the timing of the events as a guide

O Each participant discusses what went right and what could be improved.

O Notes are taken and used to guide future drills

(Corporate Surgical Committee, 2010)

Page 22: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

Clinical Tech/RNO Immediately available to run

specimens to the labO Immediately available to assist as

directed

(Corporate Surgical Committee, 2010)

Page 23: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

PACU Desk/ Charge Nurse

O Assigns staff to the patient where the MH crisis is (may include help from OR)

O Submits MH form to the national/international North American MH Registry of MHAUS

(Corporate Surgical Committee, 2010)

Page 24: Malignant Hyperthermia: Mock Code. ABC’s of managing MH O Pre-operative: O Ask about personal and family history of MH; Adverse Anesthesia reactions (unexplained

ReferencesO Corporate Surgical Committee.

(2010). Malignant hyperthermia crisis intervention. Orlando Health.

O The Malignant Hyperthermia Association of the United States[MHAUS]. (2009). Guide to malignant hyperthermia. Retrieved from http://www. mhaus.org