The March death of Stephanie Kuleba, the 18-year-old Florida resident who succumbed to malignant hyperthermia (MH) following breast surgery, should serve as a reminder for ASCs. While this genetic condition is extremely rare, your facility cannot afford to
overlook the possibility that one of your patients may experience this severe and potentially
fatal reaction.
The March death of Stephanie Kuleba, the 18-year-old Florida resident who succumbed to malignant hyperthermia (MH) following breast surgery, should serve as a reminder for ASCs. While this genetic condition is extremely rare, your facility cannot afford to
overlook the possibility that one of your patients may experience this severe and potentially
fatal reaction.
“You think it’s never going to happen and then it does,” says Gayle R. Evans, RN, MBA, CNOR, CASC, president of Continuum Healthcare Consultants, Inc., based in Kennesaw, Ga., who has worked during and witnessed two MH episodes.
A MH episode can be triggered by a reaction to anesthetic gases and the muscle relaxant succinylcholine. The onset of MH affects calcium regulation within muscle cells. According to the U.S. National Library of Medicine, patients at risk for MH may experience
- muscle rigidity;
- breakdown of muscle fibers (rhabdomyolysis);
- high fever;
- increased acid levels in the blood and other tissues (acidosis); and
- rapid heart rate.
“Basically, your blood is boiling,” says Ms. Evans. “That destroys everything.”
While MH preparedness is an accreditation requirement, it is imperative that your facility — regardless of accreditation status — be prepared to respond to this reaction.
Ms. Evans suggests ASCs take the following four steps to become prepared.
1. Acquire 36 vials of dantrolene sodium. While the cost of this drug may run your ASC a few thousand dollars every two years (the shelf-life of the drug), administering it is the most important and the first action you must take if a patient starts to experience MH as it is the only specific treatment for MH.
“Everything else is a moot point without the 36 vials,” says Ms. Evans.
Thirty-six vials of dantrolene is the amount
recommended by the Malignant Hyperthermia Association of the United States (MHAUS). It will provide you with enough of the drug to treat and stabilize even your larger patients and give you time to acquire more vials of the drug,
if necessary.
Generic dantrolene became available for the first time late last summer, which could help your facility save on the cost of the drug.
2. Place dantrolene in a central location. MHAUS suggests facilities have these vials
available within five minutes of the onset of an MH episode, so your ASC should place it in a central location where staff in any of your operating rooms can retrieve it in under five minutes.
3. Gather other necessary drugs and equipment for stabilization. Injecting dantrolene (diluted with sterile water) is the first step you must take,
but you also need access to other drugs and equipment to
completely stabilize the patient within the first 30 minutes of the episode, Evans says. One effective way to have access to all of these drugs is to develop an MH cart or kit.
Some of the drugs MHAUS suggests you have in your cart or kit:
- sodium bicarbonate,
- furosemide,
- dextrose 50%,
- calcium chloride,
- regular insulin and
- anti-arrhythmia drugs.
Some of the equipment MHAUS suggests you have in your cart or kit:
- syringes,
- angiocaths,
- blood pump,
- bucket for ice and
- cold saline solution.
To find a complete list of suggestions from MHAUS, do an Internet search for “Managing MH — Drugs, Equipment and Dantrolene” to find a copy of a brochure published by MHAUS in 2004.
4. Train and drill. If a patient has an MH reaction, your response time is slim and you cannot afford any hesitation in administering dantrolene and beginning to stabilize the patient. The only way to get your staff comfortable and prepared to respond is through training and drilling.
“A lot of your staff may not have come from a surgical environment, so they probably have never been educated to what MH actually is,” says Ms. Evans. “You have to drill. They’ve got to learn how to get that treatment going.”
Make sure to drill regularly, and perform the entire response process only without administering drugs. If you have expired dantrolene, you can set this aside for drills and actually have staff mix and prepare the solution so they get a true sense of what they will need to do to start treatment, suggests Ms. Evans.
MHAUS has created a poster describing how to perform emergency
therapy to treat MH. You can find it at http://medical.mhaus.org/PubData/
PDFs/treatmentposter.pdf. Print this poster and share it with your staff and include it with your MH kit or cart. MHAUS also offers in-service kits and procedure manuals for all types of facilities that can be used as training for responding to MH events.
Contact Rob Kurtz at rob@beckersasc.com.