From the Department of Anesthesiology (M.A.C.), Pontificia Universidad Catolica de Chile, Human Simulation and Patient Safety Center and Department of Anesthesiology (M.A.C., J.M.T.), Duke University Medical Center, Durham, NC.
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DEMOGRAPHICSCase Title: Malignant HyperthermiaPatient Name: Jose PerezScenario Name: Recognizing and treating malignant hyperthermiaSimulation Developers: Marcia Corvetto, M.D., and Jeffrey M. Taekman, M.D.Simulator: Laerdal SimmanDate of Development: October 2009Appropriate for following learning groups:Residents: Postgraduate years 2, 3, and 4Specialties: AnesthesiologyNurse Anesthesia Students: 1 and 2CURRICULAR INFORMATIONEducational RationaleMalignant hyperthermia (MH) is a rare autosomal dominant genetic disease of calcium metabolism.1 Specifically, it is a pharmacogenetic disorder of the skeletal muscle that presents as a hypermetabolic response to potent volatile anesthetic gases, such as halothane, sevoflurane, desflurane, and the depolarizing muscle relaxant succinylcholine.2 The incidence of MH reactions ranges from 1:15,000 anesthetics in children and adolescents and 1:50,000 to 1:150,000 anesthetics in adults.3 Early diagnosis and improved intervention have decreased the reported mortality of MH. In fact, after introduction of Dantrolene, the mortality decreased from 80% in the 1960s to <10% today.4 Although most anesthesiologists will not see a case of MH during their career, it is a disease that we should know how to recognize and treat. Many have used simulation to teach the diagnosis and management of MH.5–8Learning ObjectivesAccreditation Council for Graduate Medical Education General Competencies:Medical knowledgeList the triggering agents of MHDescribe the pathophysiology involved in the development of MHList the signs and symptoms associated with MHGenerate a differential diagnosis of other disorders that should be consideredPatient careDemonstrate capacity of recognition and treatment of MHDemonstrate knowledge of and proper use of DantroleneDemonstrate knowledge of management of MH susceptible patientsPractice-based learning and improvementDiscuss Malignant Hyperthermia Association of the United States (MHAUS) system and how it worksInterpersonal and communication skillsProfessionalismDemonstrate appropriate teamwork and communication (4 and 5)Systems-based practiceDemonstrate knowledge of MH postprocedural care (intensive care unit)Discuss how to counsel the patient and familyDescribe the diagnostic testing options to evaluate MH susceptibilityGuided Study QuestionsWhat drugs are known to trigger MH?How do triggering agents cause an MH crisis?What are the signs and symptoms associated with MH?Is Masseter Muscle Rigidity related to MH?What should I do to manage an acute MH case?How much Dantrolene should be used to manage an acute MH case?How should I counsel the patient and family?How can a diagnosis of MH be confirmed?How should the anesthesia machine and the operating room be prepared before surgery for an MH susceptible patient?Didacticshttp://www.mhaus.org/PREPARATIONMonitors RequiredNoninvasive blood pressure cuffThree-lead electrocardiogramTemperature probePulse oximeterCapnographArterial lineOther Equipment RequiredAnesthesia machineEndotracheal tubeLaryngoscopeDantroleneSterile water60 mL syringesCold salineBicarbonateGlucose/insulinCalciumDefibrillatorTime DurationSetup: 5 minutesPreparation: 5 minutesSimulation: 15 minutesDebrief: 35 minutesCASE STEMJose Perez is a 19-year-old man with no significant medical history who suffered a severe fall while mountain biking. The surgical team determined that he has an open left fractured ankle. The plan is to perform an external fixation under general anesthesia.Background and Briefing Information for Facilitator/Coordinator’s Eyes OnlyIn this simulation case, the patient is in the operating room, with routine monitoring equipment applied and peripheral venous access initiated. He will receive a general anesthesia, because he rejected regional anesthesia. The induction must be with a rapid sequence intubation, because he has a full stomach.