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Discussion

Malignant Hyperthermia..

The dreaded event happend today.

I was prepping for a scheduled case today and observed the OR pharmacist scrambling around for bottles of Dantrolene. Being a glutton for punishment and an adrenaline junkie, I jumped right into this one. We ran to the pharmacy and drew up 180 mgs of dantrolene. There is one of the main residents in the surgery program asking the pharmacist about how to manage a suspected MH event in the ICU. While they are talking, I take off with the 180 mgs of dantrolene drawn up and the MH cart to the ICU and to see what's up. The boardrunner MD says to give 2mg/kg and see what happens. Duh.

I arrive to the ICU and every support person (RNs, RTs, junior residents) is in the room. Currently intubated patient who recieved Anectine in a non-anesthesia related intubation by medical staff is observed to be quite hyperdynamic and a rectal temp of 105. Receivng report from the main resident, she quickly became hyperdynamic and hyperthermic after receiving 100 mg anectine. Current cooling therapies by ICU staff include only ice packs to bilat axilla and the groin. I ask the ICU RNs to start active cold lavage via the existing NGT and Foley cath. I start giving the initial 2mg/kg bolus of dantrolene. One of the CRNAs from the main OR shows up and suggests the RNs also start giving an ice and rubbing alcohol bath with a circulating fan to be placed, blowing over the patient. The residents start assisting the RNs (very impressive) with cooling therapies. A bicarb gtt is started. I rebolus her with another 2mg/kg bolus, followed by a 1mg/kg bolus, followed by a final 2mg/kg bolus. RT is managing the vent and drawing serial ABGs. She is getting only slightly more acidotic, but not massively so. No amps bicarb given in addition to the bicarb gtt.

EKG looks normal on the monitor. Her hyperdynamic state is resolving. I ask the RT to draw an ISTAT for electrolytes. K is 4.9, glucose is elevated in upper 200s, iCa is 0.98. Resident asks RNs to give IV insulin and 2 amps CaCl.

After an hour of my arrival and a total of 18 bottles of dantrolene with a total dosage of 6mg/kg, she is 102 per rectal probe. I wrote a progresss note including time of arrival to the ICU, patient findings, time / amounts of dantrolene administration, labs and temp trendings. A complete set of labs are obtained and sent for analysis.

I will go and check on her over the weekend. I will try and get the specifics of her ABGs and labs for you guys to look at and also get an update.

Managing a crisis, especially away from the OR, can certainly be unique. My facility trains very independent CRNAs. Senior SRNAs work with MDs almost exclusively. I have been paired with a CRNA maybe 6 or 7 times with a CRNA my entire senior year. It is ingrained in us (as SRNAs and CRNAs) from the start to be able to treat problems and give anesthesia without much medical input. It is a revelation sometimes to go back to such an environment where medical direction is strict.

I'm fortunate to work in such an environment that fosters / encourages independence and does not hinder us from opportunities.

Featured Replies

Great JOB!!

Sounds like you had some drills beforehand.

what was the ck? what fluids where you giving? Any diuretics, lasix/mannitol? What were the routine dantrolene orders written for? How long are yall gonna continue the dantrolene for since they are at a strong risk to relapse.

You did a kick ass job!

Nice Save.

.........There is one of the main residents in the surgery program asking the pharmacist about how to manage a suspected MH event.........

Did the pharmacist or someone suggest that the doc call 800-98-MHAUS, the hotline for MH treatment info?

http://www.mhaus.org/

?

Congrats on meeting a difficult challenge with alacrity.

deepz

  • Author
what was the ck? what fluids where you giving? Any diuretics, lasix/mannitol? What were the routine dantrolene orders written for? How long are yall gonna continue the dantrolene for since they are at a strong risk to relapse.

If this had been the OR and happened under my care, the presentation would have been much better. I was an emergent consultant in this case, away from the OR.

A full set of labs, including myoglobin / CK / the works were obtained while I was there. The resident was in touch with the OR pharmacist concerning post-crisis dantrolene. Their conversation resulted in deciding to do a bolus of 1mg/kg every so many hours and not do a gtt. That was their conversation, I was not involved in it. My main portion of during this was giving dantrolene, starting initial labs, and active cooling.

This 4th year surgery resident involved had this happen about 3 months previous, in a post surgical patient, and he very good in this suspected MH crisis. He pretty much already knew the gameplan (so did I) and really didn't have to tell me to do anything. This happened in our best ICU as far as nursing staff go and they were on this like white on rice. I had some input on additional cooling therapies, ordered some labs for my intrest.

One hour into it, total dosage of 6mg/kg, a resolving temp and CV status - I'm out. The resident and his underlings were camping out up there with EXCELLENT nursing staff, my job was finished. They were all top notch. I gave him a box of dantrolene (6 vials), told him how many bottles a redose of 1mg/kg was, and how to mix it. I left the MH cart up there. Told him to give me a call if he needed anyone from anesthesia. Immediate crisis over, done deal.

Like I said, it was not my home.

  • Author
Did the pharmacist or someone suggest that the doc call 800-98-MHAUS, the hotline for MH treatment info?

http://www.mhaus.org/

?

Congrats on meeting a difficult challenge with alacrity.

deepz

This was brought up. The attending of the resident was standing there when this happened and he replied "I don't want to talk to them". Nice huh?

We have two MDs that are all over MH - funny how people find specific disease processes to be fascinating. I personally like studying / preparing for (thankfully not so often) methemoglobinemia and acetylcholinesterase deficiency. The MD in charge (we call him the "boardrunner") was in touch with this resident when this first happened. I'm sure MHAUS will be contacted, but no one contacted them when it immediately happened.

  • Author

Congrats on meeting a difficult challenge with alacrity.

Coming from someone of your clincial authoraty, that is a compliment indeed.

Maybe one day I'll be the man, such as yourself.

Thanks deepz.

Authoraty - au-thor-a-tay (a la that fat little rotund, smar-mouthed character that lives in South Park)

Nice read.

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