Malignant Hyperthermia (MH) is a rare inherited hyper metabolic skeletal muscular disorder, which can occur when a susceptible patient is exposed to anesthetic triggering agents, such as Isoflurane, Desflurane, Sevoflurane, or the depolarizing muscle relaxant Succinylcholine. It is a life-threatening event that results in hypercapnia, tachycardia, muscle rigidity, acidosis, hypoxemia, hyperkalemia, and hyperthermia. Malignant Hyperthermia may affect all races and ethnic backgrounds; it is mainly seen in children, adolescents and young adults. In the United States the highest incident of MH is seen in Wisconsin, Nebraska, West Virginia and Michigan.
Preparedness and immediate recognition of symptoms and efficient response with interventions by team members is essential for positive patient outcomes. Through simulation drills, perioperative staff can develop the knowledge and skills to respond efficiently and effectively should a MH crisis occur.
“Practice makes perfect” is one reason simulation is such a wonderful training option. Through repeated simulation drills of a malignant hyperthermia crisis, and post simulation debriefing we have come to realize that it’s “perfect practice that makes perfect.” Simulation can be used for team training and developing or enhancing communication skills, as well as practice and assessment of specific psychomotor skills. It is an opportunity to assess and certify competency of learners in an environment without endangering a patient. It improves staff confidence and critical thinking skills and provides an opportunity to assess problem solving and decision making skills.
Prior to the first MH simulation drill, staff was educated and tested regarding their knowledge of MH. The first MH simulation drill was conducted by the perioperative service in the fall of 2011, guided by the nurse educator at the VA Medical Center in Lake City, Florida. As our department discovered debriefings have become the most effective tool for improving efficiency, streamlining processes, and reinforcing skills needed to ensure optimal patient outcome. At the conclusion of the simulations, debriefings were conducted and several important impediments to timely and effective care were revealed. These included:
• Need for interdisciplinary team approach, to include anesthesia, nursing, lab, pharmacy, respiratory therapy and ICU.
• Need for role definition with assigned tasks lead by anesthesia provider.
• Effective closed loop communication among the team based on the American Heart Association code team protocols.
Having a suggested scenario and assigned tasks with constant re-evaluation has allowed the unit to organize, plan and conduct an effective MH Drill in preparation for an actual event. MH is an example of why the perioperative team needs to have a plan and practice managing a complex medical emergency. Since timely diagnosis and intervention is of the essence, repeated simulations increase proficiency and positive patient outcome. Utilizing lessons learned has increased staff member’s ability to perform critical interventions and decreased the time it takes to mix and administer Dantrolene according to the guidelines of the Malignant Hyperthermia Association of the United States (MHAUS).
Since prognosis is related to the timing of Dantrolene administration, it is recommended that patients start receiving Dantrolene within 10 minutes of a suspected MH episode. Our facility uses a fluid dispensing system with a mini spike to facilitate and decrease mixing time of Dantrolene verses mixing with a syringe and needle. Two or three designated staff members are needed to mix and administer Dantrolene quickly and effectively.
Through MH drills, staff becomes knowledgeable about the disorder, its rapid progression, the importance of prompt recognition of signs and symptoms and immediate delivery of Dantrolene. The mere presence of a fully equipped malignant hyperthermia cart is not enough; time and staff development is a major determinant of patient survival.